key: cord- - d yfv authors: porfyridis, ilias; plachouras, diamantis; karagianni, vasiliki; kotanidou, anastasia; papiris, spyridon a; giamarellou, helen; giamarellos-bourboulis, evangelos j title: diagnostic value of triggering receptor expressed on myeloid cells- and c-reactive protein for patients with lung infiltrates: an observational study date: - - journal: bmc infect dis doi: . / - - - sha: doc_id: cord_uid: d yfv background: differential diagnosis of patients with lung infiltrates remains a challenge. triggering receptor expressed on myeloid cells (trem)- is a neutrophil and monocyte receptor up-regulated during infection. the aim of this study was to evaluate the diagnostic accuracy of trem- and of c-reactive protein (crp) from patients with lung infiltrates to discern community acquired lung infections. methods: patients admitted to a medical ward with acute respiratory illness were enrolled in the study. neutrophil and monocyte trem- expression were measured by flow cytometry, strem- by an enzyme immunoassay and c-reactive protein by nephelometry. clinical pulmonary infection score was recorded. results: patients were diagnosed with bacterial community acquired pneumonia (group a) and with non-bacterial pulmonary disease (group b). median serum trem- concentration was . pg/ml in group a and lower than . pg/ml (p < . ) in group b. mean±se neutrophil trem- expression was . ± . mfi in group a and . ± . mfi (p = . ) in group b. monocyte trem- expression was . ± . mfi in group a and . ± . mfi (p = . ) in group b and mean±se crp was . ± mg/ml in group a and . ± . mg/ml (p < . ) in group b. a cut-off of . pg/ml of strem- with sensitivity . % and specificity % to discriminate between infectious and non-infectious pulmonary infiltrates was found. strem- at admission greater than pg/ml was accompanied with unfavourable outcome. conclusion: trem- myeloid expression and strem- are reliable markers of bacterial infection among patients with pulmonary infiltrates; strem- is a predictor of final outcome. early diagnosis of lung infections remains a challenge. there is no gold standard for diagnosing microbial infection as clinical and laboratory signs are neither sensitive nor specific enough, and microbiological studies often remain negative. the presence of a new infiltrate on plain chest radiograph is considered indicative for diagnosing pneumonia, especially when is supported by clinical and laboratory findings. however it is difficult to differentiate a chest infiltrate of bacterial origin from a chest infiltrate of non-bacterial origin solely based on radiological criteria [ ] . the diagnosis of infection is not always clear in the acute setting in patients with respiratory tract disease and a surrogate marker of infection would be a major benefit in the diagnostic armamentarium. many inflammatory mediators and acute phase reactants, like c-reactive protein (crp) and procalcitonin, have been described as reliable markers of infection; however none are specific enough, since they are also increased in non-infectious inflammatory conditions [ ] . triggering receptor expressed on myeloid cells (trem)- is a recently described receptor on neutrophils and monocytes. it behaves like a pattern recognition receptor (prr) since its activation leads to the release of pro-inflammatory cytokines, namely of tumour necrosis factor-alpha (tnfα) and of interleukin (il)- . although its ligand is still unknown, activation is mediated by bacteria and fungi [ , ] . a soluble form of trem- , namely strem- , is increased in the bronchoalveolar lavage (bal) of patients with ventilator associated pneumonia (vap) [ , ] , and in the serum of patients with sepsis, with bacterial meningitis and with acute pancreatitis [ ] [ ] [ ] [ ] [ ] [ ] . this same soluble form of trem- seems to be increased in patients bearing noninfectious processes like peptic ulcer, inflammatory bowel disease, viral infections, malignant pleural effusions and chronic obstructive pulmonary disease (copd) but also among patients after cardiac surgery or cardiac arrest. increase of strem- seems particular prominent when the latter non-infectious states are complicated with systemic inflammatory response syndrome (sirs) without infection [ ] [ ] [ ] [ ] [ ] [ ] [ ] . several published studies yielded contradictory results for the diagnostic and prognostic usefulness of trem- and of strem- for infections [ , , [ ] [ ] [ ] . the created impression is that more data are necessary to yield definitive results for its usefulness as a diagnostic and prognostic marker of community acquired pneumonia (cap). the aim of the present study was to define whether expression of trem- on cell membranes of neutrophils (ntrem- ), of monocytes (mtrem- ) and serum strem- may help in the diagnosis of acute bacterial infections for patients admitted with a new pulmonary infiltrate or pleural effusion. in this observation trial, all consecutive admissions to the department of critical care and pulmonary services on predetermined and randomly selected emergency duty days were eligible. inclusion criteria were: i) age above yrs, ii) written informed consent; iii) acute respiratory illness and iii) presence of new pulmonary infiltrates or pleural effusion on chest x-ray or lung computed tomography. exclusion criteria were: i) human immunodeficiency virus (hiv) infection, ii) documented extrapulmonary infection, iii) neutropenia; and iv) oral intake of corticosteroids defined as any more than mg/kg of prednisone for more than month. the study protocol was approved by the ethics committee of the hospital and written informed consent was obtained from all patients within the first hrs after admission. clinical, laboratory, and imaging data were recorded for each patient including: i) clinical presentation; ii) body temperature, iii) arterial blood gas, iv) peripheral blood cell counts, v) gram stains and cultures of all biological fluids obtained (blood, sputum, bronchial secretions, bal, and pleural fluid); vi) imaging findings, vii) antigen serology (legionella spp and streptococcus pneumonia urinary antigen, serological testing for legionella pneumophila, mycoplasma pneumoniae, chlamydia pneumoniae) and viii) in-hospital mortality. the severity of illness was assessed by calculating acute physiology and chronic health evaluation (apache) ii, sequential organ failure assessment (sofa) and clinical pulmonary infection (cpis) scores at admission [ ] . a diagnosis of community-acquired pneumonia (cap) was established in any patient presenting with a combination of fever, cough and purulent sputum, shortness of breath, chest pain, and new consolidation on chest x-ray or computed tomography. the severity of pneumonia was assessed the first hours of admission according to confusion, urea nitrogen, respiratory rate, blood pressure (curb) index. patients having two or more criteria were identified to have severe pneumonia [ ] . sepsis, severe sepsis and septic shock were defined according to current recommendations [ ] . pneumonia was considered to be absent when: i) an alternative cause for pulmonary infiltrate was established (e.g. pulmonary embolus) and ii) full recovery was achieved without antimicrobial therapy. pulmonary embolism was diagnosed according to current recommendations [ ] . lung cancer was ruled out based on histology and/or cytology specimens. congestive heart failure was diagnosed according to american heart association [ ] , and interstitial lung disease according to american thoracic society guidelines [ ] . all cases were evaluated by two clinicians blinded to trem- and strem- results. agreement about the diagnosis was achieved in all cases. patients with cap were classified as having bacterial respiratory infection (group a). all other patients were classified as having non-bacterial respiratory disorders (group b). all patients assigned to group b were subject to chest computed tomography. for the measurement of strem- , mtrem- , ntrem- and crp ml of peripheral venous blood were sampled after venipuncture of the antecubitul vein under sterile conditions on the day of admission and on days and of hospitalization. seven ml were centrifuged and serum was stored in - °c until assayed for strem- . three ml were collected into edta-coated tubes (vacutainer, bd) for estimation of ntrem- and mtrem- expression. briefly, red blood cells were lysed by ammonium chloride. white blood cells were labelled by phycoerythrin-conjugated anti-trem- monoclonal antibodies (r&d inc, minneapolis, usa) for minutes in the dark. ntrem- and mtrem- expression were assessed after passage of labelled cells through a flow cytometer (epics xl/msl, beckman-coulter co, miami florida) and expressed as the mean fluorescence intensity (mfi) with gating for neutrophils and for monocytes by their characteristic fs/ss scattering. determination of strem- was performed in duplicate by a developmental enzyme-linked immunoabsorbent assay according to the instructions of the manufacturer (r&d inc, minneapolis, usa). the lower detection limit and inter-day variation of the assay were . pg/ml and . % respectively. measurement of serum crp was performed by an immunoturbidimetric assay on roche automated clinical chemistry analyzers and was expressed in mg/ml. crp was used as a comparator due to its universal application in all studies of evaluation of biomarkers. asumming that measured parameters between groups a and b differed by %, it was calculated that to patients should be assigned into each group to yield a difference at the % level with % power. values for ntrem- , mtrem- and crp are presented as mean ±se; those of strem- are presented as medians and % confidence intervals (ci) or interquartile range (iqr). comparisons between groups for ntrem- , mtrem- expression and for crp were done by anova, followed by the tukey's test for multiple comparisons. comparisons of strem- between groups were done by mann-whitney u test after bonferroni corrections for multiple comparisons. comparisons of strem- between consecutive days within one group were done by wilcoxon's signed rank test. receiver operator curves (roc) were designed to asses sensitivity, specificity, positive and negative predictive values for the estimated parameters to disclose infectious from non-infectious infiltrates. patients were divided into two categories according to serum levels of strem- upon admission: those with strem- below or equal to pg/ml; and those with serum strem- greater than pg/ml. this concentration has been proposed as a threshold defining final prognosis in septic populations [ , ] . since cap is a common cause of sepsis, this threshold was considered of merit. survival was assessed by kaplan-meier and comparisons were done by log-rank test. correlations between severity scores and measured parameters were done according to spearman. probability values less than . were considered statistically significant. all statistics and graphs were done using the statistical package for the social sciences software version . . (spss inc, chicago, il). the study flow-chart is shown in figure . demographic and clinical data of the patients are summarized in table . patients suffering from tuberculosis and enrolled in group b were presented with pleuritis. group a (n = ) consisted of patients with community acquired pneumonia (cap) likely to be caused by extracellural bacteria. seventeen had microbiological evidence of pulmonary infection, with isolation of the offending pathogens from sputum, blood or bal samples (when bronchoscopy was performed). seventeen patients were diagnosed with cap on the basis of typical clinical and radiological presentation and good response to antibiotic therapy. main radiological group b (n = ) consisted of patients with non-bacterial respiratory disorders. diagnoses were: lung cancer ( patients); pulmonary embolism (six patients); interstitial lung disease (six patients); heart failure (n = ); pulmonary tuberculosis (two patients); rheumatoid pleuritis (one patient); and q-fever (one patient). main radiological findings were: right pulmonary infiltrate (six patients); left pulmonary infiltrate (three patients); bilateral pulmonary infiltrates ( patients); right pleural effusion (four patients); left pleural effusion (one patient); both right lung infiltrate and right pleural effusion (four patients); both left lung infiltrates and left pleural effusion (two patients); bilateral pulmonary infiltrates and left pleural effusion (one patient); and left pulmonary infiltrate and bilateral pleural effusions (one patient). among patients from group a with cap nine (n = ) died; six patients were admitted to the icu and three were not admitted to the icu due to relatives' denial. mean age of patients not admitted to icu was years; the first two patients had a case-history of stroke and chronic heart failure; the third patient had a case-history of lung cancer. all three died from severe sepsis and multiorgan dysfunction syndrome (mods). mean age of patients admitted to icu was years; two patients had a case-history of aortic valve stenosis; two patients were under chronic intake of receiving corticosteroids; the fifth patient suffered from end-stage renal disease; and the sixth patient was suffering from hepatic failure due to alcohol intake. all six patients died from severe sepsis and multiorgan dysfunction syndrome (mods). all patients in the icu accomplished the clinical and radiological criteria for acute respiratory distress syndrome (ards) and were ventilated with the strategy of low tidal volume ventilation, according to current guidelines [ ] , with volume limited mode ventilation, low tidal volumes (about ml/kg ideal body weight), a maximum of - breaths per minute, high positive end-expiratory pressure (peep cmh o) and a goal plateau airway pressure < cmh o. among patients admitted in the icu, two died on the second day post-admission; one died on the third day post-admission; one on the seventh day post-admission; one the eighth day postadmission; and one on the twentieth day post admission. concentrations of strem- and of crp in sera of both groups and expression of ntrem- and mtrem- are given in table . all four parameters were significantly greater in group a than group b. roc of strem- , ntrem- , m-trem- and crp to differentiate whether a chest x-ray infiltrate is due to cap or to a non-infectious process is shown in figure . area under curve (auc) of strem- was . ± . ( %ci: . - . , p = . ). sensitivity and specificity to diagnose between a pulmonary infiltrate of infectious origin and a pulmonary infiltrate of non-infectious origin were . % and % respectively at concentrations above . pg/ml. auc of ntrem- and mtrem- were . ± . ( %ci: . - . , p = . ) and . ± . ( %ci: . - . , p = . ) respectively. sensitivity and specificity to diagnose between a pulmonary infiltrate of infectious origin and a pulmonary infiltrate of non-infectious origin were . % and . % for ntrem- above . mfi. sensitivity and • lung cancer ( ) • staphulococcus aureus ( ) • pulmonary embolism ( ) • haemophilus influenzae ( ) • congestive heart failure ( ) • pseudomonas aeruginosa ( ) • interstitial lung disease ( ) • other ( specificity to diagnose between a pulmonary infiltrate of infectious origin and a pulmonary infiltrate of non-infectious origin were . % and . % respectively for mtrem- above . mfi. auc of crp was . ± . ( %ci: . - . , p < . ). sensitivity and specificity to diagnose between a pulmonary infiltrate of infectious origin and a pulmonary infiltrate of non-infectious origin were % and % respectively at concentrations above . mg/ml. positive correlations were found between apache ii scores and expression of trem- on monocytes on day (r s : + . , p: . ); and between apache ii scores and strem- on day (r s : + . , p: . ). no significant correlations were found between apache ii scores and expression of trem- on neutrophils on day as well as between sofa scores and any of the measured parameters on day . correlations between serum levels of strem- and crp and expression of trem- on monocytes and neutrophils in relation to the identified causative pathogen of cap are shown in figure . serum levels of strem- were greater among patients with cap caused by gram (+) cocci and haemophilus influenzae than among patients with cap caused by other pathogens. death occurred in three out of patients were no pathogen was defined ( . %); in nil out of three patients infected by atypical pathogens ( %); in three out of seven patients ( . %) infected by gram-negative bacteria; and in three out of nine patients ( . %) infected by gram-positive cocci or h. influenzae (p: . between grouping according to pathogen). survival of patients with strem- on day below or equal to pg/ml was prolonged compared with patients with strem- on day above pg/ml ( figure ) . the results of the present study indicate that trem- can be used as marker of bacterial infection in patients with lung infiltrates. strem- , ntrem- , mtrem- and crp were comparable to their discriminating ability between a pulmonary infiltrate of infectious origin and a pulmonary infiltrate of non-infectious origin. strem- levels were decreased within the first hours in patients with cap with favourable outcome probably after the initiation of appropriate therapy followed by improvement of clinical symptoms. finally, strem- levels above pg/ml were an accurate independent predictor of in-hospital mortality from cap. discrimination of the infectious or non-infectious origin of a pulmonary infiltrate remains an everyday clinical problem. cpis was introduced for that purpose helping considerable in cases of ventilator-associated pneumonia (vap) [ ] . trem- is a surface receptor on cells of the myeloid lineage. activation of trem- leads to the production of pro-inflammatory cytokines [ , , ] . binding of its ligand is possibly linked to the activation of several transcription complexes that synergize with nf-b in order to elicit transcription of genes of pro-inflammatory cytokines [ ] . strem- is the soluble counterpart of trem- and it is probably shed in the systemic circulation from cell membranes of neutrophils and monocytes [ , , ] . the physiologic role of strem- remains under question despite data support a probable anti-inflammatory role [ , ] . trem- has been studied in patients with pneumonia, especially vap [ , , [ ] [ ] [ ] . few data are available on the diagnostic role of trem- and of strem- in patients with lung infiltrates. our data are in agreement with observations from the study by phua [ ] . their proposed strem- cut-off point was ng/ml, which is different than the one we found. this may be result from the different method of assaying strem- the used being western blotting. the results of our study are in contrast to those of another study [ ] that did not disclose any difference in ntrem- expression between patients with and without a bacterial lung infection probably due to the small number of patients included in that former study. el sohl et al [ ] reported elevated alveolar levels of strem- in pulmonary aspiration syndromes, but not in serum. however, serial plasma strem- levels were not obtained and the possibility that plasma levels might rise on subsequent days cannot be excluded. two recent studies [ , ] evaluated the diagnostic role of cpis and of strem- in bal fluid from patients with bilateral lung infiltrates in the intensive care unit (icu). these studies reported controversial results. however authors did not measure strem- in serum on consecutive days. the reported results of the present study are the first to our knowledge that evaluate the diagnostic value of trem- among patients with lung infiltrates to discriminate cap. they also disclose a relationship between levels of circulating strem- and causative pathogens. more precisely, infections caused by streptococcus pneumoniae, sthaphylococcus aureus and haemophilus influenzae were accompanied by greater levels of strem- and by greater expression of trem- on neutrophils than infections caused by other pathogens. although it may be hypothesized that gram-positive cocci and h. influenzae are strong inducers of trem- expression, it should be emphasized that trem- is one prr, the exact agonist of which remains to be found [ , ] . a former study of our group [ ] and another by gibot et al [ ] in heterogeneous populations of patients with severe sepsis of diverse aetiology investigated the role of early assessment of strem- as a determinant of final outcome. results revealed that concentrations greater than pg/ml are accompanied by survival benefit. the exactly opposing finding is reported here. this discrepancy may be explained by the enrolment of more homogeneous populations of patients, compared to these former studies [ , ] , all suffering with cap. our study presents two main limitations: a) no documented cases of cap by legionella pneumophila, mycoplasma pneumoniae, protozoa or parasites were enrolled in group a; b) mortality in the cap patient group was high probably due to the existence of severe co-morbid conditions. in conclusion, the presented results indicate that serum strem- and expression of trem- on neutrophils and monocytes may serve as markers of cap in patients with pulmonary infiltrates. concentrations of strem- in serum are particularly increased in cap caused by gram-positive cocci and haemophilus species. the real clinical value of strem- assay comes when trem- levels are low, allowing the clinician to withhold empiric antibiotics until culture results are available, and thus eliminating unnecessary antibiotic exposure to the patient. and finally, early serum levels of strem- greater than pg/ml in cap are associated with unfavourable prognosis. and evangelos j. giamarellos-bourboulis ass. prof. md have no conflicts of interest to disclose related to this study. evangelos j. giamarellos-bourboulis prof. md has received reimbursement for attending the th international symposium on intensive care and emergency medicine where participated as a speaker and unrestricted educational grants from abbott hellas sa; wyeth hellas sa; sanofi-aventis hellas sa. imaging of pneumonia: trends and algorithms diagnostic and prognostic accuracy of clinical and laboratory parameters in community-acquired pneumonia trem- (triggering receptor expressed on myeloid cells): a new player in acute inflammatory responses trem- amplifies inflammation and is a crucial mediator of septic shock does soluble triggering receptor expressed on myeloid cells- play any role in the pathogenesis of septic shock? soluble triggering receptor expressed on myeloid cells and the diagnosis of pneumonia serum of patients with septic shock stimulates the expression of trem- on u monocytes clinical review: role of triggering receptor expressed on myeloid cells- during sepsis triggering receptor expressed on myeloid cells- (trem- ) is regulated post-transcriptionally and its ligand is present in the sera of some septic patients soluble triggering receptor expressed on myeloid cells- : a biomarker for bacterial meningitis increased levels of soluble triggering receptor expressed on myeloid cells- in patients with acute pancreatitis triggering receptor expressed on myeloid cells- expression on monocytes is associated with inflammation but not with infection in acute pancreatitis soluble triggering receptor expressed on myeloid cells- (strem- ): a new mediator involved in the pathogenesis of peptic ulcer disease role of soluble triggering receptor expressed on myeloid cells- in inflammatory bowel disease trem- expression in tumor-associated macrophages and clinical outcome in lung cancer activation of triggering receptor expressed on myeloid cells- on human neutrophils by marburg and ebola viruses soluble triggering receptor expressed on myeloid cells is released in patients with stable chronic obstructive pulmonary disease increased plasma levels of soluble triggering receptor expressed on myeloid cells and procalcitonin after cardiac surgery and cardiac arrest without infection the increased expression of trem- on monocytes is associated with infectious and non-infectious inflammatory processes soluble trem- is not suitable for distinguishing between systemic inflammatory response syndrome and sepsis survivors and nonsurvivors in the early stage of acute inflammation prognosis of community acquired pneumonia(cap): value of triggering receptor expressed on myeloid cells- (trem- ) and other mediators of the inflammatory response timecourse of strem (soluble triggering receptor expressed on myeloid cells)- , procalcitonin, and c-reactive protein plasma concentrations during sepsis diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited infectious diseases society of america guidelines for the management of adult lower respiratory track infections acute pulmonary embolism focused update incorporated into the acc/aha guidelines for the diagnosis and management of chronic heart failure in adults: a report of the american college of cardiology foundation european respiratory society international multidisciplinary consensus classification of idiopathic interstitial pneumonias early changes of cd -positive lymphocytes and nk cells in patients with severe gram-negative sepsis the national heart, lung, and blood institute ards clinical trials network: higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome trem and trem-like receptors in inflammation and disease the trem receptor family and signal integration monocytes as a site of production of soluble triggering receptor expressed on myeloid cells - (strem- ) in the septic host soluble triggering receptor expressed on myeloid cells- modulates the inflammatory response in murine sepsis soluble triggering receptor expressed on myeloid cells- as an antiinflammatory mediator in sepsis soluble triggering receptor expressed on myeloid cells - in acute respiratory infections triggering receptor expressed on myeloid cells: role in the diagnosis of lung infections triggering receptors expressed on myeloid cells in pulmonary aspiration syndromes diagnostic implications of soluble triggering receptor expressed on myeloid cells- in bal fluid of patients with pulmonary infiltrates in the icu diagnostic utility of the soluble triggering receptor expressed on myeloid cells- in bronchoalveolar lavage fluid from patients with bilateral lung infiltrates funding source: none the present authors would like to thank all patients who participated in the current study, the doctors and nurses of the department of critical care and pulmonary services, national and kapodistrian university of athens, 'evangelismos' hospital, athens, greece for their hand work in the treatment of the patients and the doctors and laboratory personnel of the th department of internal medicine, national and kapodistrian university of athens, 'attikon' hospital, athens, greece for their most helpful support during the study. finally, the current authors thank paris praxitelous authors' contributions ip participated in the study design, the enrolment of patients, the estimation of trem- , strem- , crp, the follow-up of patients and wrote the manuscript. dp participated in the study design and in the estimation of trem- and strem- . vk carried out the estimation of trem- . ak and sap participated in study design, and drafted the manuscript. hg participated in study design and drafted the manuscript ejgb coordinated the lab job, analyzed the data and drafted the manuscript. all authors read and approved the final manuscript. key: cord- -gowyfu authors: kafkas, nikolaos; demponeras, christos; zoubouloglou, filitsa; spanou, loukia; babalis, dimitrios; makris, konstantinos title: serum levels of gelatinase associated lipocalin as indicator of the inflammatory status in coronary artery disease date: - - journal: int j inflam doi: . / / sha: doc_id: cord_uid: gowyfu background. atherosclerosis is a chronic inflammatory disease and the acute clinical manifestations represent acute on chronic inflammation. neutrophil gelatinase-associated lipocalin (ngal) is found in the granules of human neutrophils, with many diverse functions. the aim of this study was to evaluate the hypothesis that levels ngal in blood may reflect the inflammatory process in various stages of coronary artery disease. methods. we studied patients, with sa , ua , nstemi , and stemi , and healthy controls. serum ngal was measured upon admission and before coronary angiography. results. significant differences were observed in median serum-ngal(ng/ml) between patients with sa ( . (iqr, . – . )), when compared with ua ( . ( . – . )), nstemi ( . ( . – . )), and stemi ( . ( . – . )) patients and controls ( . ( . – . )) with significant incremental value from sa to stemi. we observed a positive and significant correlation between serum-ngal and hs-crp (spearman coefficient rho = . , p < . ) as well as with neutrophil counts (r = . , p < . ). conclusions. in patients with coronary artery disease serum levels of ngal increase and reflect the degree of inflammatory process. in patients with acute coronary syndromes, serum levels of ngal have high negative predictive value and reflecting the inflammatory status could show the severity of coronary clinical syndrome. systemic inflammation participates in atherosclerosis evolution from the early development of endothelial dysfunction, to formation of mature atheromatic plaques, to the ultimate endpoint, rupture, and thrombotic complications [ ] . plaque rupture with the formation of an occlusive thrombus is the cause of acute coronary syndromes (acs) [ ] . inflammatory cells, involving activated neutrophils, are more frequently found in plaques vulnerable to rupture [ ] . neutrophil activation has been reported in unstable angina (ua) and acute myocardial infarction (ami) but not in patients with stable angina (sa) [ ] [ ] [ ] [ ] [ ] [ ] [ ] . this activation seems to precede myocardial injury in patients with ami [ ] . therefore biomarkers of neutrophil activation could be of prognostic and even diagnostic importance. recent studies have shown that gelatinase b also known as matrix metalloproteinase- (mmp- ), an endopeptidase capable of degrading the extracellular matrix, is thought to be associated with atherosclerosis, and plaque rupture [ , ] . therefore, mmp- is considered to be an important mediator of vascular remodeling and plaque instability. the mmp- action is enhanced b neutrophil gelatinase-associated lipocalin (ngal), also known as lipocalin- , a kda glycoprotein, that is, found in the granules of human neutrophils, with many diverse functions, such as scavenger of bacterial products, modulator of inflammation, iron trafficking, and apoptosis [ ] . the formation of a complex with ngal and mmp- is crucial for atherosclerotic plaque erosion and thrombus formation [ ] . ngal is also produced by kidney tubular cells in response to various ischemic or toxic insults and has international journal of inflammation been proposed as an early biomarker for the diagnosis of acute kidney injury [ , ] . in this study, we hypothesized that levels ngal in blood may reflect the extent of neutrophil activation in various stages of acs and could discriminate various types of acs (ua, nstemi, and stemi) and stable from unstable coronary syndromes. one hundred and seventy consecutive patients programmed for coronary angiography to the invasive cardiology department of the kat general hospital athens, greece, were recruited for this study, from june to october . the study was performed according to the principles of the declaration of helsinki and was approved by the hospital's ethics committee. written informed consent was obtained from all participating patients. thirty patients were excluded from the study. exclusion criteria included a negative coronary angiography in patients with a typical chest pain which was considered as angina or had a false positive single photon emission computed tomography (spect), any surgery in the previous six months, liver disease, end stage renal disease, renal cardiac or liver transplantation, neoplasia, and infection since all these can affect serum-ngal levels. the patients who fulfilled the study criteria after the clinical assessment and final diagnosis were divided into the following groups: sa (n = ), ua (n = ), nstemi (n = ), and stemi (n = ). twenty ( ) healthy amateur athletes without risk factors served as control group (figure ). the demographics and clinical characteristics of patients and controls are shown on table . all patients, upon presentation in emergency room, underwent an initial clinical assessment that included clinical history, physical examination, -lead ecg, continuous ecg monitoring, and standard blood tests (including white blood cell, polymorphonuclear neutrophil counts, and troponin-i). these tests were repeated at at and hours as long as clinically indicated. to determine the final diagnosis for each patient cardiologists blinded to ngal results reviewed all patients available records (including patient history, laboratory results, radiologic testing, ecg, echocardiography, and coronary angiography) at the completion of their hospital stay. the sa group consisted of patients with angiographically documented organic coronary stenosis > % by quantitative coronary angiography in major arteries who had chronic symptoms of angina or a positive spect test. ua was diagnosed in patients with typical angina at rest, or a sudden increase in episodes of a previously stable angina. ami was diagnosed when there was evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia. necrosis was diagnosed by a rising and/or falling pattern of troponin-i with at least one value above the cutoff value (defined as the th percentile of a normal population where the assay shows an imprecision < %). our troponin-i assay fulfills the imprecision criteria for concentration > . ng/ml. serum and k edta-plasma samples were collected from all sa patients in the morning before the coronary angiography. in all acs patients pci was performed within hours from admission and the blood samples were collected on admission. from all healthy subjects, samples were collected in the morning and before training. serum samples were kept frozen at − • c until tested. total white blood cell count (wbc), and peripheral polymorphonuclear neutrophil count (pmn) were assessed using the cell-dyn sapphire haematology analyzer (abbott, chicago, il, usa). serum creatinine was measured with a modified jaffe method on architect ci analyzer (abbott, chicago, il, usa). high-sensitivity crp (hs-crp) was measured with a turbidimetric assay on the same analyzer. troponin-i was measured with a chemiluminescent immunoassay on the same analyzer. serum-ngal was measured with an elisa (bioporto, gentofte, denmark). this was performed with ncss statistical program. normality of distributions for quantitative data was tested with the shapiro-wilk test. for normally the mean age and the mean bmi of the patients did not differ significantly among the four groups whereas the controls were significantly younger and their bmi was significantly lower (anova-test). the proportion of diabetic patients did not differ significantly among four patient groups (chisquare = . , p = . ) as well as the proportion of patients with hypertension and dyslipidemia (chi-square = . , p = . ). finally smoking habits did not differ significantly in the first three patient groups while it was significantly higher in group . those risk factors were absent from our controls. ( . ng/ml) ( table and figure ). also significant were the differences observed between healthy controls and sa patients, between ua patients and patients with ami (nstemi or stemi). patients with stemi had higher levels of ngal than patients with nstemi but the difference was nonsignificant ( table ) . markers. the median plasma levels of hs-crp were similar in patients with sa ( . mg/dl) and those with ua ( . mg/dl) and were significantly higher than the levels in the control group ( . mg/dl). hs-crp levels were significantly increased in patients with nstemi ( . mg/dl) and stemi ( . mg/dl). in order to further investigate the relationship between serum-ngal and hs-crp, we performed regression analysis between serum-ngal and hs-crp (figure ). this analysis revealed that there is a linear and positive correlation between hs-crp and serum ngal (spearman rank correlation coefficient rho = . , p < . ). the differences that were observed among the four patient groups in wbc and pmn counts were statistically significant (p < . , anova-test). there was a positive and significant correlation between serum-ngal and wbc (r = . , p < . ) and pmn (r = . , p < . ) counts (figure ) . in a multivariate regression analysis model entering as independent parameters age, serum creatinine, hs-crp, and pmn count, we identified only hs-crp (p < . ) and pmn count (p < . ) as independent predictors of serum-ngal levels. curve for serum-ngal hs-crp and pmn counts ( figures and ). the diagnostic value for serum-ngal in discriminating patients with ua, from those with sa is high (auc = . ) and better than of hs-crp (auc = . ) or pmn count (auc = . ). if we use as cutoff for serum-ngal . ng/ml, we can predict an ua event with sensitivity and specificity, . % and %, respectively. the negative predictive value of this cutoff is high ( . %). the diagnostic value for serum-ngal in discriminating acs patients, from patients with sa is high (auc = . ) and better than of hs-crp (auc = . ) and pmn count (auc = . ). if we use as cut-off for serum-ngal . ng/ml, we can discriminate an acs patient from a stable patient with sensitivity and specificity, . % and . %, respectively. the negative predictive value of this cutoff is high ( . %). in this study, we demonstrated that serum levels of ngal are higher in patients with cad than in healthy controls patients. among acs patients, these levels are gradually elevated according to the severity of the coronary clinical syndrome (ua, nstemi, and stemi). also serum levels of ngal are higher in patients with acs than in patients with sa and could be used, with high negative value, to discriminate patients with stable or unstable coronary syndromes. the relevance of ngal to cardiovascular disease (cvd) remains primarily unknown. elevated plasma ngal levels were associated with atherosclerosis and were implicated as a predictor for cardiovascular mortality after cerebrovascular ischemia, possibly because of activation of blood leukocytes [ ] [ ] [ ] . although in recent reports has been shown that ngal is present in atherosclerotic plaques and in human abdominal aortic aneurisms, raising the possibility that expression of ngal can be induced in vascular cells during atherogenesis, the underlying mechanism for the induction of ngal in vascular cells remains unknown [ , ] . in further analysis the main source of ngal was found to be neutrophils, probably recruited in the vascular wall by platelet activation [ ] . ngal is considered to have a protective effect on mmp- and enhancing its proteolytic activity, could be considered as an important factor indirectly contributing to the progression of aneurism as well as involved in the physiologic and pathologic remodeling of vessel walls. this view is further supported by the observation that similar neutrophil ngal/mmp- overexpression can be found in atherosclerotic plaques, particularly those with intramural haemorrhagic debris and central necrosis [ , ] . the above evidence supports the clinical observations that highcirculating leucocyte (particularly neutrophil) counts are independent predictors of recurrent ischaemic attacks. this may be explained by their presence in the necrotic core of unstable plaques and by their proteolytic activity towards atherosclerotic tissue and secondary mobilization of thromboembolic fragments [ ] . the evidence derived from these experimental studies, showing the close link between neutrophils, their products and the natural history of atherosclerosis, and its complications, generated clinical studies that investigated the clinical utility of serum-ngal measurements. in two recent studies it was found that serum levels of ngal were significantly elevated in patients with angiographically confirmed cad compared to those with normal arteries or controls [ , ] . our data agree with these reports since we found that levels of serum-ngal are significantly higher in patients with all clinical syndromes of cad than in healthy controls, reinforcing the utility of ngal as biomarker of detection and the extent of cad. the expression of ngal from vascular cells during atherogenesis can also explain the differences between patients with sa and control subjects with no risk factors observed in our study. in addition to its induction in the vessels after mechanistic injury, previous studies suggest that ngal is strongly upregulated in atherosclerotic lesions and also in the heart after ischemic injury [ ] . it is possible that ngal produced by vascular cells could also be secreted into the systemic circulation. inflammation plays a critical role not only in development and progression of atherosclerosis but also in pathogenesis of the destabilization of atherosclerotic plaque that leads to acs [ , ] . activation and degranulation of polymorphonuclear neutrophils and probably an underestimated critical components of an acute coronary inflammation event. infiltrating macrophages and neutrophils participate in the transformation of stable coronary artery plaques to unstable lesions with a thin fibrous cap [ ] . it has been repeatedly reported that thrombosed plaques were densely infiltrated by neutrophils and macrophages [ , ] . macrophages and neutrophils and some other types of leukocytes produce various proteolytic enzymes which facilitate the rupture of plaques by thinning and weakening their normally thick and firm cap [ , ] . ngal is one protein, that is, produced not only by the distressed kidney but also by activated neutrophils and by the vascular wall cells. recent studies have shown that neutrophils are the main source of ngal in blood [ , ] . increase in serum ngal resulting from activation of neutrophils may reflect an acute systemic inflammatory response to events such as stroke, renal failure, or infection [ , [ ] [ ] [ ] but are also linked with the presence of chronic inflammatory diseases such as atherosclerosis [ ] whose acute clinical manifestations represent acute on chronic inflammation. besides neutrophils, ngal is also expressed by epithelial cells, renal tubular cells, and hepatocytes during inflammation or injury [ ] [ ] [ ] . our data agree with the above studies since we found a positive correlation between levels of serum-ngal and systemic inflammation (expressed by the serum hs-crp levels and neutrophil count), and also serum levels of ngal were higher in patients with acs than with sa. the higher levels of serum-ngal observed in patients with acs compared to sa could be explained by international journal of inflammation the fact that neutrophil activation is present only in patients with acute coronary events ( , ) . also, our results, as far as patients with sa and ami, are similar with the findings of a recent published study which showed that the plasma level of ngal is higher in patients with ami compared with the patients with stable cad [ ] . in clinical practice, levels of serum-ngal have a high negative predictive value, . % and . % for patients with ua and acs, respectively. so, serum-ngal could be used in discriminating of patients with acs or especially ua from whom with sa or without cad, giving the possibility to exclude patients with symptoms similar to angina but not having true acs. as far as the gradual increase of serum-ngal, according to the seriousness of unstable coronary clinical syndrome, this could reflect the intensity of the inflammatory reaction, as it is expressed by the incremental increase of hs-crp and neutrophil count and their combination with serum ngal. especially between serum-ngal and hs-crp, the correlation is linear and positive. in conclusion, our study shows that serum levels of ngal increase in patients with cad with every coronary clinical syndrome and reflect the inflammatory status in the same population. having high negative predictive value could be used as a marker for the discrimination of sa or chest pain without cad from those with acs. also in patients with acs, serum levels of ngal reflecting the inflammatory status could show the severity of coronary clinical syndrome (ua, nstemi, and stemi). acute coronary syndrome cad: coronary artery disease sa: stable angina ua: unstable angina ami: acute myocardial infarction ngal: neutrophil gelatinase associated lipocalin nstemi: non-st-elevation myocardial infarction stemi: st-elevation myocardial infarction pci: percutaneous coronary intervention. atherosclerosis-an inflammatory disease plaque rupture with severe pre-existing stenosis precipitating coronary thrombosis. characteristics of coronary atherosclerotic plaques underlying fatal occlusive thrombi site of intimal rupture or erosion of thrombosed coronary atherosclerotic plaques is characterized by an inflammatory process irrespective of the dominant plaque morphology increased neutrophil-platelet adhesion in patients with unstable angina elevated inflammatory parameters are associated with lower platelet density in acute myocardial infarctions with st-elevation widespread coronary inflammation in unstable angina comparison of coronary artery specific leukocyte-platelet conjugate formation in unstable versus stable angina pectoris neutrophil infiltration of culprit lesions in acute coronary syndromes leukocyte count and coronary heart disease: implications for risk assessment neutrophil activation status in stable coronary artery disease neutrophil activation precedes myocardial injury in patients with acute myocardial infarction increased expression of matrix metalloproteinases and matrix degrading activity in vulnerable regions of human atherosclerotic plaques peripheral blood levels of matrix metalloproteases- and - are elevated in patients with acute coronary syndromes dual action of neutrophil gelatinase-associated lipocalin expression of neutrophil gelatinase-associated lipocalin in atherosclerosis and myocardial infarction early diagnosis of acute kidney injury: the promise of novel biomarkers accuracy of neutrophil gelatinase-associated lipocalin (ngal) in diagnosis and prognosis in acute kidney injury: a systematic review and meta-analysis leukocyte activation in atherosclerosis: correlation with risk factors leukocyte activation detected by increased plasma levels of inflammatory mediators in patients with ischemic cerebrovascular diseases leukocyte activation: relation to cardiovascular mortality after cerebrovascular ischemia presence of ngal/ mmp- complexes in human abdominal aortic aneurysms involvement of intraplaque hemorrhage in atherothrombosis evolution via neutrophil protease enrichment chemokines and atherosclerosis implication of lipocalin- and visfatin levels in patients with coronary heart disease association of neutrophil gelatinaseassociated lipocalin with the severity of coronary artery disease inflammation and atherosclerosis future biomarkers for detection of ischemia and risk stratification in acute coronary syndrome thrombosis and acute coronary-artery lesions in sudden cardiac ischemic death neutrophil infiltration of culprit lesions in acute coronary syndromes current concepts of the pathogenesis of the acute coronary syndromes inflammation and thrombosis: the clot thickens isolation and primary structure of ngal, a novel protein associated with human neutrophil gelatinase molecular cloning and expression of a cdna encoding ngal: a lipocalin expressed in human neutrophils identification of neutrophil gelatinase-associated lipocalin as a novel early urinary biomarker for ischemic renal injury neutrophil gelatinaseassociated lipocalin (ngal) as a biomarker for acute renal injury after cardiac surgery expression profile of immune response genes in patients with severe acute respiratory syndrome expression of neutrophil gelatinase-associated lipocalin regulates epithelial morphogenesis in vitro neutrophil gelatinase-associated lipocalin is up-regulated in human epithelial cells by il- β, but not by tnf-α identification of neutrophil gelatinase-associated lipocalin (ngal) as a discriminatory marker of the hepatocyte-secreted protein response to il- β: a proteomic analysis plasma neutrophil gelatinase-associated lipocalin levels in acute myocardial infarction and stable coronary artery disease the authors declare that they have no conflict of interests. key: cord- -g rxygef authors: leinisch, fabian; mariotti, michele; andersen, sofie hagel; lindemose, søren; hägglund, per; møllegaard, niels erik; davies, michael j. title: uv oxidation of cyclic amp receptor protein, a global bacterial gene regulator, decreases dna binding and cleaves dna at specific sites date: - - journal: sci rep doi: . /s - - -x sha: doc_id: cord_uid: g rxygef uv light is a widely-employed, and environmentally-sensitive bactericide but its mechanism of action is not fully defined. proteins are major chromophores and targets for damage due to their abundance, but the role of proteins in inducing damage to bound dna, and the effects on dna-protein interactions is less well characterized. in e. coli (and other gram-negative bacteria) the cyclic amp receptor protein (crp/cap) regulates more than genes. in this study we show that exposure of isolated dimeric crp-camp to uv modifies specific met, trp, tyr, and pro side-chains, induces inter-protein tyr -tyr cross-links, and decreases dna binding via oxidation of met /pro residues in close proximity at the crp dimer interface. uv exposure also modifies dna-bound camp-crp, with this resulting in dna cleavage at specific g/c residues within the sequence bound to crp, but not at other g/c sites. oxidation also increases crp dissociation from dna. the modifications at the crp dimer interface, and the site-specific dna strand cleavage are proposed to occur via oxidation of two species met residues (met and met , respectively) to reactive persulfoxides that damage neighbouring amino acids and dna bases. these data suggest that modification to crp, and bound dna, contributes to uv sensitivity. . effects of uv irradiation on crp-dna complexes and isolated crp assessed by gel mobility shift assays (a,b) and sds-page (c,d). panel a: gel mobility shift assay of crp-camp complexes ( µm camp) incubated in the dark, or exposed to uv ( min exposure, λ max nm, nm band width, w m − , normoxia), before addition to p-labeled dna in crp binding buffer (see materials and methods). dtt ( mm), nan ( mm) and mannitol ( mm) were present as indicated. lane : no crp; lanes - : crp at . , and nm respectively with no uv exposure; lane - : as lanes - , respectively, but with uv-exposed crp; lanes - : as lanes - , respectively, but with dtt; lanes - : as lanes - , respectively, but with nan ; lanes - : as lanes - , respectively, but with mannitol. panel b. pre-formed crp-camp ( µm)-dna complexes were incubated in the dark, or exposed to uv, in the absence or presence of additives (as panel a). lane : no crp; lanes - : crp at . , . , and nm, respectively, with no uv exposure; lane - : uvexposed crp complex at . , and nm, respectively; lanes - : as lanes - , but with dtt; lanes - : as lanes - , but with nan ; lanes - : as lanes - , but with mannitol. panel c. sds-page of isolated crp ( μm)-camp ( µm) complex incubated in the dark (lane ), or exposed to uv (as panel a) for (lane ) or min (lane ). samples were run under reducing conditions, before visualization with instantblue staining. reactions were carried out in buffer containing: mm tris-hcl (ph . ), mm kcl, . mm mgcl , mm edta, µg ml − bovine serum albumin, . % np- and µg ml − calf thymus dna. panel d. sds-page analysis of crp ( μm)-camp ( µm) complex incubated in the dark, or exposed to uv (as panel a), in the absence or presence of plasmid dna. lane : crp alone, no uv; lane : crp with μg plasmid dna, no uv; lane : crp alone with uv; lanes - : uv-exposed crp with . , and μg plasmid dna, respectively. reactions were carried out in buffer containing: mm tris-hcl (ph . ), mm kcl, . mm mgcl , mm edta, µg ml − bovine serum albumin and . % np- . d o enhanced the loss of the crp band and increased oligomer formation ( supplementary fig. b) , consistent with a role for o . nan decreased oligomer formation particularly when present at high concentration. dtt also decreased oligomer formation but to a lesser extent ( supplementary fig. c ). the presence of the poly-histidine tag on the recombinant protein did not impact on oligomer formation ( supplementary fig. d ). inclusion of plasmid dna in the camp-crp solutions had no effect on crp in the absence of uv (fig. d , lanes versus ), but with uv exposure, the presence of dna enhanced protein oligomerization, and decreased the intensity of the parent crp band (fig. d) . these data indicate that camp-crp is highly susceptible to uv-mediated damage, and that dna enhances this damage. crp-bound to dna gives rise to site specific dna damage when exposed to uv light. experiments were carried out to test whether uv exposure affects dna integrity (as assessed by denaturing gel electrophoresis) when camp-crp is bound at the strong crp binding site on the bp dna fragment. uv exposure of the dna/crp/camp complex resulted in specific strand cleavage ( fig. a , lane and fig. b) , which was not observed when dna alone was exposed to uv light ( fig. a, lanes and fig. b ). incubation of dna/crp/camp complexes in the dark did not induce dna damage (fig. c, lane ) . this crp-and uv-light dependent cleavage occurs at specific g/c base pairs (fig. d) in one of the half-sites, in the position where a strong kink is generated in the dna structure on binding of crp/camp . omission of camp, or denaturing of either the crp or dna before irradiation prevented this dna damage (data not shown). inclusion of mannitol and nan had no effect on the dna cleavage (fig. , lanes and ) , consistent with a localized and specific oxidation. in the absence of dtt, (usually present in the crp binding buffer), both cleavage at the specific g/c pair and limited cleavage at other sites was detected (fig. , lane ) . these data indicate that dna cleavage occurs via two mechanisms: a highly-specific process in the presence of dtt that involves a camp-crp-derived intermediate that reacts at specific nucleotides, and a less-selective and more limited process in the absence of dtt, that . uv exposure alters the chemical composition of crp in the absence and presence of dna. isolated crp-camp complex ( . and μm, respectively) was incubated in the dark, or exposed to uv light (λ max nm, nm band width, w m − , normoxia) for min, before analysis using uplc with pre-column derivatization and fluorescence detection (panels a,b) or lc-ms/ms (panels c-f). panel a: changes in amino acid composition determined by acid-hydrolysis and total amino acid analysis. data are expressed as % modification of the indicated amino acids (positive values indicating loss, negative values indicating formation) relative to the uv exposure control. mean ± sd from independent experiments. panel b: material balance for trp and tyr residues determined by uplc analysis with direct fluorescence detection on acid-hydrolysed uv-exposed crp-camp complex. levels of unmodified parent amino acid, formation of dopa, the total of nfk and kyn (as nfk is converted to kyn during acid hydrolysis) and unknown products (difference to control values) are indicated. mean ± sd from independent experiments. panel c: extent of modification at different amino acids (met, m; pro, p; ser, s; tyr, y; his, h; trp, w) detected by lc-ms/ms for control crp-camp, uv-exposed crp-camp, and preformed crp-camp-dna complex exposed to uv. modifications detected at individual sites (panels d-f) were summed and are expressed as a percentage of the total (native and modified) concentration of the amino acid detected. panels d-f: percentage extents of modification at individual amino acids in the crp sequence (indicated on horizontal axis as position number in sequence). panel d: control crp-www.nature.com/scientificreports www.nature.com/scientificreports/ involves diffusible oxidants that can react at multiple sites. thus, the presence of thiols, as would occur in vivo, limits dna damage to a highly-specific, uv-driven, process involving camp-crp-derived species. characterization of uv-induced modification on crp. oxidative damage to crp was examined using two complementary techniques: total amino acid analysis (uplc with fluorescence detection), and peptide mass mapping using lc-ms/ms, with the former providing data on the overall extents of modification, and the latter data on the sites of oxidation and the identity of the species formed. uplc analysis of native and oxidized crp showed that uv exposure of crp resulted in significant modification (relative to controls) to trp, tyr, ser, met and arg residues (fig. a) . lower extents of modification (< %) were detected at other residues. lys, pro or cys could not be quantified using this method. data for his are not reported, as the -his tag on the expressed crp confounds analysis. a significant increase in methionine sulfoxide, a major met oxidation product, was also detected. trp-and tyr-derived products were identified and quantified using uplc with direct fluorescence detection, with n-formylkynurenine (nfk)/kynurenine (kyn) detected from trp (~ %; quantified as the sum due to acid catalyzed conversion of nfk to kyn), and , -dihydroxyphenylalanine (dopa; ~ . %) detected from tyr (fig. b ). the discrepancy between the parent trp and tyr lost, and products detected ( fig. b ) indicates the formation of additional materials. lc-ms sequence coverage of control and uv-exposed protein was high (~ %; supplementary fig. ), with most of the missing sequence being a single peptide near the n-terminus. q-tof-ms analyses of the uv-exposed samples, showed that met was the most modified ( . %), followed by pro ( . %), ser ( . %) and tyr ( . %) (fig. c ). analysis using an orbitrap-fusion-ms, showed a similar order but slightly higher levels of modification (met, . %; pro, . %; tyr, . %; his, . %). controls showed only low levels of modification (fig. c ). no trp modifications were detected as these residues occur in non-detected peptides ( supplementary fig. ). the decreased extent of modification detected by ms relative to uplc likely reflects the incomplete sequence coverage, and search strategies that use predefined mass changes (m/z + , + , + da); uncharacterized modifications are therefore not detected. q-tof ms analysis of camp-crp-dna complexes exposed to uv light showed a similar pattern of damage, but higher extents of met modification ( . %; fig. c ). the modifications detected at met and pro were m/z + da species, consistent with met sulfoxide and hydroxylation of pro. sequence mapping indicates an uneven distribution of modifications (fig. ) . met was the most heavily modified, followed by met and met , then met and met . low levels of modification at met were also detected using the orbitrap-fusion machine. the data for crp exposed to uv in the presence of dna, showed higher levels of oxidation at met , , and ( fig. e versus f). in the presence of dna, met is the most extensively modified residue ( . %), with this situated very close to the dna strands. in contrast, met , which is also modified to a major extent is positioned close to the dimer interface, and near the camp binding site (fig. ) . the extent of modification at other sites (e.g. met , pro ) was not markedly affected by the presence of dna. the uv-induced crp cross-links ( fig. d ) were characterized using ms with h o labelling (reviewed ). this method provided strong evidence for a di-tyr cross-link between tyr and tyr in a cross-linked peptide (kemilsylnqgdfigelglfeegqer) (kaetlyyivk); this species was not detected in controls. this cross-linked peptide showed the expected − . da mass difference compared to the sum of the parent peptides, and a theoretical mass close to the experimental ( . vs . da; error . ppm). the ms spectrum showed the expected + da mass shift (at m/z . ) for a peptide with two carboxyl termini following h o digestion (fig. a) . ms/ms analysis (fig. b ) revealed multiple fragment ions that retain the cross-link site confirming the identification (b -b for the longer α peptide; y for the shorter β peptide). the distance distribution of the atoms forming this cross-link (fig. c,d) , are consistent with this being inter-protein (i.e. a cross-link between two chains on different dimer molecules), as the average calculated distances between these residues for a putative intra-chain link is . Å (shortest . Å), for an inter-chain link . Å (shortest . Å), values that are much larger than those over which such cross-links are likely to form (cf. data for zero-link chemical cross-linking reagents ). this conclusion is supported by the surface accessibility of these residues in crp structures (pdb structures o t, hif and wc ), and the oligomer formation detected by sds-page. uv light, and particularly uvc, is widely used as an environmentally-sensitive sterilization and bactericidal agent in the health sector, and in water and waste stream disinfection. uvb light, (λ - nm) can initiate direct dna damage and formation of oxidized nucleobases, cyclobutane pyrimidine dimers, and endonuclease-sensitive sites . proteins are also major uv absorbing species in biological systems due to both their abundance ( - mm in mammalian cells; - mm in plasma), and significant uvb absorption bands in the - nm region from trp, tyr and cystine residues [ ] [ ] [ ] [ ] . some proteins have longer wavelength absorptions arising from interaction of trp residues with metal cations or charged side-chains , or the presence of co-factors . the high abundance of proteins makes these major targets for oxidants , with trp, tyr, cys, cystine, his, and met side-chains being particularly prone to modification , , . camp complex. panel e: uv exposed crp-camp. panel f: crp-camp exposed to uv in presence of dna (as above). modifications at the indicated residues are given as the change in m/z (− , − , + , + , + , + , + ) detected by ms for the modifications included in the data searches. the majority of the modifications correspond to m/z + species assigned to the addition of one oxygen atom (formation of an alcohol at pro and tyr; generation of the sulfoxide from met). ( ) : | https://doi.org/ . /s - - -x www.nature.com/scientificreports www.nature.com/scientificreports/ as crp regulates a large number of transcription units in e. coli , and is a global regulator in other gram negative bacteria, uv-mediated damage to the crp-dna complex may have significant biological effects. the data presented here indicate that isolated camp-crp is sensitive to biologically-relevant uvb and uva wavelengths ( - nm) and doses, with this generating chemical modifications on specific side-chains, and structural expansions of the dimer-interface region from panels b and c, indicating the pro (yellow)-met (red) pairs on the individual monomers and the increased proximity of these species at the dimer interface in the dnabound structure (panel e) compared to the non-bound (panel d). modification at these residues, with conversion of met to the sulfoxide and pro to an alcohol are proposed to result in significant steric and electronic interactions that limit binding of uv-oxidised isolated camp-crp to dna (cf. fig. a) , and dissociation of camp-crp from dna when the bound complex is exposed to uv (cf. fig. b) . in panel e, the trp residues (orange) are also indicated as these residues move closer to the pro -met residues on dna binding. ( ) : | https://doi.org/ . /s - - -x www.nature.com/scientificreports www.nature.com/scientificreports/ changes (dimer/oligomer formation). significant uv-induced modification was detected at met, trp, tyr, pro, ser and arg. ms peptide mass mapping indicate that specific met, tyr, and pro residues are modified, with large differences in parent loss and % conversion to products between sites. the extent of modification at individual trp sites could not be determined, but the overall extent of trp oxidation was significant, with a proportion of this being nfk and kyn, together with other uncharacterized materials. oxidation at met yielded the sulfoxide, and tyr oxidation yielded both dopa and dityrosine. unusually, significant modification was also detected at ser and pro, with these not being typical uv targets. some of the ser loss may arise from their proximity to the bound camp . products from ser (probably carbonyls) were not detected, as these were not included in the ms modification database. the products from pro were detected as m/z + species, consistent with the formation of alcohols (hydroxypro , ). these chemical modifications are consistent with the observed structural changes. sds-page data indicates significant levels of non-reducible cross-links, supported by the ms detection of a covalent tyr -tyr (dityrosine) link, assigned as an inter-molecular linkage, as the calculated intra-chain and inter-chain distances are too large for such species, unless the protein adopts conformations markedly different to those of free crp, or dna-bound crp. whether dityrosine is the sole type of cross-link is however unclear. the sequence of these two peptides is indicated, together with the site of the di-tyr linkage between the two tyr (y) residues (vertical green line). a number of the detected fragment ions retain this cross-link confirming its location. panels c and d: rendering of the structure of the crp-camp complex (pdb structure: wc ) indicating the relative positions of the tyr and tyr residues both within the individual monomer chains, and between tyr when these are present on different monomer chains. the corresponding vectors for intra-chain (▪) and inter-chain (▪) cross-links are indicated. in panel d, these vectors are plotted as distance distributions for a putative intra-chain cross-link (blue bars: average . Å, . Å shortest) and a putative inter-chain cross-link (red bars: average . Å, shortest . Å). these high shortest and median distances (> Å) imply that the observed cross-links are inter-molecular in nature and occur between monomers in two different dimers. this conclusion is supported by the surface accessibility of the two tyr residues in both the dna-free and dna-bound forms (supplementary fig. ). ( ) : | https://doi.org/ . /s - - -x www.nature.com/scientificreports www.nature.com/scientificreports/ the binding of crp to dna is camp dependent, with no gel shift detected in the absence of camp. however, uv-induced modification of camp-crp had a marked effect on native camp-crp binding to dna. it is well established that camp-crp binding to dna is associated with structural changes at the dimer interface, with the monomer units rotating relative to each other (fig. b,c) . interestingly, two of the most heavily modified residues, met and pro , are in close proximity both to each other, and to the respective residues on the other monomer, at this interface (fig. b,c) . the distance between the imine nitrogen on pro, and the sulfur on met calculated as . Å. conversion of the met residue to the sulfoxide, or addition of an oh group to the pro ring, is predicted to provide significant adverse steric and electronic interactions between these sites, thereby preventing the rotation and structural changes required for binding of camp-crp to dna. these residues are close to trp , with the distance between c of trp and imine nitrogen of pro ~ . Å in the non-dna bound structure. this proximity rationalizes the high extent of modification at these residues. extensive modification was also detected at these residues when the camp-crp complex was bound to dna before uv exposure. oxidation at these same met and pro residues in the dna-bound complex, and their resulting unfavourable interactions, may promote dissociation of the dimer from the dna and rationalize the decreased binding seen in the gel shift assays (cf. fig. a, lanes versus ) . the modifications detected on both the protein, and also on the bound dna when the camp-crp-dna complex was exposed to uv light, occur in a selective and localized manner. thus, some of the met, tyr and pro residues present in crp were not modified, or only to a limited extent, whereas others are extensively altered (fig. e,f) . a marked selectivity was also detected for dna chain cleavage, with this only detected at g and c residues within the binding dna sequence despite the presence of alternative g/c sites. this dna strand cleavage required both uv light and the protein, pointing to highly-selective protein-mediated events. the requirement for o , and the lack of effect of mannitol, is consistent with a role for o generated via type photochemistry, probably arising from initial light absorption at either camp, or more likely the trp residues. camp absorbs light with λ max ~ nm with a rapid tailing to higher wavelengths and little significant absorption > nm. it should also be noted that crosslinking occurs in the absence of camp. in contrast, trp residues typically have λ max values at ~ nm with a significant tail up to ~ nm. however, λ max for trp residues varies with solvent polarity, ph, metal ion, cations and nearby charged groups; thus some trp residues show absorption bands in the visible region . these data indicate that the trp residues in crp are the likely uv-absorbing chromophores. freely-diffusible o would be expected to react rapidly with all accessible target residues -both on the protein and the dna chains, which is not observed. furthermore, the presence of other materials in the reaction buffers, including dtt, would be expected to remove a large proportion of free-diffusible oxidants. thus, we propose that the selective damage detected at the dimer interface, and also to the bound dna chains, arises from the reaction of some of the , and selective oxidants. reaction of these species with a target results in the formation of met sulfoxide from the persulfoxide, and oxidation of the target. such protein-bound, met-derived persulfoxides formed by o , would therefore rationalize the oxidation at met /pro at the dimer interface, and met and the neighbouring g/c bases in the bound dna. overall, these data indicate that exposure to low levels of uvb and uva light (λ - nm) can result in highly selective and specific damage to camp-crp complexes, which then affects the binding of the complex to its target dna sequence. furthermore uv-induced oxidation of the dna bound complex appears to both promote dissociation of the bound crp, and induce site-specific cleavage of the bound dna. these data may provide a mechanism for damage to gram negative bacteria by uvb light via interference with the critical action of crp in gene transcription in these species. protein purification. the e. coli crp clone (paskacrp jw ) was acquired from the aska (gfp-) collection. the version used contained a his-tag and no gfp. e. coli crp was purified from bl (de ) containing the paskacrp jw plasmid in which the crp coding sequence is cloned under lac promoter control in the his-tag vector pca n . cells were grown in lb medium supplemented with μg ml − chloramphenicol, and crp expression was induced at od . with mm isopropyl-β-d-thiogalactopyranoside. cells from l were then harvested by centrifugation and the pellet frozen overnight at − °c. native crp was purified by resuspending the pellet in lysis buffer ( mm sodium phosphate, mm sodium chloride and mm imidazole supplemented with a protease inhibitor cocktail) followed by sonication at °c. insoluble material was removed by centrifugation ( g, min), and the supernatant was then incubated with nickel-nitriloacetic acid agarose beads for h at °c, with gentle rocking. the agarose beads were then loaded in to a column and washed twice with four column volumes of wash buffer ( mm sodium phosphate, mm sodium chloride and mm imidazole). the crp was then eluted and collected using elution buffer ( mm sodium phosphate, mm nacl and mm imidazole). purified crp protein was then dialyzed twice against l dialysis buffer ( mm sodium phosphate, mm kcl, mm β-mercaptoethanol, ph . ) and stored at − °c. crp purity was assessed using sds-page with coomassie staining, and the protein concentration was determined by the bca method. crp protein lacking the poly-histidine tag was prepared as described previously . amino acid analysis by uplc with fluorescence detection. samples were prepared and subjected to acid hydrolysis using m methanesulfonic acid as previously , . the resulting amino acid mixtures were subjected to pre-column derivatization using o-phthaldialdehyde and separated by uplc with eluted materials detected by fluorescence (λ ex nm, λ em nm). identification and quantification were made versus standards, with the data were normalized to the ala content. detection and quantification of oxidation products by uplc. protein samples were hydrolysed and neutralized as described above, then analyzed as described previously , . samples were injected on to a reversed phase column (phenomenex kinetex evo) and separated by gradient elution. product elution was monitored using fluorescence detector channels parametrized according to the retention times of the products and their fluorescence maxima. data analysis was carried out with shimadzu lab solutions browser software. materials were identified and quantified by comparison with commercial standards. to compensate for any losses during processing, data are expressed relative to parent tyr. mass spectrometric analysis of oxidation products. the detection and quantification of oxidation products was determined on peptides generated by tryptic digestion as described previously [ ] [ ] [ ] . samples ( µg protein) were prepared as described above, then subjected to buffer exchange into mm ammonium bicarbonate buffer (abc buffer) using spin filters ( kda cut-off). reduction and alkylation was carried out using tris( -carboxyethyl)phosphine (tcep, mm) and chloroacetamide ( mm) solution in abc buffer. residual materials were removed by centrifugation, and the samples digested overnight at °c, using trypsin with . % deoxycholic acid. peptides were then collected by centrifugation and the removed by precipitation using formic acid. samples were then analyzed on either a bruker impact ii esi-qtof (bruker daltonics) or an orbitrap fusion mass spectrometer (thermo fisher). for the former separation was carried out using a dionex ultimate chromatography system (thermo fisher) with an aeris peptide xb c column ( cm, . μm particle size, . mm internal diameter). samples were eluted using a solvent gradient system over min, using acetonitrile with . % formic acid and . % dimethyl sulfoxide at a flow rate of μl min − . sampling rate was hz for ms - hz ms (idas, top ), and a scan range of to m/z. for the fusion system, samples were separated on an easy nlc chromatograph using a flow rate of nl min − and gradient of solvents a ( . % trifluoroacetic acid, tfa) and b ( % acetonitrile and . % tfa). data acquisition was carried out with a universal method consisting of a full ms orbitrap scan followed by data-dependent high-energy collisional dissociation ms/ms scans. data analysis was performed using maxquant (version . . . ) , with semi-specific tryptic constraints and a % peptide level false discovery rate. carbamidomethylation of cysteine was used as a fixed modification. data was filtered in order to extract peptide-spectrum matches corresponding to established oxidative modifications using a list of known oxidative modifications , with changes at met, his, tyr and pro as variable modifications , . the % modification at a particular site was estimated using label-free quantification ratios relative to the parent, as determined using maxquant. peaks with changes of > % were evaluated in respect to elution times, isotopic distribution and msms using skyline (version . ) . mass spectrometric analysis of cross-linked peptides. analysis of cross-linked peptides by ms was performed as described previously , . briefly, after tryptic peptides were digested in h o-or h o, they were subjected to solid-phase extraction on activated stagetip c reversed-phase discs, and peptides were then dried down (speedvac concentrator, mins), re-suspended in μl h o and h o water, respectively, and mixed at a : ratio immediately prior to analysis. mass spectrometric analysis was carried out on an orbitrap fusion mass spectrometer (thermo fisher) as described above. data acquisition was performed either with a universal ( ) : | https://doi.org/ . /s - - -x www.nature.com/scientificreports www.nature.com/scientificreports/ method characterized by a full ms orbitrap scan followed by data-dependent high-energy collisional dissociation (hcd) ms/ms scans, or a data-dependent method where a group of signals with mass shifts of , and da are selected for ms/ms. massai software (univ. of southern denmark, april ) was used to identify and verify cross-linked peptides. the following settings were used: fixed (carbamidomethylation of cys) and variable (met, his, and tyr oxidation) modifications; maximum missed tryptic cleavages; parent mass tolerance ppm; ms/ms peak tolerance . m/z. tyr-tyr, lys-tyr, lys-his, his-his, and arg-his were selected as potential cross-links. rendering of protein structures. protein structures o t and hif (crp with and without dna) were visualized and distance distributions obtained, using molmol using scripts generated in gnu octave , and the pdb nmr structure wc . for distance distributions, all mesomers/chemically equivalent atoms of the coordinate set capable of forming a cross-link were considered, resulting in a sample size of - . histograms were generated using a bin size of . Å. statistics. data are presented as means ± sd from three replicate independent experiments, with errors propagated when data are normalized to another parameter. statistical analysis was carried out using the packages available in excel with p < . taken as significant. the data that support the findings of this study are available from the corresponding author upon reasonable request. regulondb v . : tackling challenges to unify classic and high throughput knowledge of gene regulation in e. coli k- studies of the distribution of escherichia coli camp-receptor protein and rna polymerase along the e. coli chromosome a comprehensive library of dna-binding site matrices for proteins applied to the complete escherichia coli k- genome cyclic adenosine monophosphate receptor: loss of camp-dependent dna binding activity after proteolysis in the presence of cyclic adenosine monophosphate structural studies of protein nucleic-acid interaction -the sources of sequence-specific binding lac dna, rna polymerase and cyclic amp receptor protein, cyclic amp, lac repressor and inducer are essential elements for controlled lac transcription structure of catabolite gene activator protein at . a resolution suggests binding to left-handed b-dna catabolite activator protein: dna binding and transcription activation phylogeny of the bacterial superfamily of crp-fnr transcription regulators: exploiting the metabolic spectrum by controlling alternative gene programs transcription activation by catabolite activator protein (cap) the chemical basis of radiation biology excited states and free radicals in biology and medicine singlet oxygen-mediated damage to proteins and its consequences photo-oxidation of proteins protein-bound kynurenine is a photosensitizer of oxidative damage protein oxidation and peroxidation structure of the cap-dna complex at . angstroms resolution: a complete picture of the protein-dna interface identification and characterization of protein cross-links induced by oxidative reactions chemical cross-linking/mass spectrometry targeting acidic residues in proteins and protein complexes ultraviolet radiation-mediated damage to cellular dna the color of cation-pi interactions: subtleties of amine-tryptophan interaction energetics allow for radical-like visible absorbance and fluorescence cyclic-amp and bacterial cyclic-amp receptor proteins revisited: adaptation for different ecological niches nonenzymatic hydroxylations of proline and lysine by reduced oxygen derivatives recent advances in the analysis of oxidized proteins persulfoxide: key intermediate in reactions of singlet oxygen with sulfides complete set of orf clones of escherichia coli aska library (a complete set of e. coli k- orf archive): unique resources for biological research scanning calorimetric study of the thermal unfolding of catabolite activator protein from escherichia coli in the absence and presence of cyclic mononucleotides dissecting direct and indirect readout of camp receptor protein dna binding using an inosine and , -diaminopurine in vitro selection system peroxyl radical-and photo-oxidation of glucose -phosphate dehydrogenase generates cross-links and functional changes via oxidation of tyrosine and tryptophan residues quantification of protein modification by oxidants structural and functional changes in rnase a originating from tyrosine and histidine cross-linking and oxidation induced by singlet oxygen and peroxyl radicals mass-spectrometry-based identification of cross-links in proteins exposed to photo-oxidation and peroxyl radicals using o labeling and optimized tandem mass spectrometry fragmentation unrestricted mass spectrometric data analysis for identification, localization and quantification of oxidative protein modifications maxquant enables high peptide identification rates, individualized p.p.b.-range mass accuracies and proteomewide protein quantification andromeda: a peptide search engine integrated into the maxquant environment redox proteomics: chemical principles, methodological approaches and biological/ biomedical promises skyline: an open source document editor for creating and analyzing targeted proteomics experiments molmol: a program for display and analysis of macromolecular structures structural basis for camp-mediated allosteric control of the catabolite activator protein the authors are grateful to the novo nordisk foundation (grant: nnf oc to mjd) for financial support. we are grateful to neel louv-jansen for expert technical assistance. the authors declare no competing interests. supplementary information is available for this paper at https://doi.org/ . /s - - -x.correspondence and requests for materials should be addressed to n.e.m. or m.j.d.reprints and permissions information is available at www.nature.com/reprints.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons.org/licenses/by/ . /. key: cord- -l nzq rv authors: kim, hwan soo; won, sulmui; lee, eu kyoung; chun, yoon hong; yoon, jong‐seo; kim, hyun hee; kim, jin tack title: pentraxin as a clinical marker in children with lower respiratory tract infection date: - - journal: pediatr pulmonol doi: . /ppul. sha: doc_id: cord_uid: l nzq rv background: pentraxin (ptx‐ ) is an acute‐phase protein that increases in the plasma during inflammation. objective: we aimed to evaluate the usefulness of ptx‐ as a clinical marker in children with lower respiratory tract infection (lrti) and examine the correlation of ptx‐ with other biomarkers such as c‐reactive protein (crp) and procalcitonin (pct). methods: we enrolled consecutive patients admitted to seoul st. mary's hospital with lrti using the who criteria. we recorded data on fever duration and peak temperature before admission, duration of fever after admission, respiratory rate, heart rate, oxygen saturation upon admission, duration of oxygen supplementation, and duration of hospital stay. upon admission, white blood cell (wbc) count, erythrocyte sedimentation rate, crp level were measured. multiplex respiratory virus polymerase chain reaction was performed using nasal swabs. ptx‐ , pct, and various cytokines were measured after the study had been completed. results: we found that there was no significant difference in the level of ptx‐ according to the type of viral infection. ptx‐ levels showed a significant correlation with pct levels, but not with levels of crp. the level of ptx‐ showed a significant correlation with peak temperature and duration of fever before admission as well as interleukin (il)‐ levels. pct levels showed a significant correlation with il‐ and granulocyte‐colony stimulating factor levels, peak temperature, and duration of fever before admission, and duration of hospital stay. crp levels showed a significant correlation with duration of fever before admission, total wbc count, and neutrophil count. pct levels significantly predicted a hospital stay of days or more. ptx‐ , pct, and crp levels showed no correlation with any other clinical features. conclusion: ptx‐ reflected disease severity but failed to predict length of hospital stay. further studies evaluating the use of ptx‐ as a biomarker in mild lrti would be useful. pediatr pulmonol. ; : – . © wiley periodicals, inc. lower respiratory tract infection (lrti) is common, particularly in the first years of life. in many cases, lrtis are caused by viruses and have a mild course, unless they are complicated by bacterial superinfection. , however, because some cases can proceed to a more severe course, early diagnosis and recognition of the disease severity are necessary for optimal care. many inflammatory markers have been developed to serve this purpose such as erythrocyte sedimentation rate (esr), c-reactive protein (crp) levels, and procalcitonin (pct) levels. pentraxin (ptx- ) is a novel biomarker that behaves as an acute-phase protein: as its blood levels, which are low in normal conditions (< ng/ml in humans, . ng/ml [ . - . ] in children), rapidly increase in the plasma during inflammation (e.g., sepsis, endotoxin shock, and other inflammatory conditions). , ptx- is released in response to microbial recognition and can bind specific pathogens such as fungi, bacteria, and viruses. a previous study found that plasma ptx- levels could be used to diagnose the severity of community acquired pneumonia with higher sensitivity compared to crp, and also correlated with the length of hospital stay. another study found that a high concentration of ptx- helps to differentiate parapneumonic effusion from non-parapneumonic effusion. however, no study has investigated the value of ptx- in viral infection, which is the most common cause of lrti in children. the aim of this study was to evaluate the usefulness of ptx- as a clinical marker in lrti and examine the correlation of ptx- with other biomarkers such as crp and pct. we enrolled consecutive patients with lrti admitted to the ward from the emergency department or outpatient department using the who criteria, that is, patients with fever, cough, a fast respiratory rate for their age, chest in-drawing, and rhonchi or crepitations on auscultation. children were excluded if they had received antibiotics in the days preceding admission or if they were suffering from an underlying chronic disease (e.g., anatomical abnormalities of the respiratory tract, immunological deficits, progressing neurological conditions, psychomotor retardation, congenital heart disease, or hemoglobinopathy), severe malnutrition, or other concurrent infections. we recorded data on fever duration and peak temperature before admission, duration of fever after admission, respiratory rate, heart rate, oxygen saturation upon admission, duration of oxygen supplementation, and duration of hospital stay. upon admission, total white blood cell (wbc) count, esr, and crp levels were measured from blood samples before any medical treatment and multiplex respiratory virus polymerase chain reaction (pcr) was performed using nasal swabs. blood samples for measurement of ptx- , pct, cytokines, and chemokines were placed in tubes containing edta, immediately centrifuged at , g and stored at À c. assays were performed after the study was completed. after admission, patients under months of age received mg/kg/day of intravenous amoxicillin sodium and potassium clavulanate (moxicle injection; daewoong pharm., seoul, korea), patients between months and years of age received mg/kg/day of intravenous amoxicillin sodium and potassium clavulanate, and patients over years of age received , mg of intravenous amoxicillin sodium and potassium clavulanate. patients with positive results upon mycoplasma pneumoniae pcr received mg/kg/day of oral clarithromycin (klaricid dry syrup; abbott korea limited., seoul, korea). children with a medical diagnosis of lrti admitted to seoul st. mary's hospital from may , to november , were enrolled. enrollment was conducted by pediatric pulmonologists. the institutional review board of the seoul st. mary's hospital approved the study (protocol no: kc tisi ). written informed consent was obtained from parents or guardians; assent was obtained from invited children. the resplex ii assay (qiagen, hilden, germany) simultaneously targets viruses: respiratory syncytial virus (rsv), human rhinovirus (hrhv), influenza virus (iv), human metapneumovirus (hmpv), human coronaviruses (hcov), parainfluenza virus (piv), adenovirus (adv), and human bocavirus (hbov). specimenextracted rnas were tested in a single reaction using the resplex ii assay, following the protocol of the manufacturer, as described previously. quantification of five cytokines: (interleukin [il]- b, il- , il- , interferon (ifn)-g, and tumor necrosis factor (tnf)-a), and four chemokines: (il- , granulocyte stimulating factor (g-csf), mig (cxcl ), and interferon gamma inducible protein- ) in sera was performed with the bio-plex pro human cytokine assay (bio-rad laboratories, inc., hercules, ca). assays were carried out according to the manufacturer's instructions. m. pneumoniae specimens were obtained from throat swabs and dna was then extracted from subcultures or clinical specimens by centrifuging the samples at , g for min at c in a refrigerated minicentrifuge and digesting the pellets with ml proteinase k ( mg/ml) lysis buffer for hr at c. proteinase k was inactivated by incubation at c for min. we used the binaxnow streptococcus pneumoniae antigen card (binax, portland, me) to test for urinary pneumococcal antigen. this test detects the c-polysaccharide present on the cell wall of all pneumococcal strains. urine was concentrated -fold by selective ultrafiltration (pm , , minicon urifil- concentrator; millipore, bedford, ma). the results were considered qualitatively as either positive or negative. we used a human ptx- elisa kit (boster biological technology co., ltd., fremont, ca) to measure plasma concentrations of ptx- in blood samples. for each plasma sample, ml was directly transferred to the micro-test strip wells of the elisa plate and subsequently incubated for hr at room temperature. after three washing steps, a detection antibody was added, and the reaction system was incubated for hr at room temperature. antibody binding was detected with streptavidinconjugated horseradish peroxidase and developed with a substrate solution. next, the reaction was stopped, and the optical density was determined with a microplate reader set to nm. wavelength correction was set to nm. sample results were calculated from a standard curve generated by dilutions of a known amount of recombinant ptx- protein. each standard or sample was assayed in duplicate. pct measurements were performed using a timeresolved amplified cryptate emission technology assay (kryptor pct; brahms ag, hennigsdorf, germany) with a functional assay sensitivity of . g/l, which is about fourfold above normal mean levels. the coefficients of variation at concentrations of . , . , . , and ng/ml were , , , and %, respectively. the assay time was less than min and results were routinely available within hr. the pediatric early warning score (pews) is an easily scored tool that is based on five domains: behavior, cardiovascular status, respiratory status, nebulizer use, and persistent postsurgical vomiting. the tool is further supported by an algorithmic response that is based on the score. a critical pews is defined as a total score of or a score of in any of the pews domains which reflects a critical value that requires consultative action. each patient was scored according to the pews upon admission. statistical analyses were performed using sas software, version . (sas institute, inc., cary, nc). all continuous variables are expressed as mean ae se, and numbers (n) with percentages are expressed for categorical variables. to compare ptx- levels in different types of viral infection, the mann-whitney u-test was performed for continuous variables that did not follow a parametric distribution, and the wilcoxon signed-ranks test was used to compare categorical variables. a linear regression analysis was applied for correlations between ptx- and all of the clinical and laboratory variables of lrti patients. receiver operating characteristic (roc) curves were generated to predict a hospital stay of days or days or more according to crp, pct, and ptx- levels. statistical significance was defined at p < . in a two-tailed test. in total, patients were included in the study. the mean age of the study population was . ae . years and there were males. with regards to the clinical features of the patients, the mean duration of fever before admission was . ae . days, the mean peak temperature before admission was . ae . c, the mean hospital stay was . ae . days, and the mean pews score was . ae . . with regards to the laboratory data, the mean esr was . ae . mm/hr, the mean wbc count was , . ae , . Â cells, and mean number of neutrophils was , . ae , . Â cells. the mean crp level was . ae . mg/dl, the mean pct level was . ae . ng/ml, and the mean ptx- level was . ae . ng/ml (table ) . within the study population, causative agents were found in patients. in those with positive pcr results, rsv was the most frequently isolated agent ( cases). there were two cases of iv, eight cases of adv, eight cases of hmpv, ten cases of piv, ten cases of hrhv, two cases of hcov, nine cases of hbov, four cases of m. pneumoniae infection, and three cases of s. pneumonia infection ( table ). there was no significant difference in the level of ptx- when cases with any type of causative agents were compared to those with no causative agent (fig. ) . in the infected group, there were cases with superinfection and cases without superinfection. there was no significant difference in the level of ptx- according to superinfection (data not shown). ptx- levels showed a significant correlation with pct levels, but not with the levels of crp (table ) . ptx- levels showed a significant correlation with the peak temperature and duration of fever before admission as well as il- levels. pct levels showed a significant correlation with the peak temperature and duration of fever before admission as well as hospital stay. pct also showed a significant correlation with il- and g-csf levels. crp levels showed a significant correlation with the duration of fever before admission, esr, total wbc count, and neutrophils count (table ). however ptx- , pct, and crp levels showed no significant correlation with the duration of fever after admission, respiratory rate, heart rate, oxygen saturation, or duration of oxygen supplementation. ptx- , pct, and crp also showed no significant correlation with tnf-a, il- b, il- , ifn-g, or il- ( table ) . we assessed the ability of inflammatory markers, ptx- , pct, and crp in its ability to predict a hospital stay of days or days or more. ptx- , pct, and crp did not significantly predict a hospital stay of days or more. in addition, ptx- and crp did not significantly predict a hospital stay of days or more. however, pct levels significantly predicted a hospital stay of days or more ( table ). in this study, we aimed to evaluate the usefulness of ptx- as an inflammatory marker in lrti and examine the correlation of ptx- with other biomarkers such as crp and pct. we found that there was no significant difference in the level of ptx- between cases with any type of viral infection and those with no causative agent. ptx- levels showed a significant correlation with the peak temperature and duration of fever before admission as well as il- levels. pct levels showed a significant correlation with the peak temperature and duration of fever before admission, as well as duration of hospital stay. pct also showed a significant correlation with il- and g-csf levels. crp levels showed a significant correlation with the duration of fever before admission, esr, total wbc count, and neutrophil count. pct levels significantly predicted a hospital stay of days or more. ptx- levels are known to be increased in various disease such as kidney disease, cardiovascular disease, and acute respiratory distress syndrome. [ ] [ ] [ ] we found that the level of ptx- reflects disease severity in children with lrti by showing a significant correlation with the peak temperature and duration of fever before admission. this result was similar to that reported in a previous study which found that plasma ptx- levels could be used to diagnose the severity of community acquired pneumonia in adults. we also found that the pct level reflects disease severity and prognosis in children with lrti. our findings support previous studies which reported similar findings. , there was a lack of correlation with other clinical signs of disease severity. this might be because the age of the study population and the disease category were different from previous studies which involved rather serious diseases such as acute respiratory distress syndrome, cardiovascular disease, and sepsis in adults. , , there was no difference in ptx- levels between those who were found to be infected with a causative agent and those who were not. one possible explanation for this finding is that it might have been due to the limitations of a nasopharyngeal swab: we presume that even patients with no detectable viruses might actually have been infected. our study also found that ptx- levels did not vary depending on the types of virus causing infection. this is because ptx- acts as a part of the innate immune system as a pattern recognition molecule. ptx- is also involved in resistance against some viral infections. ptx- binds both human and murine cytomegalovirus (hcmv and mcmv, respectively) and reduces the viral infection of dendritic cells in vitro. accordingly, ptx -/mice present a higher susceptibility to infections than wild-type mice, and the viral titer is reduced upon treatment with recombinant ptx- . moreover, ptx- protects mcmv-infected mice from aspergillus fumigatus superinfection and enhances the production of il- and ifn-g by dendritic cells and t cells, respectively. finally, human and murine ptx- binds influenza virus (h n ) through interaction between viral hemagglutinin glycoprotein and the sialic acid residue present on ptx- . ptx- inhibits virus-induced hemagglutination and viral neuraminidase activity and neutralizes virus infectivity. treatment with recombinant ptx- reduces mortality and viral load. further study will be needed to discover the differential effect of ptx- on different types of virus in vivo. our study found that ptx- level correlated with il- levels. this result is similar to those of previous studies which found that ptx- correlated with il- in patients with acute pancreatitis and obstructive sleep apnea. , however, ptx- showed no significant correlation with tnf-a, il- b, il- , ifn-g, or il- in the current study. this was different from previous studies which found that ptx- was produced in response to proinflammatory stimuli including il- b, tnf-a, microbial moieties, and toll-like receptor (tlr) engagement. there are some limitations to our study. the first is that the study population was limited to mild cases of lrti: there were no cases requiring intensive care, and the mean pews score was . ae . , having only one case with a score of . secondly, the distribution of causative agents was concentrated to selected viruses. a recent study examined the ptx- levels of induced sputum in asthmatic patients and another study investigated the usefulness of ptx- level in bronchoalveolar lavage fluid to discriminate microbiologically confirmed pneumonia in mechanically ventilated patients. , further study involving local levels of ptx- in lrti would be of interest. in conclusion, ptx- reflected the disease severity of lrti in children but failed to act as a prognostic marker. further study in order to evaluate the use of ptx- as a biomarker in mild lrti would be useful. management of severe community acquired pneumonia of children in developing and developed countries viruses in community-acquired pneumonia in children aged less than years old. 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from viral pathogens date: - - journal: int j infect dis doi: . /j.ijid. . . sha: doc_id: cord_uid: yvek vjz objectives: we investigated causes of fever in the primary levels of care in southeast asia, and evaluated whether c-reactive protein (crp) could distinguish bacterial from viral pathogens. methods: blood and nasopharyngeal swab specimens were taken from children and adults with fever (> . ˚c) or history of fever (< days) in thailand and myanmar. results: of patients with at least one blood or nasopharyngeal swab specimen collected, ( . %) had a target organism detected. influenza virus type a was detected in / cases ( . %), followed by dengue virus ( cases, . %), respiratory syncytial virus ( cases, . %) and leptospira spp. ( cases, . %). clinical outcome was similar between patients with a bacterial or a viral organism, regardless of antibiotic prescription. crp was higher among patients with a bacterial organism compared to those with a viral organism (median mg/l, interquartile range [ - ] versus mg/l [≤ - ], p-value . ), with an area under the curve of . , % confidence interval ( . - . ). conclusions: serious bacterial infections requiring antibiotics are exceptions rather than the rule in the first lines of care. crp-testing could assist in ruling out such cases in settings where diagnostic uncertainty is high and routine antibiotic prescription is common. the original crp randomised-controlled trial (rct) was registered with clinicaltrials.gov, number nct . fever is a common reason for seeking healthcare in southeast asia and as malaria incidence declines, bacteria and viruses now represent the main contributors to acute febrile illness [ ] [ ] [ ] [ ] [ ] . identifying these pathogens is challenging, even in well-resourced laboratories with specialised staff, and most aetiological data for febrile illness originate in tertiary hospitals [ ] . hospitalised patients, however, are by definition more severely ill, often with important comorbidities, implying that findings may not be applicable to febrile patients attending primary levels of care. primary care in low-middle income countries (lmics) is typically characterised by a shortage in human resources, diagnostics and evidence-based guidelines [ ] . studies investigating causes of fever in this environment are few and frequently of poor quality: enrolment is often limited to a single clinical presentation and specific age category, and microbiological investigations rarely use goldstandard methods [ ] [ ] [ ] . additionally, most primary care patients attend early after symptom onset with non-severe presentations, lowering the chances of detecting a pathogen [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . empiric treatment guidelines are therefore based on limited epidemiological evidence and are often implemented by insufficient and poorly trained staff, contributing to irrational antibiotic prescription practices [ ] [ ] [ ] . high prescription levels are partly driven by frequent clinical overlap between bacterial and viral infections, challenging the identification of patients who might benefit from antibiotics [ , , ] . given these limitations in clinical judgment and laboratory structures, point-of-care testing (poct) to guide fever management could be beneficial in primary care settings [ ] . pathogen-specific tests represent one such option but several barriers undermine their potential use: these only exist for a small number of pathogens, with inconsistent performance, and most are antibody detection-based that might preclude the distinction between active infection and past-exposure [ , ] . a few antigen detection-based pocts exist but their integration in low-level care is unrealistic: a salmonella typhi rapid test requires laboratory infrastructure with poor detection in blood even at high concentrations and results are not available before - hours [ , ] ; test sensitivities for influenza virus a, respiratory syncytial virus (rsv) and group a streptococcus antigen-based pocts are inconsistent j o u r n a l p r e -p r o o f [ ] [ ] [ ] [ ] ; and accurate dengue antigen-based rdts have not been found to be cost-effective in resource-poor settings [ , ] . non-specific host biomarkers measure the host-response to stimuli, and have been evaluated in the context of fever to discriminate between bacterial and viral pathogens [ ] . c-reactive protein (crp) is one of the most studied host-response biomarkers of bacterial infection, consistently showing high sensitivity and moderate specificity, and crp pocts have been shown to be cost-effective in resource-poor environments [ , ] . however, % studies evaluating crp performance originate from high income countries [ ] . in southeast asia, these evaluations are mainly hospital-based [ ] [ ] [ ] other than a single community-based study [ ] . good diagnostic performance of crp in identifying bacterial infections was observed but generalisability was limited due to demographic, clinical and diagnostic heterogeneity of these studies. in this study, we aim to identify key organisms among acutely febrile children and adults attending primary health care in southeast asia, and to evaluate the performance of crp for discriminating between bacteria and viruses. chiang rai province is the northernmost province in thailand bordering myanmar and lao people's democratic republic. the majority of the population are thai, with approximately % ethnic minorities and hill-tribes. the six participating primary care sites were located within a -kilometre radius of chiang rai city centre, covering rural and peri-urban as well as mountainous and plateau areas. hlaing tha yar, lower myanmar, is a peri-urban township on the west side of yangon. the township has the highest rates of diseases related to hygiene and environmental conditions (e.g. diarrhoea, dysentery, and tuberculosis) in yangon [ ] . four sites were included: three primary care clinics and one outpatient department from a public governmental hospital. both chiang rai and hlaing tha yar are defined by a tropical climate. specimens were collected from febrile patients recruited into a previously described multi-centre randomised-controlled trial evaluating the impact of c-reactive protein (crp) testing on antibiotic prescription in primary care [ ] . febrile children and adults (defined as ≥ years of age) were recruited between june and august . inclusion criteria were age ≥ year with a documented fever (defined as a tympanic temperature > . ˚c) or a chief complaint of acute fever (< days), regardless of previous antibiotic intake and co-morbidities other than malignancies. exclusion criteria were symptoms requiring hospital referral defined as either impaired consciousness; inability to take oral medication or convulsions; a positive malaria test; the main complaint being trauma and/or injury; suspicion of either tuberculosis, urinary tract infection, local skin infection or dental abscess; any symptom present for more than days; any bleeding; and inability to comply with the follow-up visit at day . on the day of enrolment, all patients had demographic information collected and underwent a routine clinical examination including vital signs (blood pressure, pulse, respiratory rate, temperature). patients were followed-up after their enrolment both at day and day . of the , febrile children and adults recruited, were randomly allocated to the control group with blood specimens collected for off-site crp testing (as compared with the intervention groups that had crp tests performed on-site). details are illustrated in figure . antibiotics were prescribed to this group according to routine clinical practice, clinicians were not informed of the crp results or any aetiological findings. in case of co-detection in blood and np swabs, target organisms detected in blood were assumed to be the primary cause of illness. bacterial and viral aetiological groups included all cases where any bacteria or viruses were detected in blood, respectively, and only target viruses and bacteria detected in np swabs. we described organism distribution among children and adults (defined as ≥ years of age) separately. descriptive analysis for continuous variables with normal distribution used means and standard deviations (sd) and medians with inter-quartile ranges (iqr) for non-normally distributed continuous variables. comparison between groups used t-tests for normally distributed variables, the mann-whitney test for non-normally distributed variables, and chi-squared test for categorical variables. crp values were compared across aetiological groups and clinical syndrome using the mann-whitney u test for two-group comparisons and the kruskal-wallis test for multi-group comparisons. non-parametric receiver operating characteristic (roc) curves were plotted and the wald test was used to compare areas under the curve. covariates included the following factors: patient age and prior use of antibiotics. diagnostic accuracy was assessed by calculating the areas under the roc j o u r n a l p r e -p r o o f curves (auc). an auc of > . was considered excellent; . - . , very good; . - . , good; . - . , average; < . , poor [ , ] . sensitivity, specificity, and percentage of correctly classified cases were also assessed for the two crp cut-off points used in the original trial: mg/l and mg/l and these were compared with the accuracy of routine prescribing practice [ ] . data analyses were performed with stata version (college station, texas, usa). the protocol, informed consent form and case record forms were reviewed and approved by the of the patients prospectively enrolled and randomised into the trial control group, ( . %) had at least one blood or np swab specimen collected, including ( . %) children and adults ( . %). out of these patients, had only a np swab and no blood collected, while had only a blood specimen collected without a np swab. among these patients, had a blood specimen obtained on a dried blood spot (dbs). as shown in table , children presented significantly earlier after symptom onset than adults, with fewer comorbidities and less self-reported medication (p < . ). antibiotic intake declaration was similar in children and adults (p = . ). page of j o u r n a l p r e -p r o o f clinically, respiratory syndrome was the most prevalent presentation both in children and adults. within patients with a respiratory syndrome, the most frequent symptoms were localised in the upper respiratory tract including common cold, diagnosed in . % ( / ) of children and . % ( / ) of adults (p = . ). gastrointestinal syndrome was the second most prevalent presentation, and there were no differences between children and adults. blood specimens tested for bacterial screening, using taqman array card (n= ) and bacterial singleplex polymerase chain reaction (n= ) ** blood specimens tested for leptospira screening, using the taqman array card (n= ), the bacterial singleplex polymerase chain reaction (n= ) and the microagglutination test (n= ) *** blood specimens tested for orientia tsutsugamushi and rickettsia spp. screening, using taqman array card (n= ), the bacterial singleplex polymerase chain reaction (n= ), and the indirect immmunofluoresence assay (n= ) **** blood specimens tested using the taqman array card only (n= ) ***** blood specimens tested for dengue, chikungunya and zika virus screening, using taqman array card (n= ), the viral singleplex polymerase chain reaction on fresh blood (n= ) and dried blood spot (n= ) no evidence for a difference in antibiotic prescription was observed between the bacterial and viral groups at day , and clinical outcomes were also not significantly different between the two groups (table ). outcome characteristics by aetiological group in chiang rai, northern thailand and hlaing tha yar, lower myanmar, - . the prescription of antibiotics at the facility was considered between the enrolment at day until day of the follow-up severity was ranked from - with severity= as the less severe presentation crp: c-reactive protein elevated crp defined as ≥ mg/l in children and ≥ mg/l in adults sae: serious adverse event, defined as admission to hospital or death within days of enrolment broad-spectrum antibiotics include ceftriaxone, cefixime, ciprofloxacin, levofloxacin, azithromycin, and amoxicillin with clavulanic acid. among patients with a bacterial organism, two-thirds did not receive any antibiotic ( occurrence of sae, n (%) ( ) ( ) . unscheduled visits, n (%) ( ) ( . ) . antibiotic. no evidence for a difference in clinical outcomes was observed after days of follow-up, regardless of whether an antibiotic was prescribed. of we investigated the spectrum of organisms among febrile children and adults in the community and evaluated the performance of crp in distinguishing bacteria from viruses including its potential impact on antibiotic prescription compared with current practice. patients were recruited prospectively across ten sites in thailand and myanmar including urban, semi-urban and rural areas spanning over a full calendar year. in our study, leptospira spp., influenza virus and dengue virus were the leading organisms identified, which is consistent with previous reports in the region [ , ] . the broad inclusion criteria, allowing for enrolment of all patients over year old regardless of previous antibiotic intake, comorbidities, or clinical presentation, make our findings more generalisable than previous studies. investigating non-malarial acute febrile illness remains challenging in resource-poor areas [ ] , and despite screening for multiple organisms on blood and respiratory specimens, we were only able to identify a probable cause of fever in ( . %) of patients. this low detection may be explained by the inclusion of only non-severe outpatients [ , , ] , while other studies in southeast asia recruiting more severe and hospitalised patients identified an organism in around % of cases [ ] [ ] [ ] ] . only . % ( / ) of organisms detected were bacteria, which may be explained by the lower risk of bacterial infections in non-severely ill patients, and where present, characterised by lower bacterial loads [ ] . most bacteria were identified using a singleplex pcr and not the tac assay, while viruses were equally detected by these two molecular methods. this lower sensitivity in the tac assay for the detection of bacteria has been described in previous studies using multi-pathogen molecular detection platforms [ , ] . the trade-off between advantages for screening multiple organisms at the same time with a simplified molecular platform should be weighed against potentially lower sensitivity, especially for bacteria such as o. tsutsugamushi or leptospira spp., which are considered important drivers of acute febrile illness in southeast asia [ , ] . the tac assay to identify infections among neonates in south asia, but detected the presence of certain organisms among both controls and cases [ ] . a multi-country study into causes of severe pneumonia also excluded molecular assay results positive for k. pneumoniae because of poor assay specificity [ ] . furthermore, most of our patients presented with low crp regardless of whether a bacterial or viral organism was detected, and recovered regardless of whether an antibiotic was prescribed. it is likely that invasive bacterial infections requiring an antibiotic are exceptions while most primary care patients present with a self-limiting infection [ ] . other primary care-based studies have recently supported restriction of antibiotic prescription to a small minority of patients: in tanzania, a clinical trial using a mg/l threshold lowered antibiotic reduction to . % without affecting outcomes, while a u.s. study concluded that % of outpatients attending a general practice for a respiratory presentation should not even require a medical consultation, let alone an antibiotic prescription [ , ] . strategies whereby testing for crp as a predictor of clinical outcome rather than determining aetiology have been evaluated in primary care: a cluster-randomised controlled trial in belgium showed crp to rule-out serious infection using a mg/l threshold, while a systematic review found crp-testing to be useful in identifying serious infections among febrile children [ , ] . in our study, crp performance in distinguishing bacteria from viruses was average (auc . ) and lower than another study from the region which found (auc . among , patients with a microbiologically-confirmed diagnosis from thailand, cambodia and lao pdr [ ] our study has several limitations, mostly relating to the limited scope and accuracy of the reference diagnostic tests, and the impact of even slightly less than perfect "gold-standard" reference tests on the evaluation of new diagnostic and biomarker tests can be profound [ , ] . as mentioned above, the sensitivity and specificity of the multiplex tac assay was not optimal for bacteria detection, and the absence of convalescence specimens impeded our ability to diagnose patients based on serology, particularly with respect to bacterial zoonoses. even genuine detection of bacterial and viral dna in normally sterile sites cannot be used to conclusively determine causality, as this has been reported among healthy individuals, and in patients even weeks after recovery from infections, challenging the interpretation of molecular assays [ , ] . blood culture was not available and this further limited our aetiological investigation. we did not recruit a concomitant control group, which precludes robust attribution of causality in the organisms we detected, particularly in np swabs. in a paediatric study in asia and africa, the inclusion of controls matched with pneumonia cases weakened the evidence of causality for almost all organisms detected [ ] , and only rsv, hmpv, influenza virus a and b, parainfluenza virus type and b. pertussis were considered pathogenic, consistent with other lmicbased studies [ , ] . these organisms, however, are sometimes present in healthy individuals, with a prevalence of influenza virus among healthy children between - %, rsv at - % and hmpv between - % [ ] . on the other hand, we did not regard other organisms detected in np swabs such as rhinovirus, parainfluenza virus or s. pneumoniae as pathogenic, because these are commonly detected among healthy individuals [ , , ] . all these limitations in reference diagnostic tests might explain the average performance of crp in our analysis. we presented the key organisms detected among febrile children and adults attending primary healthcare in southeast asia. the performance of crp in distinguishing between bacterial and viral organisms was limited, although the current findings suggest that crp-guided treatment would increase the appropriate use of antibiotics with respect to aetiology. this is supported by the overall reduction in prescribing compared with current practice demonstrated in the original trial. our findings also support conclusions from previous studies that even in the presence of bacterial organisms, very few ambulatory patients are likely to benefit from the extensive and poorly targeted antibiotic prescribing practices that currently prevail in most southeast asian primary care settings. the funders had no role in study design, data collection, data interpretation or writing the manuscript. the corresponding author had full access to all the data and took the final decision to submit for publication.  point-of-care diagnostic tools could guide health workers' antibiotic prescription  c-reactive protein was significantly increased in case of bacterial infections  most primary care patients recovered regardless of antibiotic prescription  antibiotic prescription should be an exception in the primary levels of care influenza virus type b with cases ( . 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trial evaluating a novel electronic clinical decision algorithm (epoct) necessity of office visits for acute respiratory infections in primary care diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review point-of-care c-reactive protein testing to reduce inappropriate use of antibiotics for non-severe acute respiratory infections in vietnamese primary health care: a randomised controlled trial the effect of uncertainty in patient classification on diagnostic performance estimations imperfect gold standards for biomarker evaluation van der pol b. duration of polymerase chain reaction-detectable dna after treatment of chlamydia trachomatis, neisseria gonorrhoeae, and trichomonas vaginalis infections in women. sexually transmitted diseases detection of the latent form of epstein-barr virus dna in the peripheral blood of healthy individuals microorganisms associated with pneumonia in children< years of age in developing and emerging countries: the gabriel pneumonia multicenter, prospective, case-control study the role of influenza, rsv and other common respiratory viruses in severe acute respiratory infections and influenza-like illness in a population with a high hiv sero-prevalence viral and bacterial interactions in the upper respiratory tract frequent detection of respiratory viruses without symptoms: toward defining clinically relevant cutoff values asymptomatic shedding of respiratory virus among an ambulatory population across seasons. msphere we thank all primary care patients and health workers from chiang rai primary care centres and hlaing tha yar public hospital and mam clinics for taking part in the study. we are very grateful to the study staff and to the clinical trial support group at mahidol-oxford tropical medicineresearch unit for ensuring the successful completion of the study. we thank heiman wertheim, arjen dondorp, direk limmathurotsakul, christopher parry, and paul newton for guidance on the study design; clare ling, toni whistler, ampai tanganuchitcharncha, areerat thaiprakhong, nattapon pinthong, prapaporn srilohasin and kyaw soe for laboratory support, as well as duangjai suwancharoen from the national institute for animal health (niah) for carrying out the leptospira mat. finally, we thank elizabeth ashley, jeroen bok, joshua cohen, ni ni tun, and khin yupar soe for their assistance in study site coordination. key: cord- -h cufyp authors: sahu, bikash r; kishor kampa, raj; padhi, archana; panda, aditya k. title: c-reactive protein: a promising biomarker for poor prognosis in covid- infection date: - - journal: clin chim acta doi: . /j.cca. . . sha: doc_id: cord_uid: h cufyp background: the novel coronavirus disease (covid- ) break out from wuhan, china, spread over countries and caused approximately . million death worldwide. several biomolecules have been explored for possible biomarkers for prognosis outcome. although increased c reactive protein (crp) has been associated with death due to covid- infections, results from different populations remain inconsistent. for a conclusive result, the present meta-analysis was performed. methods: we conducted a literature survey in pubmed and scopus database for the association of crp concentration with covid- disease outcomes. a total of eligible studies were enrolled in the present analysis comprising of survivors and non-survivors cases. concentrations of crp were compared and analyzed by a meta-analysis. results: egger’s regression analysis (intercept= . , p= . , %ci=- . to . ) and funnel plot revealed an absence of publication bias in the included studies. due to the presence of significant heterogeneity across the studies (q= . , p(heterogeneity)= . , i( )= . ) random model was used for the analysis of the present study. the results of the meta-analysis demonstrated a significant role of crp in covid- infection outcome (standard difference in means= . , p= . ). conclusions: concentrations of crp remained increased in patients who died in covid- infection and could be a promising biomarker for accessing disease lethality. the first case of novel coronavirus disease was detected in wuhan, china, in late december, that broke out worldwide, affecting over countries and caused approximately three lakhs deaths till date (https://www.worldometers.info/coronavirus/ accessed on / / ). the mortality rate remained . % worldwide (https://www.worldometers.info/coronavirus/ accessed on / / ). world health organisation had declared covid- as pandemic disease (http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid- /news/news/ / /who-announces-covid- -outbreak-a-pandemic). as of today ( / / ), the united states of america contributed the highest number of infected cases and death due to covid- in comparison to other populations (https://www.worldometers.info/coronavirus/ accessed on / / ). covid- infection displays a wide range of clinical manifestations. a recent study [ ] highlighted cough, sputum production, diarrhoea, nausea/vomiting, and shortness of breath as more frequent clinical phenotypes in critical/non-survived covid- patients, and in contrast, fever and headache were less prevalent. furthermore, the pathogenesis of the diseases is regulated by several host factors. various biomolecules such as aspartate aminotransferase, creatinine, high-sensitive cardiac troponin, procalcitonin, lactate dehydrogenase, and d-dimer has been increased in covid- critical patients in comparison to those with non-severe infected cases [ ] . the upregulation of c reactive protein (crp) has been reported during severe acute respiratory syndrome (sars) outbreak in and associated with respiratory dysfunctions and death of the patients [ ] . based on these observations, various studies were carried out in covid- patients hypothesizing crp as one of the possible biomolecules linked with the death of the infected patients. however, the observations of the reports remained contradictory. two authors, rkp and brp searched various databases (medline, sciencedirect, and scopus) to trace eligible studies for the present meta-analysis. the keywords used for the search were "covid- , coronavirus , -ncov, sars-cov- , crp, c-reactive protein, survivors, non-survivors, death, (till th may ). the title and abstracts of the articles obtained were screened, and apposite papers were downloaded. furthermore, various preprint servers (biorxiv, medrxiv and ssrn) were also screened with the above-mentioned keywords. various inclusion and exclusion criteria were considered in the present investigation. inclusion of a report in the current meta-analysis must have a) added analysis for death and survivors, b) plasma/serum crp concentrations, c) data must be presented in mean± standard deviation (s.d) or median (interquartile range). exclusion of the articles was based on the following conditions: a) duplicate articles, b) research articles including only survivors or death cases, c) lack of crp concentrations data d) review article, summaries, or case report. two authors brs and ap extracted data such as authors' details, years of publication, population, number of covid- infected subjects, death and survivors, crp concentrations in mean± s.d. or median (interquartile range), significance value. details are shown in table- the meta-analysis was performed by comprehensive meta-analysis v . software (biostat). begg's funnel plot and eggers linear regression analysis were employed to test publication bias. crp data was available in the median (interquartile range) format in most of the included reports, and those were converted into mean ± standard deviation according to an earlier report [ ] . association of crp concentrations with covid- disease prognosis was analyzed, and the combined standard difference in means and p-values were calculated. the q test and i statistics evaluated heterogeneity among included reports. based on the results of heterogeneity statistics, random (heterogeneous), or fixed model (nonheterogenous) were deployed for analysis. furthermore, a sensitivity analysis was performed to test the robustness of the meta-analysis. a total of and articles were obtained after searching pubmed and scopus, respectively. after screening the titles, abstracts, and full text based on inclusion and exclusion criterias, articles including data of different cohorts were enrolled for the present analysis. further, we found two articles related to our searched norms from preprint servers. baseline data from all eligible publications were extracted and presented in table- . crp data in median (interquartile range) were converted into the required format of cma v . software (mean ± s.d and sample number) [ ] . infected patients include acute respiratory distress syndrome, acute cardiac injury, acute kidney injury, shock, disseminated intravascular coagulation, and a significant alterations in crp level have been observed in these subjects [ ] . a positive correlation between crp concentrations with the lung lesion in covid- infected patients has been demonstrated [ ] . furthermore, the induction of acute kidney damage [ ] and the extent of the cardiac injury [ ] has been directly linked with the crp concentrations. possibly for clearance of viral infections, immune system responded more vigorously by producing various immune molecules and production of crp [ ] beyond threshold limit may lead to dysfunction of risk factors of critical & mortal covid- cases: a systematic literature review and meta-analysis c-reactive protein levels in the early stage of covid- estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range clinical characteristics of fatal and recovered cases of coronavirus disease (covid- ) in wuhan, china: a retrospective study c-reactive protein promotes acute kidney injury by impairing g /s-dependent tubular epithelium cell regeneration infarct size, microvascular obstruction, and left-ventricular remodelling following acute myocardial infarction c-reactive protein in acute viral infections human crp gene polymorphism influences crp levels: implications for the prediction and pathogenesis of coronary heart disease clinical characteristics of deceased patients with coronavirus disease : retrospective study clinical characteristics of fatal and recovered cases of coronavirus disease (covid- ) in wuhan, china: a retrospective study covid- in persons with haematological cancers clinical characteristics of deceased patients infected with sars-cov- in prognostic value of c-reactive protein in patients with covid- correction to: clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan clinical features of sequential hospitalised patients with novel coronavirus disease (covid- ), the first uk cohort clinicolaboratory study of fatal cases of covid- in wuhan clinical and laboratory predictors of in-hospital mortality in patients with covid- : a cohort study in wuhan, china coronavirus disease in elderly patients: characteristics and prognostic factors based on -week follow-up clinical course and outcomes of intensive care patients with covid- risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease clinical characteristics and outcomes of patients with severe covid- with diabetes characteristics, treatment, outcomes and cause of death of invasively ventilated patients with covid- of the clinical data from critically ill patients with coronavirus disease : a single-centered, retrospective, observational study predictive factors for disease progression in hospitalized patients with coronavirus disease in wuhan crp level is elevated in covid- patients. . the present meta-analysis revealed significant association of crp with poor prognosis of covid- infection key: cord- -ipmcqz n authors: cheng, biao; hu, jiahao; zuo, xiuran; chen, jian; li, xiaochao; chen, yuchen; yang, guoliang; shi, xiaowu; deng, aiping title: predictors of progression from moderate to severe covid- : a retrospective cohort date: - - journal: clin microbiol infect doi: . /j.cmi. . . sha: doc_id: cord_uid: ipmcqz n objective: most coronavirus disease (covid- ) cases were identified as moderate, which is defined as having a fever or dry cough and lung imaging with ground-glass opacities. the risk factors and predictors of prognosis in such cohorts remain uncertain. methods: all adult patients with covid- of moderate severity diagnosed using qrt-pcr and hospitalized at the central hospital of wuhan, china, from jan to mar , were enrolled in this retrospective study. the main outcomes were progression from moderate to severe or critical condition or death. results: among the enrolled patients with moderate covid- , / ( . %) had poor prognosis. multivariate logistic regression analysis identified higher nlr on admission (or = . , %ci . - . , p = . ) and higher crp on admission (or = . , %ci . - . , p < . ) were associated with increased odds ratios of poor prognosis. the area under the receiver operating characteristic (roc) curve (auc) for nlr and crp in predicting progression to critical condition was . ( % ci . - . , p < . ) and . ( % ci . - . , p < . ), with a cut-off value of . and . mg/l, respectively. the auc of nlr and crp in predicting death was . ( % ci, . - . , p < . ) and . ( % ci . - . , p < . ), with a cut-off value of . and . mg/l, respectively. conclusions: higher levels of nlr and crp at admission were associated with poor prognosis of moderate covid- patients. nlr and crp were good predictors of progression to critical condition and death. as of apr , , there have been , , confirmed cases of covid- worldwide, including , deaths reported by who [ ] . the outbreak of covid- has become an international public health emergency [ , ] . the prognosis of covid- patients with different severities at admission is significantly different. most mild or moderate patients that receive basic medical care at fangcang shelter hospitals, which are large-scale, temporary hospitals rapidly built since feb in china, have better prognosis [ ] . relative to the moderate cases, severe or critical patients have a higher probability of being admitted to intensive care units (icu), have longer stays [ , ] , and are more likely to die [ , ] . identification of which initially mild or moderate patients will deteriorate into severe or critical illness is useful, as it would allow for earlier treatment to prevent worsening outcomes and save medical resources for other patients. in this study, we focus on the clinical features and outcomes of patients with moderate covid- treated at a single institution and explore the factors and indicators associated with their prognosis. all adult patients with moderate cases of covid- hospitalized at the central hospital of wuhan from january to march , , were enrolled in this retrospective cohort study. this is a tertiary hospital located in the central area of wuhan, china, and is one of the designated hospitals for treating covid- patients. the data cutoff for this study was march , . the flowchart of confirmed patients enrolled in this study is shown in fig s . all patients were diagnosed with covid- based on positive sars-cov- qrt-pcr using throat swab samples, in accordance with the diagnosis and treatment protocol for novel coronavirus pneumonia recommended by the national health commission (nhc) of china (version . ) [ ] . this study was approved by the central hospital of wuhan hospital ethics committee (no. - ). written informed consent was waived by the ethics commission of the designated hospital for emerging infectious diseases. epidemiological, demographic, clinical, laboratory, treatment, and outcome data (progression to severe/critical/death) were reviewed and extracted from electronic medical records using a standardized data collection form by experienced clinicians and independently reviewed by two researchers. fever was defined as an axillary temperature of at least . °c. disease severity grading (mild, moderate, severe, or critical) of covid- was defined according to the diagnosis and treatment protocol for novel coronavirus pneumonia. mild grade was defined as few symptoms (low fever, fatigue) and without lung computed tomography (ct) findings. moderate grade was defined as fever, respiratory symptoms (dry cough, chest distress, and shortness of breath after activities), and lung ct findings (i.e. ground glass opacity, multiple small patchy shadows, and pulmonary consolidation). severe grade was defined as respiratory frequency ≥ /min, blood oxygen saturation ≤ %, oxygenation index < mmhg, and/or lung infiltrates > % within to hours. critical grade was defined as respiratory failure, septic shock, and/or multiple organ dysfunction or failure. poor prognosis refers to progression from moderate to severe grade, critical grade, or death. categorical variables are reported as number (%). normally distributed continuous data were reported as mean ± standard deviation (sd) and non-normally distributed continuous data were reported as median (interquartile range [iqr] ). categorical data were compared using the χ test or fisher exact test. independent t-tests were used to compare normally distributed continuous data, while the mann-whitney u-test or exact mann-whitney rank sum test was used to compare non-normally distributed continuous data. to adjust for the risk factors associated with illness progression inhospital, univariable and multivariable logistic regression models were used. considering the total number of prognoses (n= ) in our study and to avoid overfitting of the model, variables were chosen for multivariable logistic analysis on the basis of univariable logistic analysis results and clinical significance. multivariable cox proportional hazards regression analyses were used to further adjust the risk factors associated with survival. considering the total number of deaths (n= ) in our study and to avoid overfitting of the model, four variables were chosen for cox regression analysis on the basis of multivariable logistic analysis results and clinical significance. receiver operating characteristic (roc) curves were used to evaluate the potential predictive value of risk factors on prognoses in-hospital. the hosmer-lemeshow test was used to calibrate the roc curves. the net reclassification index (nri) was used to determine which indicators of roc curves analysis were better at predicting outcomes, in line with previously published methods [ ] . p value less than . was considered statistically significant. statistical analysis was performed using spss (version . ) and graphpad prism (version . ) software. a total of ( %) moderate cases were recruited in this study (table ) the laboratory data of all moderate cases on admission are shown in table . numerous variables were significantly associated with outcome, and cases with poor prognoses generally had lower lymphocyte counts, and higher levels of c-reactive protein (crp), neutrophil/lymphocyte ratio (nlr), and procalcitonin. treatment and outcome data are presented in table . as indicated, antiviral treatment (i.e. ribavirin, arbidol and lopinavir/ritonavir) was the most common treatment method for moderate cases ( / , . %), followed by antibiotic treatment (i.e. ephalosporins and quinolones; / , . %) and glucocorticoid treatment ( / patients, . %). glucocorticoid treatment and intravenous immunoglobin were more commonly used for patients with poor prognoses than patients that did not progress. the median time of illness onset to admission was days (iqr . - ) in all moderate patients and did not differ significantly between two groups (p > . ). were associated with increased odds ratios of poor prognoses. furthermore, we calculated the odds ratio for the different of prognoses in more detail (table s ) . briefly, older age, male gender, and nlr and crp levels at admission greater than . mg/l were associated with increased odds ratios of severe progression. male gender, nlr, crp greater than . mg/l on admission were associated with increased odds ratios of progression to critical condition. older age, male gender, nlr, procalcitonin greater than . ng/ml, and crp greater than . mg/l on admission were associated with increased odds ratios of death. these results are consistent with our cox regression analysis (table s ) . to explore risk factors that can predict prognosis of patients with moderate covid- , we used roc curve analysis. the roc curve of nlr and crp in predicting the total poor prognoses and severe progression is shown in figure a table . in this retrospective study, the major symptoms of moderate covid- were fever and cough and these symptoms did not differ between the two outcome groups (table ). therefore, predicting prognosis based on symptoms is not possible. using comparative and multivariable analyses of basic patient characteristics, we found that comorbidities in moderate cases are not a risk factor for poor prognosis, which is consistent with recent studies [ ] . however, older age, male gender, and nlr and crp levels on admission were significantly associated with poor prognoses in patients with moderate covid- . in our study, the auc of both nlr and crp in predicting progression to critical condition and death was more than . (table ) , which suggests that nlr and crp may act as predictors of progression. compared with nlr, the nri of crp was greater than in predicting progression to critical condition and death, indicating that crp is a better predictor, which is consistent with auc results. additionally, although the auc of pct in predicting death was also more than . , the p value of roc curve of the hosmer-lemeshow test for pct was less than . (table ) , which suggests poor calibration of the roc curve. hence, the difference between the predicted value and the true value cannot be explained by chance. thus, these results indicate that pct is not a good predictor of death in moderate covid- cases in our study. additionally, multivariable logistic analysis revealed that antibiotic, intravenous immunoglobin, and glucocorticoids treatments were not associated with prognosis (table s ), suggesting that these medications did not improve prognosis when given to patients with moderate covid- . as most covid- cases are mild or moderate and medical resources are limited, these findings are clinically significant for taking appropriate treatment options and utilizing medical resources in a cost-effective way. however, randomized controlled trials (rcts) are required to confirm the impact of drug treatment on moderate covid- patients. there are several limitations of the study. first, this is a single center, retrospective study. second, most moderate covid- patients that were enrolled in this study were older and had multiple comorbidities, and thus were more likely to have adverse outcomes. hence, the rate of disease progression in our study may not reflect the true rate. in conclusion, age, gender, and nlr and crp levels at admission are associated with poor prognoses of patients with moderate covid- . nlr and crp levels on admission tend to be a good predictor of critical progression and death. the authors declare that they have no conflicts of interest. total poor prognoses, moderate cases progress to severe, critical cases or death; nlr, neutrophil-lymphocyte ratio. crp, c-reactive protein. coronavirus disease (covid- ) outbreak situation characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention fangcang shelter hospitals: a novel concept for responding to public health emergencies clinical progression of patients with covid- in shanghai clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study coronavirus disease in elderly patients: characteristics and prognostic factors based on -week follow-up diagnosis and treatment protocol for novel coronavirus pneumonia recommended discrimination and calibration of clinical prediction models: users' guides to the medical literature prevalence of comorbidities in the novel wuhan coronavirus (covid- ) infection: a systematic review and meta-analysis none. this work was supported by the natural science foundation of hubei province of china ( cfa ). key: cord- - dtzrd authors: villard, orianne; morquin, david; molinari, nicolas; raingeard, isabelle; nagot, nicolas; cristol, jean-paul; jung, boris; roubille, camille; foulongne, vincent; fesler, pierre; lamure, sylvain; taourel, patrice; konate, amadou; maria, alexandre thibault jacques; makinson, alain; bertchansky, ivan; larcher, romaric; klouche, kada; le moing, vincent; renard, eric; guilpain, philippe title: the plasmatic aldosterone and c-reactive protein levels, and the severity of covid- : the dyhor- study date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: dtzrd background. the new coronavirus sars-cov- , responsible for the covid- pandemic, uses the angiotensin converting enzyme type (ace ), a physiological inhibitor of the renin angiotensin aldosterone system (raas), as a cellular receptor to infect cells. since the raas can induce and modulate pro-inflammatory responses, it could play a key role in the pathophysiology of covid- . thus, we aimed to determine the levels of plasma renin and aldosterone as indicators of raas activation in a series of consecutively admitted patients for covid- in our clinic. methods. plasma renin and aldosterone levels were measured, among the miscellaneous investigations needed for covid- management, early after admission in our clinic. disease severity was assessed using a seven-category ordinal scale. primary outcome of interest was the severity of patients’ clinical courses. results. forty-four patients were included. at inclusion, patients had mild clinical status, moderate clinical status and severe clinical status. in univariate analyses, aldosterone and c-reactive protein (crp) levels at inclusion were significantly higher in patients with severe clinical course as compared to those with mild or moderate course (p < . and p = . , respectively). in multivariate analyses, only aldosterone and crp levels remained positively associated with severity. we also observed a positive significant correlation between aldosterone and crp levels among patients with an aldosterone level greater than . pmol/l. conclusions. both plasmatic aldosterone and crp levels at inclusion are associated with the clinical course of covid- . our findings may open new perspectives in the understanding of the possible role of raas for covid- outcome. a new coronavirus called sars-cov- is responsible for the pandemic of covid- , which has led to tens of thousands of deaths around the world so far [ ] . briefly, the disease develops in two phases: the first one is linked to the viral invasion, and the second one consists of a severe acute inflammatory immune response, including a "cytokine storm", which results in severe morbidity and mortality, mainly related to lung injury [ ] . in this context, the intensity of the inflammatory process contributes to the disease severity and the plasmatic level of c-reactive protein (crp) (a biomarker of systemic inflammation) could represent a marker of poor outcomes in covid- patients [ ] [ ] [ ] [ ] . as observed with the sars-cov responsible for sars [ ] , sars-cov- uses the angiotensin converting enzyme type (ace ) as a cellular receptor to infect cells. ace is a physiological inhibitor of the renin angiotensin aldosterone system (raas) through the catabolism of angiotensin type (ang ) into angiotensin ( - ) peptide [ ] . ang can induce pro-inflammatory responses through its receptor at r, while ace reduces anti-inflammatory reactions through its receptor masr. the assessment of raas involvement in the course of covid- in humans is not easy, due to the poor value of ang and angiotensin ( - ) peptide assays in peripheral blood to investigate raas and ace in affected patients. therefore, we explored the levels of plasma renin and aldosterone as indicators of raas activation in a series of consecutively admitted patients for covid- in our clinic. relationships with the severity of disease course were investigated to assess whether raas activation could be considered as a biomarker of covid- outcomes. in a series of consecutive patients with covid- diagnosis, hormonal assays including plasma renin and aldosterone levels were performed among the miscellaneous investigations needed for the management of covid- , early after admission in our clinic. this study is called dyhor- (dysfunctional hormone regulation during covid- ) and its protocol was reviewed and approved by the university hospital of montpellier institutional review board (irb-mtp_ _ _ , clinicaltrials.gov identifier: application in process). the disease severity was assessed using a seven-category ordinal scale (os) [ ] , as follows: -not hospitalized, no limitation on activities; -not hospitalized, limitations on activities; -hospitalized, not requiring supplemental oxygen; -hospitalized, requiring supplemental oxygen; -hospitalized, on non-invasive ventilation or high flow oxygen devices; -hospitalized, on invasive mechanical ventilation or extracorporeal membrane oxygenation (ecmo) and -death. the primary outcome of interest was the severity of patients' clinical courses during hospitalization, defined as severe for an ordinal scale higher than and corresponding to the transfer to the intensive care unit and death from all-causes. clinical status using the seven-category ordinal scale was assessed at three different time points: (i) early after admission corresponding to the day of the biological test (day ), (ii) two days later (day ) and (iii) considering the maximum ordinal scale during the overall period of hospitalization (os max). the past medical history, clinical manifestations, comorbidities, treatment strategies, radiologic assessments and laboratory testing on admission were extracted from the electronic medical records. disease severity was assessed by the os, as indicated above. diagnosis of covid- was considered as suspected in patients with typical lung ct-scan lesions and negative sars-cov- pcr. laboratory variables were tested with conventional methods, including routine blood tests: blood count, renal function, inflammatory markers. determination of crp was performed using a cobas /e ® analyzer (roche diagnostic, meylan, france) using the immunoturbidimetric method with reagents from roche (total cv imprecision results in the laboratory = %). renin and aldosterone were determined on an ids-isys multi-discipline automated system (immunodiagnosticsystem, boldon, united kingdom) using kits from ids (total cv imprecision results in the laboratory % and % for renin and aldosterone respectively). a cutoff of . pmol/l was the lower limit of plasma aldosterone detection in our condition. plasma cortisol and adrenocorticotropic hormone (acth) levels were measured by automated electrochemiluminescence assays (cobas , roche, basel, switzerland). laboratory confirmation of sars-cov- infection was determined by reverse transcription-pcr from nasopharyngeal swab specimens. categorical variables were described as frequency rates and percentages, analyzed using the chi-squared test or fisher's exact test. continuous variables were described using mean and standard deviation (sd). means for continuous variables were compared using student t-test or mann-whitney test according to the data distribution. due to skewed distribution, biological variables were presented with median (min-max), and median difference (hodges-lehamann estimator). a logistic regression was used for the analysis of the main criteria with odds ratio of disease severity adjusted on the delay from admission. covariates were selected in a backward selection procedure if p < . in the univariate analysis and then presented as adjusted odds ratios (ors). potential confounding factors were investigated by testing differences between groups. studying the relationship between variables was done using spearman correlation. statistical analyses were performed using sas enterprise guide, version . (sas institute, cary, nc, usa) and graphpad prism, version . . for mac os (graphpad software, san diego, ca, usa). forty-four patients were included in the study during the period from march to april . clinical characteristics of the patients are described in table at inclusion, on day , patients with severe clinical course (os max ≥ ) had more frequently a thyroid or chronic kidney disease, and a concomitant acute bacterial disease, compared to patients with mild or moderate course (os max ≤ ). a history of hypertension was present in patients ( . %). among antihypertensive treatment, the use of raas blockers (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers) was not different between mild or moderate and severe clinical course and concerned ( %) and patients ( %) respectively. beta-blockers and loop diuretics were more frequently used in patients with severe clinical progression (os max ≥ ) than in those with mild to moderate clinical course (os max ≤ ). the most common symptoms on admission were fever ( . %) and cough ( . %) with no differences found between patients with mild or moderate and those with severe clinical course. as expected, treatments during hospitalization including corticosteroid therapy, antibiotics and vasoactive drugs, which were significantly more frequently delivered in patients with severe compared to those with mild or moderate clinical courses. laboratory findings according to disease severity during the overall period of hospitalization are described in table between mild/moderate (os max ≤ ) versus severe (os max ≥ ) groups. in univariate analyses, aldosterone levels at inclusion were significantly higher in patients with severe clinical course (os ≥ ) (median (min-max), . ( . - . ) pmol/l) as compared to those with mild or moderate course (os ≤ ) ( . ( . - . ) pmol/l) (p < . ). of note, at inclusion, potassium levels and aldosterone/renin ratios were not different between these two groups ( figure a ,c), but in some cases, we observed a trend toward an association between higher levels of aldosterone and lower renin and potassium levels ( figure b,d) . concerning cortisol and acth levels, no difference was observed between groups. among common hematological and inflammatory markers at baseline (including lymphocyte, monocyte and eosinophil counts, fibrinogen and d-dimers), crp at inclusion was significantly higher in patients with severe clinical course ( ( - ) mg/l) compared to those with mild or moderate course ( ( - ) mg/l, p = . ). in multivariate analyses including coexisting conditions, long-term anti-hypertensive treatments, care during hospitalization and laboratory findings at inclusion, only aldosterone (or = . ( . - . ), p = . ) and crp (or = . ( . - . ), p = . ) remained positively associated with the severity of clinical course. table . biological findings at inclusion (on day ) according to disease severity of patients with covid- infection classified in two groups: mild/moderate (os max ≤ ) and severe (os max ≥ ). number in addition, the plasma aldosterone and crp levels were examined according to the clinical status at three different time points (figures and a) : (i) at inclusion (day ), (ii) two days later (day ) and (iii) at the maximum ordinal scale during the overall period of hospitalization (os max). at inclusion, aldosterone levels were not clearly associated with a specific clinical status (p = . ) (figure a) . however, higher aldosterone levels at inclusion were observed in patients with os at day or os max ≥ (p = . and p = . respectively) (figure a) . moreover, aldosterone levels were also gradually and significantly increased when we compared clinical status of patients in the three following categories: mild (os ≤ ), moderate (os = ) and severe (os ≥ ) on day and at os max (analysis of variance, p = . and p = . , respectively) ( figure b) . notably, similar findings were observed when patients receiving a raas blocker were excluded from the analysis on day and at os max (analysis of variance, p = . and p = . , respectively) (supplemental figure s ) . similarly, these findings were also observed when patients receiving beta-blockers were excluded from the analysis on day and at os max (analysis of variance, p = . and p = . , respectively). notably, we also investigated the effects of age and sex on our findings and did not observe any significant differences between groups. an additional analysis with crp level at baseline found concordant results. as compared to patients with mild or moderate clinical status, crp levels were significantly higher in patients with os ≥ on day or at os max (p = . and p = . , respectively) ( figure a ). considering the hypothesis that aldosterone may be involved in inflammatory damages of covid- , we searched for a relationship between the aldosterone and crp levels. we conducted this further analysis independently from disease severity (as assessed by the os), after having excluded the patients who had developed a documented acute bacterial infection in the days close to the biological investigation. finally, we observed a correlation between aldosterone and crp levels among patients with an aldosterone level greater than . pmol/l. in this group of patients, aldosterone level was positively correlated with crp level at baseline (spearman coefficient r ( % ci) . ( . - . ), p = . ) ( figure b ). in the present study based upon data collected in the real-life settings of the brutal sars-cov- outbreak, we report an association between the plasma levels of aldosterone close to admission and the severity of covid- course, as defined by the ordinal scale grade. indeed, the most severe an additional analysis with crp level at baseline found concordant results. as compared to patients with mild or moderate clinical status, crp levels were significantly higher in patients with os ≥ on day or at os max (p = . and p = . , respectively) ( figure a ). considering the hypothesis that aldosterone may be involved in inflammatory damages of covid- , we searched for a relationship between the aldosterone and crp levels. we conducted this further analysis independently from disease severity (as assessed by the os), after having excluded the patients who had developed a documented acute bacterial infection in the days close to the biological investigation. finally, we observed a correlation between aldosterone and crp levels among patients with an aldosterone level greater than . pmol/l. in this group of patients, aldosterone level was positively correlated with crp level at baseline (spearman coefficient r ( % ci) . ( . - . ), p = . ) ( figure b ). in the present study based upon data collected in the real-life settings of the brutal sars-cov- outbreak, we report an association between the plasma levels of aldosterone close to admission and the severity of covid- course, as defined by the ordinal scale grade. indeed, the most severe patients, who required at least intensive care (os ≥ ), had significantly higher plasma levels of aldosterone when admitted than those hospitalized in medical units, with (os = ) or without (os = ) oxygen support. this association appears to be relevant both when considering the os days after admission and according to the maximal os during the overall period of hospitalization. in most patients, aldosterone levels remained within a physiological range, but the significant differences observed between groups according to severity were independent of the renin levels and aldosterone/renin ratio. such a hormonal profile is suggestive of a renin-independent hyperaldosteronism [ ] , which could be a hallmark of some patients with the most severe forms of covid- . conversely, low aldosterone levels were observed in those with a less severe disease (os = or ). this could be related either to a failure of the aldosterone assay to discriminate within the minimal values or reflect a tendency to adrenal insufficiency. however, this latter hypothesis is not supported by the plasma cortisol levels. as previously reported [ ] [ ] [ ] , crp levels were coherent with the severity of covid- , which is characterized by a severe inflammatory syndrome. interestingly, patients with aldosterone levels higher than . pmol/l exhibited a linear relationship between crp and aldosterone levels. this further finding is in line with the suspected role of the viral load in the ace/ace imbalance, which occurs before the onset of the cytokine storm [ , , ] . indeed, sars-cov- could disrupt the raas through its binding to ace , which is the negative regulator of the system [ ] . hence, the defective inactivation of ang could lead to the activation of raas, including an increased secretion of aldosterone. the role of ang in the severity of lung inflammatory damage in covid- is supported by previous investigational reports. first, imai et al. [ , ] demonstrated in several animal models of acute lung injury (acid inhalation, sepsis or pneumonia) that ang can worsen pulmonary lesions (including inflammatory infiltrates) through the stimulation of the ang type receptor (at r). conversely, ace and ang type receptor (at r) can down-regulate these deleterious effects, whereas abrogated ace expression can induce severe respiratory failure in mice models. in addition, the levels of ang are increased in these mice, which exhibit severe lung involvement partially reversible with the pharmacological inhibition of the at r [ , ] . during sars-cov- infection, ace knockout mice were resistant to virus infection and their lung samples were devoid of inflammation [ ] . in contrast, the binding of the sars-spike protein to ace downregulates this regulator pathway, leading to severe lung injury and acute respiratory failure, as illustrated in a mouse model by kuba and coll [ ] . in their study, blocking the raas limited the lung injury. these findings are in line with the concept that raas disruption could trigger inflammation in covid- . furthermore, beside coronavirus infections, the potentially deleterious effects of raas have been documented in several tissues (including heart and lung) and medical conditions (such as hypertension, heart failure, obesity, etc.) [ ] and have been also documented beyond the regulation of sodium, extracellular volume and blood pressure. the mechanisms leading to raas toxicity also include (i) modulation of the production of pro-inflammatory cytokines (such as tnf alpha and il- by ang [ ] and il- by aldosterone [ ] ), leading potentially to recruitment of mono/macrophages; (ii) induction of fibrosis (through at r) [ ] ; and (iii) induction of vascular toxicity [ ] and modulation of angiogenesis [ , ] . in the context of ace neutralization by sars-cov- , all these mechanisms could be exacerbated, while their clinical consequences are more limited in classical conditions of raas hyperactivation (such as chronic heart failure, etc. [ ] ). importantly, the pathogenic mechanisms of covid- are concordant with autoptic observations and biological findings, which include the cytokine storm (with il , il , tnf, etc.) [ , , ] , fibrosis [ ] , endothelitis and modulated angiogenesis [ , ] . in addition, the key role of raas toxicity could be also corroborated by the promising beneficial effects observed with anti-aldosterone and raas blocker treatments in several experimental conditions of pulmonary diseases [ ] . in covid- , these protective effects are extensively debated [ , , ] . finally, the potentially deleterious effects of raas may take place in the pathophysiology of covid- . from this point of view, our findings suggest that both crp and aldosterone levels may impact the clinical status. further studies are required to document and confirm the suspected role of raas in covid- . our study has limitations due to the collection of plasma samples for hormonal assays in an emergency setting related to the admission for covid- acute infection. hence, optimal standardized conditions for assessing plasma renin and aldosterone levels were not met, and multiple confounding factors could be involved in the modulation of plasma aldosterone secretion. however, when we adjusted for all of these confounding parameters, plasma aldosterone levels remained significantly associated to disease severity. in the present study, higher plasmatic aldosterone and crp levels at inclusion are associated with severe clinical course of covid- in hospitalized patients, and both parameters appear to be correlated. our results suggest that aldosterone levels may reflect the severity of covid- , but this remains to be demonstrated at a larger scale. our findings open new perspectives into the understanding of the contribution of raas in covid- and its possible role in the outcomes of covid- . further investigations are awaited to explore more thoroughly the association between increased aldosterone levels, ace/ace imbalance, inflammatory biomarkers and the severity of the covid- course. supplementary materials: the following are available online at http://www.mdpi.com/ - / / / /s , figure s : patients with no raas blocker therapy: clinical status course according to aldosterone level at inclusion, * p < . (mann-whitney test) (a) and laboratory findings of raas explorations by severity of clinical status during the overall period of hospitalization (b), table s : clinical characteristics of patients with covid- according to disease severity classified in three groups: mild (os max ≤ ), moderate (os max = ) and severe (os max ≥ ). author contributions: o.v.: data collection, design and conceptualization of the study, statistical analysis, drafting and reviewing of the manuscript; d.m.: data collection, investigation, software, design and conceptualization of the study, statistical analysis, supervision, drafting and reviewing of the manuscript; n.m.: methodology, statistical analysis, drafting and reviewing of the manuscript; i.r.: design and conceptualization of the study, drafting and reviewing of the manuscript; n.n.: design and conceptualization of the study, drafting and reviewing of the manuscript; j.-p.c.: data collection, drafting and reviewing of the manuscript; b.j.: data collection, investigation, drafting and reviewing of the manuscript; c.r.: data collection, investigation, drafting and reviewing of the manuscript; v.f.: data collection, investigation, drafting and reviewing of the manuscript; p.f.: data collection, investigation, drafting and reviewing of the manuscript; s.l.: data collection, investigation, drafting and reviewing of the manuscript; p.t.: data collection, investigation, drafting and reviewing of the manuscript; a.k.: data collection, investigation, drafting and reviewing of the manuscript; a.t.j.m.: design and conceptualization of the study, drafting and reviewing of the manuscript; a.m.: data collection, investigation, drafting and reviewing of the manuscript; i.b.: data collection, investigation, drafting and reviewing of the manuscript; r.l.: data collection, investigation, drafting and reviewing of the manuscript; k.k.: data collection, investigation, drafting and reviewing of the manuscript; v.l.m.: data collection, investigation, drafting and reviewing of the manuscript; e.r.: design and conceptualization of the study, methodology, drafting and reviewing of the manuscript; p.g.: design and conceptualization of the study, methodology, statistical analysis, supervision, drafting and reviewing of the manuscript. all authors have read and agreed to the published version of the manuscript. funding: this research received no external funding. acknowledgments: this work was supported by montpellier university hospital, montpellier university. the authors declare no conflict of interest. clinical characteristics of coronavirus disease in china severe sars-cov- infections: practical considerations and management strategy for intensivists predictive factors for disease progression in hospitalized patients with coronavirus disease in wuhan viral and host factors related to the clinical outcome of covid- phenotypic characteristics and prognosis of inpatients with covid- and diabetes: the coronado study early predictors of clinical deterioration in a cohort of patients hospitalized for covid- infection in lombardy angiotensin-converting enzyme is a functional receptor for the sars coronavirus renin-angiotensin-aldosterone system inhibitors in patients with covid- a trial of lopinavir-ritonavir in adults hospitalized with severe covid- syndromes that mimic an excess of mineralocorticoids cytokine release syndrome in severe covid- immunology of covid- : current state of the science angiotensin-converting enzyme protects from severe acute lung failure angiotensin-converting enzyme (ace ) in disease pathogenesis a crucial role of angiotensin converting enzyme (ace ) in sars coronavirus-induced lung injury abu-izneid, t. renin-angiotensin-aldosterone (raas): the ubiquitous system for homeostasis and pathologies angiotensin ii: its effects on fever and hypothermia in systemic inflammation interleukin- plays a critical role in aldosterone-induced macrophage recruitment and infiltration in the myocardium il- trans-signalling contributes to aldosterone-induced cardiac fibrosis the renin-angiotensin-aldosterone system in vascular inflammation and remodeling angiotensin ii and aldosterone in retinal vasculopathy and inflammation aldosterone inactivates the endothelin-b receptor via a cysteinyl thiol redox switch to decrease pulmonary endothelial nitric oxide levels and modulate pulmonary arterial hypertension dying with sars-cov- infection-an autopsy study of the first consecutive endothelial cell infection and endotheliitis in covid- pulmonary vascular endothelialitis, thrombosis, and angiogenesis in covid- targeting the renin-angiotensin system as novel therapeutic strategy for pulmonary diseases drugs and the renin-angiotensin system in covid- renin-angiotensin-aldosterone system inhibitors and risk of covid- this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord- -s vv rw authors: zhou, y.; yang, z.; guo, y.; geng, s.; gao, s.; ye, s.; hu, y.; wang, y. title: a new predictor of disease severity in patients with covid- in wuhan, china date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: s vv rw background: severe acute respiratory syndrome coronavirus (sars-cov- ) broke out in wuhan, hubei, china. this study sought to elucidate a novel predictor of disease severity in patients with coronavirus disease- (covid- ) cased by sars-cov- . methods: patients enrolled in this study were all hospitalized with covid- in the central hospital of wuhan, china. clinical features, chronic comorbidities, demographic data, and laboratory and radiological data were reviewed. the outcomes of patients with severe pneumonia and those with non-severe pneumonia were compared using the statistical package for the social sciences (ibm corp., armonk, ny, usa) to explore clinical characteristics and risk factors. the receiver operating characteristic curve was used to screen optimal predictors from the risk factors and the predictive power was verified by internal validation. results: a total of patients diagnosed with covid- were enrolled in this study, including with severe pneumonia and with non-severe pneumonia. the independent risk factors for severe pneumonia were age [odds ratio (or): . , % confidence interval (ci): . - . ; p < . ], n/l (or: . , % ci: . - . ; p < . ), crp (or: . , % ci: . - . ; p = . ), and d-dimer (or: . , % ci: . - . ; p = . ). we identified a product of n/l*crp*d-dimer as having an important predictive value for the severity of covid- . the cutoff value was . . the negative predictive value of less than . for the n/l*crp*d-dimer was . %, while the positive predictive value was . % in the test sets. the sensitivity and specificity were . % and . %. in the training sets, the negative and positive predictive values were . % and . %, respectively, with a specificity of . % and a sensitivity of . %. conclusions: a product of n/l*crp*d-dimer may be an important predictor of disease severity in patients with covid- . since last december, a growing cluster of pneumonia cases caused by the novel coronavirus was reported in wuhan, hubei province, china. the virus rapidly spread from wuhan to the surrounding provinces and cities, which attracted worldwide attention and public panic [ ] [ ] [ ] . eventually, the pneumonia was designated as coronavirus disease- (covid- ) by the world health organization (who) on february , . the international committee on taxonomy of viruses declared that the virus was officially classifiable as severe acute respiratory syndrome (sars) coronavirus (sars-cov- ) on the same day. sars-cov- belongs to the genus beta coronavirus of the coronaviridae family, which includes the deadly sars and middle east respiratory syndrome coronaviruses [ ] [ ] [ ] . studies have shown that sars-cov- displays roughly an % homology with bat sars-like-covzxc and % homology with human sars-cov . it is highly contagious and has a high mortality rate the disease is prone to causing respiratory symptoms, such as high fever, dyspnea, and cough. it may rapidly develop into severe pneumonia, acute respiratory distress syndrome (ards), multiple organ dysfunction syndrome, and death . as the number of patients with covid- increases, so too does the number of severe cases. thus far, there are no drugs approved or verified that are specific to the virus , . thus, the treatment of patients critically ill with covid- is becoming one of the main challenges facing clinicians and there is a need adopt reliable predictors of the severity of covid- to identify and treat the most severe patients in the early stage. this study therefore sought to explore the adoption of a factor for the prediction of severity in patients with covid- and provide evidence of its use for the screening of severely ill patients. patients enrolled in this study were hospitalized at the central hospital of wuhan, which is a tertiary teaching hospital and which is responsible for the treatment for patients of covid- , as assigned by the chinese government. all of the patients were local residents of wuhan and . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint had contact with people who had been confirmed (or suspected) to have contracted the illness. the relevant laboratory examinations, common pathogen detection, and chest computed tomography (ct) scans were completed. each patient also underwent the sars-cov- nucleic acid swab test, with some patients testing positive and others testing negative. the immaturity of the methods and an incorrect sampling method used for sars-cov- nucleic acid detection may have contributed to the false-negative results. high-resolution ct scans with a scan layer thickness of mm and a reconstruction of a -to . -mm thick layer are recommended for the radiological examination of covid- . the included patients were clinically diagnosed with covid- according to the who's interim guidance . for patients who were suspected to have the illness, two senior respiratory doctors made the diagnosis together. the study participants were divided into two groups: patients with severe pneumonia and those with non-severe pneumonia. patients with the following clinical signs were considered to have severe pneumonia: fever or suspected respiratory infection plus either a respiratory rate of greater than breaths/min, severe respiratory distress, or spo of less than % on room air. patients with ards, sepsis, or septic shock were also included. those patients without the above severe signs were included in the non-severe pneumonia group. patients with other viral, bacterial, and fungal infections upon admission and those with missing data were excluded. this study was approved by the ethics committee of wuhan central hospital. as the study is a retrospective study and does not involve patients' privacy, the informed consent can be exempted chronic comorbidities, demographic data, laboratory examinations, and chest ct scans were reviewed using electronic medical records. data on white blood cell (wbc) count and lymphocyte (l), neutrophil (n), alanine transaminase (alt), aspartate aminotransferase (ast), serum albumin (alb), serum creatinine (cr), blood urea nitrogen (bun), d-dimer, and c-reactive protein (crp) levels were included. these data were acquired by physicians and were the results of an examination on the first day after admission. all of the data were checked by another researcher to ascertain their accuracy. patients were randomly assigned in a : fashion to undergo training and hold-out test sets. the predictors were trained in the training group and the optimal cutoff value was obtained. this internal validation assessed the value for predicting the severity of with covid- . statistical performance for the classifier was measured by calculating sensitivity, specificity, and negative and positive predictive values. the continuous variables were either presented as means and compared using t-tests if they were normally distributed or were described using medians. the mann-whitney u test was used for comparisons. categorical variables were presented as count (%) and compared by the chi-squared test or fisher's exact test. logistic regression analysis was used to assess risk factors of severe pneumonia. a receiver operating characteristic (roc) curve was used to filter predictors, and internal validation was used to validate the predictive value of predictors. a two-sided α value of less than . was considered to be statistically significant. we used the statistical package for the social sciences, version . (ibm corp., armonk, ny, usa) for statistical analysis. between january and february , , a total of patients with covid- were enrolled, but only eligible participants were finally included in our analysis. among them, there were ( . %) patients with positive sars-cov- nucleic acid test results, ( . %) patients with non-severe pneumonia, and ( . %) patients with the severity of covid- . the basic characteristics of the study population are shown in table . the patients with severe pneumonia tended to older. also, patients with chronic comorbidities, such as high blood pressure (hbp), type diabetes mellitus (t dm), coronary heart disease (chd), and chronic obstructive pulmonary disease, accounted for a larger proportion of the population in the severe pneumonia group. relative to those with non-severe pneumonia, patients with severe pneumonia had significantly high serum wbc count and n, crp, cr, bun, d-dimer levels and lower albumin and lymphocyte levels. the ratio of neutrophils to lymphocytes (n/l) was significantly higher in patients with severe pneumonia. in addition, no significant differences in alt, ast, or time between onset and admission were apparent. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint to further determine the independent risk factors of severe pneumonia, we performed a logistic regression analysis. the results indicated that, after adjusting for confounding factors such as gender, t dm, hbp, chd, cr, bun, and alb, the independent risk factors for severe pneumonia were age [odds ratio (or): . , % confidence interval (ci): . - . ; p < . ], n/l (or: . , % ci: . - . ; p < . ), crp (or: . , % ci: . - . ; p = . ), and d-dimer (or: . , % ci: . - . l p = . ) ( table ) . the roc curve was used to analyze the predictive value of n/l, crp, and d-dimer for determining disease severity in patients with covid- . the area under the roc curve to further explore the predictive value of n/l*crp*d-dimer in the severity of covid- , we also conducted an internal validation. about % of patients were randomly selected from the total population as test sets and the rest were designated as the training sets. basic characteristics of patients in the two sets are listed in table . roc curves for the new predictor in the test sets are shown in figure ; the cutoff point was not derived. the auc was . ( % ci: . - . ), with a specificity of . % and a sensitivity of . % in the training sets ( figure ), and the cutoff value was . . the optimal cutoff value obtained from the average cutoff value of the original data group and the training sets was . ; thus, patients in the training and test sets were reclassified according to this result. patients with n/l*crp*d-dimer results of less than . were classified as patients with non-severe pneumonia in predicted groups. otherwise, they were classified as patients with severe pneumonia. as can be seen from tables and , the negative predictive value (a diagnosis of non-severe pneumonia) of less than . for the n/l*crp*d-dimer was . % ( % ci: . - . ), and the positive predictive value (a diagnosis of severe pneumonia) . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. tables and . this was a cross-sectional study that sought to investigate predictive factors of the severity of covid- . we found that age, n/l, crp, and d-dimer were independent risk factors for the severity of covid- . our results suggested that age was positively correlated with the severity of covid- . the result was also confirmed in other research . this is probably because the resistance of the elders against virus decreases with age increase, basic diseases, and many other factors. moreover, the aggravation of the basic disease profile of elderly patients would also lead to deterioration in the face of the severe pneumonia. the increases in n/l and crp may be related to cytokine storms, which produce a series of inflammatory responses and cause disorders in peripheral wbcs and immune cells such as lymphocytes . the observed decrease in lymphocytes indicated that coronavirus consumes many immune cells and inhibits the body's cellular immune function. damage to lymphocytes might contribute to exacerbations of patients and even cause death . a significant increase of d-dimer in the progression of severe pneumonia was also observed, which was consistent with the results of wang . this may be correlated with the damage to the pulmonary arteries caused by the virus , which leads to significant embolization in the extensive alveolar terminal capillaries. these changes eventually contribute to an increase in d-dimer. although n/l, crp, and d-dimer were independent risk factors for the severity of covid- , the roc curve showed that they have a low predictive value for the severity of the infection. in clinical practice, a very high negative predictive value is crucial in the evaluation of a patient with the severity of covid- , since failure to detect severe patients could have devastating consequences for these individuals. this study suggested that the product of n/l*crp*d-dimer had better predictive performance for the severity of covid- relative to single biomarkers. the predictive value of n/l*crp*d-dimer was also confirmed in the internal validation stage. the observed negative predictive value of . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint n/l*crp*d-dimer was more than %, while the positive predictive value was more than %, with a specificity of . % and a sensitivity of . %, which appears to represent an improvement in prediction as compared with other clinical variables. in general, the product of n/l*crp*d-dimer is a new predictive value for the severity of covid- . the study validated an n/l*crp*d-dimer cutoff point of . for the prediction. clinicians should pay close attention to these indicators and calculate the value to identify severe patients as early as possible. importantly, our study has limitations. first, laboratory testing methods may not be the same in every hospital and the optimal cutoff point for the product value may vary. further, only patients were included in this study, where the product of n/l*crp*d-dimer was found for the first time, so larger-scale data from randomized trials are needed to estimate whether to use this predictor in clinical practice. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . patients with n/l*crp*d-dimer results of less than . were reclassified into the non-severe group and those with results of greater than or equal to . were reclassified into the severe group . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/ . / . . . doi: medrxiv preprint outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle the continuing -ncov epidemic threat of novel coronaviruses to global health -the latest novel coronavirus outbreak in wuhan, china coronavirus infections of man associated with diseases other than the common cold a novel coronavirus from patients with pneumonia in china emerging coronaviruses: genome structure, replication, and pathogenesis return of the coronavirus: -ncov genomic characterization of the novel human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting wuhan updated understanding of the outbreak of novel coronavirus ( -ncov) in wuhan clinical features of patients infected with novel coronavirus in wuhan drug treatment options for the -new coronavirus ( -ncov) potential benefits of precise corticosteroids therapy for severe -ncov pneumonia clinical management of severe acute respiratory infection when novel coronavirus n o infection is suspected: interim guidance hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study t-cell immunity of sars-cov: implications for vaccine development against mers-cov discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin key: cord- -t b h authors: duijker, g.; bertsias, a.; symvoulakis, e. k.; moschandreas, j.; malliaraki, n.; derdas, s. p.; tsikalas, g. k.; katerinopoulos, h. e.; pirintsos, s. a.; sourvinos, g.; castanas, e.; lionis, c. title: reporting effectiveness of an extract of three traditional cretan herbs on upper respiratory tract infection: results from a double-blind randomized controlled trial date: - - journal: journal of ethnopharmacology doi: . /j.jep. . . sha: doc_id: cord_uid: t b h abstract ethnopharmacological relevance observations from the island of crete, greece suggest that infusions of traditional cretan aromatic plants, well known for their ethnopharmacological use in eastern mediterranean region and near east, could be effective in the prevention and treatment of upper respiratory tract infections, including viral-induced infections. the aim of this study was to report the effectiveness of an essential-oil extract of three cretan aromatic plants in the treatment of cases with an upper respiratory tract infection. materials and methods a double blind randomized controlled trial was implemented between october and february . an essential-oil extract of cretan aromatic plants in olive oil (total volume of ml of essential oil per litre of olive oil) was administered as . ml soft gel capsules, twice a day, for days. placebo treatment was . ml olive oil in soft gel capsules. eligible patients were those presenting for clinical examination in the selected setting with signs and symptoms of upper respiratory tract infection that had begun within the previous hours. real-time polymerase chain reaction (pcr) was used for the detection of respiratory viruses. the primary outcome was the severity and duration of symptoms of upper respiratory tract infection, assessed using the wisconsin upper respiratory system survey (wurss- ) questionnaire. a secondary outcome of interest was the change in c-reactive protein (crp) status. results one hundred and five patients completed the study: in the placebo group, and in the intervention (treated) group. baseline characteristics were similar in the two groups. no statistically significant differences were found in symptom duration or severity between the two groups, although small and clinically favorable effects were observed. when the analysis was restricted to subjects with a laboratory-documented viral infection, the percentage of patients with cessation of symptoms after days of treatment was % in the intervention group and % in the control group (p= . ). at baseline, one third of the patients in each group had elevated crp levels. at follow-up, the respective proportions were % in the intervention group and % in the placebo group (p= . ). the data were also in a favorable direction when % and % symptom reduction points were considered for specific virus types. conclusions compared with placebo the essential-oil extract of three cretan aromatic plants provided no detectable statistically significant benefit or harm in the patients with upper respiratory illness, although descriptive differences were identified in favorable direction mainly in the virus-positive population. novel h n , referred also as "swine flu", as well as other viral agents involved in common cold infections, compose a public health problem, accountable for many visits to primary and secondary health care services and hospital admissions; additionally, a considerable number of deaths is likewise documented, especially in vulnerable people. these infections are easily transmitted by exposure to infected droplets expelled by coughing or sneezing that can be inhaled, or contaminated hands or surfaces. symptoms include fever, cough, headache, muscle and joint pain, sore throat and runny nose, and sometimes vomiting and diarrhea. the new influenza a (h n ) appears to be as contagious as seasonal influenza, and spreads rapidly, particularly amongst young people. the severity of the disease ranges from very mild symptoms to serious illness and occasionally even death. the majority of people who contract the virus experience mild disease and recover without antiviral treatment or medical care. additionally, more than % of serious hospitalized cases have underlying health conditions or impaired immune function. antiviral drugs may reduce the symptoms and duration of illness and may also contribute to preventing severe disease and death. however, the effectiveness and cost of administered therapy remains an interesting topic for further investigation, as a recent cochrane meta-analysis, although contested, reported a limited effect of oseltamivir (tamiflu s ), a classical antiviral drug (jefferson et al., ) , mainly related to the time-limited and usual self-healing nature of the disease. much discussion has been dedicated to the use of herbal medicine for the common cold. a randomised controlled trial (rct) has reported on the effects of so-cheoug-ryong-tang (ko et al., ) and yeon-gyopae-dok-san on the common cold (byun et al., ) . the use of herbs as ailments in the island of crete has been mentioned since the bronze age (arnott, ) . herbal medicine also has a long history in ancient greece. popular medical handbooks from the byzantine era forward incorporated material rooted in ancient medicine and routinely claimed hippocrates and galen (among others) as sources (clark, ) . in current times, the antioxidant activity of herbs in rural crete has been investigated and it has been shown that herbal extracts decrease lipid peroxidation in cultured lung cells exposed to iron or ozone (lionis et al., ) . previous ethnobotanical field studies have revealed the existence of an indigenous knowledge system in rural crete and certain combinations of different aromatic plants in rural areas of crete have been used for the prevention and cure of the common cold and influenza (lionis et al., ) . the biological effects and bioactivity of essential oils and as well as their antibacterial properties have been reported in the literature (cowan, ; burt, ; bakkali et al., ; koroch et al., ) . similarly, the antiviral potential of medicinal plants has been discussed as well (jassim and naji, ; mukhtar et al., ) . it is also exciting that even though the term "virus" is a very recent term in modern medicine (silverstein, ) , these rural societies, without any prior knowledge of the term and in the absence of any immunologic knowledge, were protecting the population using traditional and folkmedicine. as stated above, it was interesting to study to what extent this ethnopharmacological knowledge is evidence-based and effective in virus-induced diseases. to that effort we have also taken into account certain cretan history and archeological elements, as well as their ethnopharmacological uses in the eastern mediterranean and near east regions, suggesting a beneficial action of such a combination in upper respiratory viral infections (dafni et al., ; honda et al., ; lev and amar, ; said et al., ; hanlidou et al., ; lardos, ; hudaib et al., ) . as stated above, this study reports the results of the effectiveness of an extract based on three cretan aromatic plants in the reduction of duration and severity of symptoms of patients with upper respiratory tract infections, utilizing a standardized questionnaire, physical examination measurements and the decrease of inflammation assayed by c-reactive protein [crp] levels. plant material has been identified by one of the authors (sp) and voucher specimens of the three species have been deposited at the herbarium tau of the aristotle university of thessaloniki (uocsp - , uocsp - , and uocsp - ). formulation of the essential oil extracts was provided by the authors and prepared by olvos sa, according to the patents and patent applications related to the subject (wo gb ; gb ; ep ; cn ) of thyme or spanish oregano (coridothymus capitatus (l.) rchb. f. synonym of thymbra capitata (l.) cav.), dictamnus or cretan dittany (origanum dictamnus l.) and sage (salvia fruticosa mill., salvia pomifera l.) extracts through steam distillation. analysis of essential oils was performed by gas chromatography-mass spectroscopy, in a gc-ms, shimadzu, qp a apparatus. gc was equipped with mdn- column (length m, film thickness . mm, diameter . mm, max. useable temperature c) and a quadrupole mass spectrometer as detector. mdn- column temperature was initially c for min. it was then gradually increased to c at c/min and kept for min, and finally increased to c at c/min and held for min. the carrier gas was helium, the flow rate . ml/min. μl was used as an injection volume. the sample was measured in a split mode procedure with a split ratio : . injector and detector were maintained at and c, respectively. for gs-ms detection an electron ionization system was used with ionization energy at ev. the chemical and percentage composition of specific constituents in each essential oil (adams, ) is shown in supplemental tables - . essential oils (at a dilution of ml/l) in extra virgin olive oil (used as a vehicle) were formulated as . ml soft-gel capsules, for a daily dose of two capsules. this dose has been based on anthropological reports of fieldwork work studies carried on crete (lionis et al. ) and corresponds to two cups of infusion of the aforementioned aromatic plants. placebo capsules contained only extra-virgin oil, equally formulated as . ml soft-gel capsules. gc-ms chemical and percentage composition of the formulated mixture (adams, ) are shown in supplemental table . participants were recruited from october th, to february th, . eligible subjects were patients aged years or older, presenting at their local health centre of harakas in the prefecture of heraklion, in rural crete, greece, with symptoms of upper respiratory tract infection, initiated within the previous h. the jackson criteria were used in order to identify patients suffering from common cold (jackson et al., ) . these criteria consist of sneezing, nasal discharge, nasal obstruction, sore throat, cough, headache, malaise and chilliness. a patient was considered as eligible for participation when the jackson score was greater or equal than two (with at least one of the first four 'cold-specific' symptoms present). patients on a daily dosage of acetylsalicylic acid greater than mg were excluded from the study. further criteria for exclusion were the presence of malignancy, immunosuppression and pregnancy. harakas health center serves a population of , , in rural crete. of the general practitioners (gps) practicing at the centre, agreed to participate. eligible patients were informed about the study and enrolled after providing written consent. a randomized placebo-controlled, double-blind, parallel group design was used and the consort herbal medicinal interventions guidelines were followed (gagnier et al., ) . stratified randomization using a varying block size ( or ) was implemented using the statistical environment r, version . (〈http://www.r-project.org〉, package blockrand); stratification was by sex and age (cut-off taken at years). the packages containing the capsules were stored at the health centre and were identical in appearance but with differing id labels, corresponding to specific patients. enrolled patients received either the cretan aromatic plants product or the placebo. both gps and patients were blind to treatment group, as were the study coordinators, clinical chemistry and immunology diagnostic laboratories and other participating personnel. patients were examined at the gp's office on the day of presentation and at follow-up ( days later) and were contacted by telephone on a daily basis by their gps between their initial and final visits, for the completion of the daily questionnaire (see below, section . ). this study received approval by the commission of bioethics of the university general hospital of heraklion (no , - - ) . a written, fully informed consent was obtained from all patients enrolled in the study. the trial was registered in the international standard randomised controlled trial number register (〈http://www. isrctn.org〉) (isrctn number: isrctn ). after appropriate permission, the validated -item wisconsin upper respiratory system survey (wurss- ) instrument, translated in greek, was used to quantify symptoms' severity and duration (barrett et al., ). the wurss- is an evaluative illness-specific quality of life instrument, designed to assess the negative impact of acute upper respiratory infection. daily wurss summary scores are calculated by summing scores of individual items. the first and last of the items are not included in the summation as they have categorically different reference domains (〈http://www.fammed.wisc.edu/ research/external-funded/wurss〉, accessed on august ). higher scores indicate more severe symptoms (the theoretical maximum score being ) whilst a score of indicates the complete absence of symptoms. the questionnaire was completed on a daily basis, seven times in total. initially (day one) and at final follow-up (day seven) it was completed by the patient at the gp's office and in between, completion was undertaken by their gp, using telephone interviews. during the initial visit, information was also obtained on participant gender, date of birth, self-reported weight and height, smoking history (number of cigarettes per day, years of smoking, year started, year quitted), alcohol consumption (type of drink, milligrams per day), medical history (chronic illnesses, type of drugs provided, drug dosage), vaccinations (against streptococcus pneumoniae and influenza) and hospitalization history. each subject underwent a clinical examination, including the following: systolic blood pressure (sbp, mmhg), diastolic blood pressure (dbp, mmhg), o saturation (%), pulse (beats per minute), body temperature (degrees celsius) and respiratory rate (breaths per minute). these measurements were repeated at day , at the follow-up visit to the gp's office. blood was drawn on days one and seven, for the following tests: erythrocyte count (rbc, /μl), hemoglobin (g/dl), hematocrit (%), white blood cell count (wbc, / l), neutrophil (%), lymphocytes (%), monocytes (%), thrombocytes (%), alanine aminotransferase (alat or sgpt, u/l), aspartate aminotransferase (asat or sgot, u/l), alkaline phosphatase (alp, u/l), creatinine (mg/dl) and c-reactive protein (crp, mg/dl). all assays were performed at the university hospital of heraklion, after a specific agreement, with routine standard methods (number of protocol: / - - ). real-time pcr assays . . . dna/rna extraction nucleic acids were extracted from nasopharyngeal swabs, using a commercial purification kit (purelink viral dna/rna kit, invitrogen), suitable for viral dna/rna extraction, according to the manufacturer's instructions. all samples were quantified spectrophotometrically and normalized aliquots were produced for each sample. dna/rna isolation was performed in a separate area of the laboratory distant from the polymerase chain reaction (pcr) area. meticulous care was taken to avoid cross-contamination of the dna/rna. one hundred swabs were taken. six swabs were used as internal controls, resulting in available samples. the detection of respiratory viruses was carried out using two commercial kits, by real time pcr. the first kit allowed the multiplex real-time pcr detection and identification of human respiratory viruses, namely human respiratory syncytial virus (hrsv) rna, human metapneumovirus (hmpv) rna, human parainfluenza virus- - (hpiv) rna, ОС , Е , nl and hkui human coronavirus (hcov) rna, human rhinovirus (hrv) rna, human b, c and e adenovirus (hadv) dna as well as human bocavirus (hbov) dna (cat no tv - frt, sacacce). in addition, a second commercial kit was also employed for the simultaneous detection of pandemic h , influenza a virus and influenza b virus (anyplex™ flua/b typing real-time detection (v . ), seegene). real-time pcr reactions were set up according to the manufacturers' protocols, following the amplification conditions recommended and data were collected during annealing (two measurements) and at all times during melt curve analysis. experiments were conducted on an abi fast system real-time pcr thermal cycler, using software version v. . . (applied biosystems). the quality control of the dna/rna samples was accomplished by checking for the successful amplification of beta- microglobulin gene. the primary outcomes of interest were the duration of symptoms and changes in the severity of symptoms over the study period. duration of symptoms was assessed as the number of days from enrollment, before the participant reported "not sick" to the question "how sick do you feel today?" i.e. a response of on a likert scale of - . symptom severity was assessed by the outcome of wurss- questionnaires. a secondary outcome of interest was the normalization (crpo . mg/dl) of crp positive subjects, at day . the number needed to treat (nnt) that indicates the number of patients we need to treat to benefit one was also calculated in order to measure the study's effect. an overall sample size of ( in each group) was calculated to be necessary to detect a medium-large effect size ( . ) with power % at a significance level of % (comparison of means), using gpower . . (faul et al., ) . general characteristics of the patients in each group at baseline were summarized using descriptive statistics. univariate comparisons of patient characteristics between the two study groups were performed using pearson's chi-square test of independence (for categorical data), the independent samples t-test (for normally distributed variables) and the non-parametric the mann-whitney test (for not normally distributed variable). severity of symptoms over the study period was compared between intervention and control groups, using the -item wurss- scores, with both univariate techniques and multiple linear regression models, adjusting for age, sex, initial crp level, body mass index (bmi) and the presence of chronic diseases. severity was assessed in three ways: (a) firstly, the average total wurss- score over the time period was compared between groups (i.e. the sum of daily wurss- scores). (b) differences between the groups were assessed by calculating the area under the time-severity curve (the y-axis being the wurss- score). the area under the curve (auc) was calculated using a trapezoidal approximation. (c) finally, the average maximum wurss score (for each subject) was compared between groups. the percentage of missing values for the daily wurss- scores ranged from . % (n¼ out of at baseline) to . % (n¼ out of on day three). confidence intervals for median daily scores were calculated using a binomial method (the centile command in stata ). multiple linear regression models were applied, with dependent variable the natural logarithm of the auc [ln(auc)] and independent variables the treatment (intervention/placebo), age (in years), bmi (kg/m ), gender (male/female), presence of chronic illnesses (yes/no) and crp-level upon presentation (z . mg/dl vs r . mg/dl). discrete-time survival analysis was used to assess possible differences in time to symptom cessation (i.e. symptom duration) between groups. symptoms were considered absent on the first day in which the wurss score dropped to zero. an intention-totreat approach was used. a complementary log-log model (a discrete time proportional hazards model) was also applied to our data. the model was estimated by maximum likelihood adjusting for age and sex (stata command cloglog). the proportions of initially crp-positive subjects who were crp-negative at the end of the study were compared between groups. in addition, within-group comparisons of crp changes were made using mcnemar's test. at randomization, all diagnosed upper respiratory tract infections were presumed to be of viral etiology. respiratory viruses were only detected, however, in ( %) of the patients tested. the statistical methods described above were initially applied to the total sample and the analyses were subsequently repeated using data only from the subsample of virus-positive patients. the significance level was set to % and the statistical software used was spss version (for univariate analysis) and stata version (for the survival analysis). results are presented below by outcome, for the complete sample and for the sample of virus-positive patients. a total of patients with signs and/or symptoms of upper respiratory tract infection visited the health centre of charakas over the month time-period, ( . %) females and ( . %) males. one hundred and thirty five ( . %) did not meet eligibility criteria ( females, males); subjects ( %) because they presented to their doctor more than h after their symptoms had begun. other reasons for exclusion included pregnancy (n¼ , . %), treatment with acetylsalicylic acid with a daily dose mg (n¼ , . %) and malignancy or immunosuppression (n¼ , . %). fifty-four ( ) out of the eligible patients ( . %) did not agree to participate in the study. the most common reason stated was lack of time/inability for follow-up (n¼ , . %). four patients ( %) were not willing to participate in a clinical trial. fourteen of the patients ( . %) did not provide details, while ( . %) denied for various other reasons. comparison between patients willing to participate and those who were not did not produce significant results in terms of gender distribution. those who were willing to participate were significantly older than those who were not (mean age versus years; % ci for the difference from . to . years). one hundred and eight ( ) patients were enrolled in this study; however, three ( ) patients ( . %) did not complete it (two in the placebo group and one in the intervention group). one patient developed pneumonia, one patient reported being unable to swallow the pills and one patient was lost to follow-up after the initial examination (fig. ) . intervention (n¼ ) and control (n¼ ) group patients had similar demographic characteristics (gender, age, bmi, smoking habit, alcohol consumption) and vaccination pattern against streptococcus pneumoniae and influenza (supplemental table ). in each group, about half of the patients reported suffering from at least one chronic illness. most frequent chronic illnesses were heart diseases (n¼ , %), metabolic diseases (n¼ , %) followed by respiratory and musculoskeletal diseases (n¼ , %). clinical examination characteristics (which included systolic and diastolic blood pressure, oxygen saturation, pulses per minute, respiratory rate and temperature) were also similar in both groups (supplemental table ). finally, hematological (rbc, hemoglobin, hematocrit, wbc, neutrophils, lymphocytes, monocytes, thrombocytes), biochemical (sgpt, sgot, alp and creatinine) and immunological (crp) parameters were sim-ilar in both groups of patients (supplemental table ). the median lymphocyte count was not increased in either group, suggestive of the very initial phase of the respiratory infection. the median wurss- score at baseline was (lower quartile q ¼ , upper quartile q ¼ ) in the placebo group and (q ¼ , q ¼ ) in the intervention group (supplemental table ). there was one missing bmi measurement ( . %), two missing values for pack-years of smoking ( . %), one for pneumococcal vaccination ( . %) and two regarding previous hospitalization of patients ( . %). there were no missing measurements regarding presence of chronic diseases, vaccination against influenza and alcohol consumption. forty eight out of patients that were tested ( %) were found to be positive for at least one viral strain (fig. ) , assayed by specific rt-qpcr. the distributions of the demographic, hematological and biochemical variables appeared similar when the analysis was restricted to virus-positive patients (supplemental tables and ) with the possible exception of exception of lymphocyte count, which appeared somewhat higher at baseline in the intervention group (p¼ . ). interestingly, in % (n¼ ) of positive patients human rhinovirus (hrv) was detected ( % in the intervention group, % in the control group), while h n influenza, human metapneumonovirus (hmpv) and human coronavirus strain nl were identified in $ % (n¼ ) of virus-positive patients. the severity of symptoms at baseline, as assayed by the wurss- score, appeared highest in h n -positive patients (p¼ . , supplemental table ). the severity of symptoms for the total duration of the study was assessed using the wurss- score. the auc, the maximum wurss- score and the sum of the daily wurss- scores were calculated per individual to estimate the severity of symptoms over the followup period. using data from all participants, average auc values and total wurss- score appeared lower in the intervention compared to the placebo group but not to a statistically significant extent (with respective medians of cf. , p¼ . , and cf. , p¼ . ). average maximum wurss- scores were (min , max ) and (min max ) in intervention and control groups respectively (p¼ . ). boxplots of total wurss- score by day and group are presented in fig. a for all subjects and in fig. b for symptomatic patients only. no statistically significant differences in comparisons of daily scores between placebo and intervention groups were observed. using multiple linear regression of log-transformed auc on treatment and other possible predictor variables, treatment was not found to significantly affect ln(auc) (b¼ . ; % ci from À . to . ) adjusting for age (b¼ . ; % ci from . to . ), bmi (b¼ . ; % ci from À . to . ), gender (b¼ À . ; % ci from À . to . ), presence of chronic illnesses (b¼ À . ; % ci from À . to . ) and baseline crp-level (b¼ . ; % ci from À . to . ). no treatment-viral status interaction was found. the distributions of the daily wurss- scores in virus-positive intervention and control group patients are depicted in fig. c . administration of the cretan aromatic plants extract in virus-positive patients did not modify the total wurss- score to a statistically significant extent, although lower scores were identified in the intervention group compared to placebo group: median (min , max ) cf. (min max ), p¼ . . the average auc scores were also not found to differ to a statistically significant extent, although again lower scores were seen in the intervention group (median ) compared to the control group (median , p¼ . ). average maximum wurss- scores (out of a possible ) were (min , max ) and (min , max ) in intervention and control groups respectively (p¼ . ). using discrete-time hazard modeling with the complete data set, the "risk" of symptom cessation appeared % higher in the intervention group (hazard ratio, hr . , % ci . - . ), adjusting for age and gender. similar results were found when the analysis was restricted to virus-positive patients only: hr . , % ci . - . .the probability of cessation of symptoms per day is presented in fig. a and b for the total sample and the viruspositive patients respectively. a trend towards a higher, albeit nonstatistically significant, probability of symptom cessation in the intervention group can be seen. seventy percent of patients in the placebo group had a cessation of symptoms at the time of their final consultation, while the respective proportion in intervention group was . % (p¼ . ). finally, symptom amelioration was considered per virus infection (fig. a-d) . fitting the curves with a logistic equation (fig. e ) permitted us to evaluate the time (in days) of a % and an % amelioration of symptoms, as quantified by the wurss- questionnaire. despite the small number of patients, it becomes evident that a significant amelioration ( days) was observed in the % decrease of objective symptoms of the disease in patients with h n . at baseline, the proportion of patients with elevated crp levels was similar in both groups ( % and % in intervention and placebo groups respectively). at follow-up, the respective proportions were % in the intervention group and % in the placebo group (p¼ . ). in the intervention group, out of patients with initially elevated crp levels had low crp levels at follow-up ( %) as compared to out of patients in the placebo group ( %). a % ci for the percentage unit difference in favor of the intervention treatment was calculated as À % to %. within group changes in the proportion of patients with consistently elevated crp were statistically significant (po . and p¼ . for intervention and placebo groups respectively). details are presented in supplemental table , fig. . in the virus-positive group, normalization of crp values also occurred preferentially in the intervention group (fig. , supplemental table ). at baseline, the proportion of patients with elevated crp levels was identical in both groups. at follow-up, the respective proportions were % in the intervention group and % in the placebo group (p¼ . ). when the analysis was restricted within each study group, a statistically significant reduction of the number and proportion of patients with consistently elevated crp level was found only within the intervention group (p¼ . ). from the calculation of the number needed to treat (nnt), we found that we have to treat subjects from the whole group to see one with symptoms being ceased on the th day of the followup. the corresponding numbers of the ntt when we analyze the data in virus-positive subjects were on the th day. on the final day of their participation, all patients were asked to report on any possible adverse effect. six out of the that completed the study reported adverse effects; three of them had received the cretan aromatic plants (intervention) treatment. all three participants were females and their respective age was , and years old. one of them reported frequent urination, the second reported mild abdominal pain in the left upper quadrant (for one day), and the third participant reported rash on her arms which was present for three days. no change in hepatic or renal function was observed, as evidenced by sgot-sgpt and creatinine levels respectively. it is therefore concluded that the administration of the herbal extract, at least for the duration of our intervention, is safe. there is much research on the anti-viral and especially the antiinfluenza activity of a variety of medicinal plants worldwide, either in vitro by reporting the reduction of the viral cytopathic effect or in vivo. the main country in which such in vivo research has been conducted is china, where more than chinese patented medicinal recipes have been reported in (tang et al., ) . an interest in the effectiveness of herbal remedies in treating or preventing influenza or influenza-like illness has been acknowledged; however, a systematic review performed in databases until reported table presented in (e) shows the time in days at which half ( %) and % of wurss- encoded symptoms were relieved in the control and the intervention group, according to the virus found at day . data were calculated through a logistic fit of curves presented in a-d. rcts and concludes that the majority of performed studies concern small groups, assayed with questionable methodologies or they report clinically irrelevant effects (guo et al., ) . another systematic review (wu et al., ) , searching the evidence from cochrane systematic reviews, about the effectiveness of traditional chinese medicinal herbs in treating acute respiratory infections, came to similar conclusions. the authors also reported lack of quality in the researched trials and the presence of certain biases that have an impact on study validity (wu et al., ) . a recent chinese rct (wang et al., ) described the mean symptom population scores, as well as the number of recovered patients, as primary endpoints for treating influenza patients while one of the secondary endpoints included the time required to alleviate both fever and the severity of clinical symptoms (wang et al., ) . in our randomized clinical trial, we have compared the essentialoil extract of three cretan aromatic plants with placebo; our main finding is that the plant extract did not show a statistically significant benefit or harm in patients with upper respiratory illness of any cause, although a slight albeit non-significant amelioration of symptoms was detected in the treated patients. this is further more evident in virus-positive patients. in details, the following primary or secondary endpoints of the trial are: (a) the proportion of patients who presented symptom-free on day seven is higher in the intervention ( %) than in the control group ( %), a result close to statistical significance. interestingly, and in spite of the small number of patients, a favorable effect was found in the subgroup of h n influenza-infected patients. (b) the proportion of patients whose crp levels were normalized by the end of the follow-up period is significant in the intervention (p¼ . ), but not within the placebo group (p¼ . ). in addition, we found a number needed to treat (nnt) of in the total population decreasing to in the virus-positive population, meaning that at least one out of six virus-positive patients received the beneficial effect of our preparation. two key issues should be taken into consideration, prior to any safe conclusions on the effectiveness of the cretan extracts in our population: ( ) the definition of common cold that in our study was based on the jackson score is based on a subjective assessment and could have potentially introduced selection bias. we are not certain to what extent non-infectious diseases have been included in the study sample. this may explain the high number of patients without a virus-infection (resulting in a sample size far lower than that required to detect a medium-large effect size-see methods). the possible inclusion of non-infectious diseases could seriously have affected the design of the study that assumed a high proportion of patients with virus infection. ( ) the primary endpoint of this trial was also based on self-reported symptoms and it is known that subjective self-assessment might also be another potential source of bias. furthermore, the self-healing nature of the disease and the small duration of the symptoms presents additional difficulties in the exploitation of the data. in this report, we provide only clinical data, without any attempt to decipher underlying mechanisms of action, explaining the anti-viral properties of our preparation. however, preliminary data suggest a direct in vitro anti-viral action of our preparation. in a recent review it was highlighted that the use of certain herbal extracts rich in polyphenols could play an important role in controlling virus outbreaks and alleviating their symptoms (hudson, ) . actually, we are in the process of further delineating the direct anti-viral action of our preparation, as well as of some of its specific constituents, detected after an nmr analysis, although we strongly believe that the beneficial effect might be attributed to a combined effect of more than one constituent, as we have previously reported in the case of wine extracts kampa et al., ) . the present study is the first rct on the subject. randomization was successful in creating comparable baseline groups in terms of other disease prevalence, demographic, anthropometric and laboratory (biochemical, hematological and immunological) data. in addition, the proportion of patients completing the study was very high. however, there are certain limitations that need to be considered in the interpretation of results. our sample is limited in size ($ participants) and becomes even smaller when focussing on patients with a documented viral infection. even in the sub-sample of virus positive patients, our sample was very heterogeneous as several types of viruses were identified. however, the effect of our extract might be underestimated, since a sample of subjects with a virus-documented infection does not provide enough statistical power, to respond to the question of the potency of our preparation in a large spectrum of common cold and influenza viruses. this can only be addressed through laboratory estimation of the potency of our preparation on virallyinfected cells (which is under investigation) and through a larger analysis, permitting the collection of a significantly higher number of virus-infected patients. the use of herbs is extensively diffused among local cultures and it represents a time-line between ancient and modern traditions. tradition and culture can further create ideal synergies in engaging the pharmaceutical industry towards innovative herbal-oriented research and possibly new products. however, our main intention was to introduce and promote research based on indigenous knowledge of the european regional flora, especially from the island of crete, considered as a herbarium of the mediterranean flora. we do not, of course, suggest to the health practitioners that they replace existing guidelines about the use of anti-viral treatment in influenza virus, although the use of specific anti-viral agents has been recently criticized, nor we suggest the combined use of anti-viral drugs and herbal extracts, which may lead to unwanted drug-herb interactions (yang et al., ) . the study findings arrive on a time where much criticism has been published on the effectiveness of the neuraminidase inhibitors (jefferson et al., ) . very few adverse effects were reported in our study group. indeed, our current laboratory data suggest that our preparation is effective in a broad spectrum of viruses, at doses similar or higher to those reported here. compared with placebo the essential-oil extract of three cretan aromatic plants provided no detectable statistically significant benefit or harm in the patients with upper respiratory illness, although descriptive differences were identified in favorable direction mainly in the virus-positive population. in general, our rct study provides promising new data in the field of the use of aromatic plants and their therapeutic potential as anti-viral therapeutics, and calls for additional basic and interventional research either for prevention or treatment of common cold and influenza in larger group of patients. this study was supported by an unrestricted grant (grant no. -olv-herb- ) from olvos sa. the company did not interfere to the design and execution of the study, and the results presented represent the opinion of the authors. the established standards were strictly followed with the university of crete's special account for research (elke). identification of essential oil components by gas chromatography/mass spectorscopy healing and medicine in the aegean bronze age biological effects of essential oils-a review validation of a short form wisconsin upper respiratory symptom survey (wurss- ) essential oils: their antibacterial properties and potential applications in 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immunity research on component law of chinese patent medicine for antiinfluenza and development of new recipes for anti-influenza by unsupervised data mining methods chinese herbs in treatment of influenza: a randomized, double-blind, placebo-controlled trial traditional chinese medicine in the treatment of acute respiratory tract infections interaction between oseltamivir and herbal medicines used for treating avian influenza. hong kong medical journal ¼xianggang yi xue za zhi/hong kong academy of medicine the authors thank all participating primary care physicians who were responsible for the enrollment and clinical examination of eligible patients: nikolaos drakonakis, despoina chatzisymeon, vasiliki lemonomichelaki, dimitrios brimis, emmanouel doulgerakis, eva ladoukaki, anastasia stefanaki, irene stefanaki, georgios papadopoulos, and zoe troulaki. we also express our gratitude to maria dagianta who worked as the health centre coordinator.all authors would like to thank the team members from the clinic of social and family medicine, school of medicine, university of crete for their assistance: myron galenianos, irene vasilaki, and vasiliki-irene chatzea. the authors also appreciate the assistance of maria titaki and maria kouroupi in the implementation of the project. cl, sp and ec conceived and shaped the idea. ab, jm, cl, and eks prepared the first draft of the manuscript. jm was responsible for designing the randomization procedure. ab participated in the study, and was responsible for data entry and data analysis under the supervision of jm. gd participated in the study as coordinator and reviewed the manuscript. nm, spd, and gs were responsible for the biochemical and immunological analysis. gkt and hek were responsible for gc-ms analyses of specimens. cl provided clinical details and technical input, revised the manuscript and performed editing and format changes throughout the manuscript. all authors read and approved the final manuscript. supplemetary data (supplemental tables) associated with this article can be found in the online version at http://dx.doi.org/ . /j.jep. . . . key: cord- - c lsy g authors: yufei, yan; mingli, liu; xuejiao, li; xuemei, deng; yiming, jin; qin, qin; hui, shen; jie, guo title: utility of the neutrophil-to-lymphocyte ratio and c-reactive protein level for coronavirus disease (covid- ) date: - - journal: scandinavian journal of clinical and laboratory investigation doi: . / . . sha: doc_id: cord_uid: c lsy g to investigate the value of the combined detection of the neutrophil-to-lymphocyte ratio (nlr) and c-reactive protein level (crp) in the diagnosis of covid- . a total of patients with covid- were recruited at the third hospital of wuhan from january to february . fifty healthy volunteers were randomly selected as the control group. age, gender, white blood cell count (wbc), crp, lymphocyte percentage, and nlr were extracted. quantitative clinical characteristics and laboratory values were compared between groups. risk factors and receiver operating characteristic (roc) curves for covid- were analyzed. we found that the nlr and crp were higher, while the lymphocyte percentage was lower in patients with covid- than in healthy controls. among patients confirmed to have covid- , the nlr and crp of the moderate group were lower than those of severely ill patients (severe, critical and death groups), and the lymphocyte percentage of the moderate group was higher than that of the critical and death group. there were no significant differences in wbc among all groups. logistic regression analysis showed that the nlr, crp, and lymphocyte percentage were independent risk factors for covid- . the auc of the combined determination of nlr and crp was . , which was higher than that of nlr, crp, wbc, and lymphocyte percentage (auc: . , . , . , and . , respectively). our results showed that the nlr and crp were independent risk factors for covid- , and the combined detection of the nlr and crp showed improved diagnostic performance for covid- . coronavirus disease (covid- ) is a newly recognized pneumonia that has spread rapidly throughout wuhan, hubei province, and to other provinces in china and around the world [ , ] . as of march , , confirmed cases had been reported in mainland china, causing deaths. in addition, epidemics have spread to over countries around the world. covid- is an emerging, rapidly evolving situation [ ] . the pathogen has been identified as a novel rna beta coronavirus that has been subsequently named severe acute respiratory syndrome coronavirus (sars-cov- ) [ ] . control of the spread of disease relies on rapid diagnosis and appropriate clinical management. early and reliable detection of sars-cov- in clinical specimens will determine which patients should be immediately isolated and managed according to strict procedures of infection control. the protocols of who network laboratories [ ] facilitated the development of the rapid diagnosis of sars-cov- using nucleic acid amplification tests (naats), such as rt-pcr. however, the results of naats could be false negatives depending on the assay, specimen, and time course of the disease [ ] . public health testing capacity is likely to become overwhelmed in areas of widespread disease activity, and turnaround times are likely to be prolonged. decentralized testing will likely need to be made available at the hospital level. viral infection may produce various hematological changes. early studies have shown that lymphocytopenia is common among patients with covid- [ ] [ ] [ ] . accordingly, the neutrophil to lymphocyte ratio (nlr) in peripheral blood has been suggested to be useful in discriminating between types of infection [ ] and predicting the outcome of infection [ ] . c-reactive protein (crp), as a classic inflammatory biomarker, is one of the most sensitive acute-phase reactants and is virtually absent from blood serum in healthy people. crp levels can increase dramatically after bacterial and viral infections, inflammation, and severe trauma [ ] . elevated crp levels were also observed in covid- patients [ ] . however, the diagnostic performance of nlr and crp in covid- remains elusive. this study is aimed at testing the combined usability of nlr and crp as laboratory parameters, which may provide additional benefits in both the diagnosis of sars-cov- pneumonia and the early recognition of complications that may develop as a result of these clinical pictures. this retrospective observational study was conducted in the third hospital of wuhan (wuhan, hubei province, china). the study protocol was approved by the ethics board of the third hospital of wuhan. a total of consecutive patients with confirmed covid- who were admitted to the third hospital of wuhan from january to february were enrolled. all patients with covid- enrolled in this study were diagnosed according to world health organization interim guidance [ ] . fifty healthy volunteers from shanghai kongjiang hospital were selected randomly as the control group. chest computed tomographic (ct) scans were normal in all healthy controls. the following clinical information and initial laboratory data upon admission of all subjects were extracted from medical records: age, gender, white blood cell count (wbc), c-reactive protein level (crp), lymphocyte percentage, and nlr. wbc, lymphocyte percentage, neutrophil percentage and crp were measured by an automated hematology analyzer, namely, mindray bc- (mindray diagnostics, shenzhen, china), according to the manufacturer's instructions. the nlr was defined as the neutrophil percentage divided by the lymphocyte percentage. all patients confirmed to have covid- were divided into moderate, severe, critical, and death groups based on the severity of their illness according to the treatment protocol for novel coronavirus-infected pneumonia (trial version ). all statistical evaluations were performed using the statistical package for social sciences (spss inc., chicago, il) version . . categorical variables were presented as frequency rates and percentages. continuous variables were evaluated for normality using the kolmogorov-smirnov test. normally distributed continuous variables were expressed as the mean ± standard deviation, while non-normally distributed parameters were expressed as the median and range. to compare quantitative clinical characteristics and laboratory values between two groups, the mann-whitney u test was used, and the comparison between multiple groups was tested using the kruskal-wallis h test. the analysis of risk factors for covid- was performed using logistic regression; binary logistic regression was used to combine indicators. receiver operating characteristic (roc) curve analysis was performed to assess the predictive effect of various markers for covid- and identify a cutoff value as well as the corresponding sensitivity and specificity. a two-tailed pvalue < . was considered statistically significant. a total of patients with confirmed sars-cov- infection were enrolled in the study. a total of ( . %) of the patients were male, and ( . %) of them were female. the mean age was . years (standard deviation: . ). no significant difference in gender or age was observed between healthy controls and covid- patients. nlr, crp, wbc, ly% were non-normally distributed, so the data of each group were presented as median and - % tiles. the lymphocyte percentage of covid- patients was identified to be significantly lower than that of healthy controls. the nlr and crp level were significantly higher in covid- patients. no significant difference was observed in wbc values (table ) . for the comparison between multiple groups tested by kruskal-wallis h test, the values of nlr, crp, and lymphocyte percentage were distributed differently among the healthy controls and the moderate, severe, critical, and death groups (p < . ) ( table ). the nlr and crp of moderate, severe, critical, and death groups were all higher than those of the healthy controls, while the lymphocyte percentage values were all lower than those of the healthy controls. for the moderate group, the nlr and crp were lower than those of the severe, critical and death groups (p < . ), and the lymphocyte percentage was higher than that of the critical and death groups (p < . ). there was no significant difference in lymphocyte percentage, nlr or crp among the other groups (p > . ). there was no significant difference in the wbc value among all groups (p ¼ . ) (table and figure ). logistic regression analysis was performed using nlr, crp, wbc, lymphocyte percentage, gender, and age as independent variables and sars-cov- infection as the dependent variable. the results are detailed in table . the results showed that nlr, crp, and lymphocyte percentage were possible risk factors for sars-cov- infection, among which nlr was the most strongly associated with covid- (or ¼ . , % ci: . - . , p < . ). the diagnostic performance of nlr, crp and the combined detection of the nlr and crp for covid- the roc curve analysis showed that the area under the curve (auc) of nlr, crp, wbc, and lymphocyte percentage diagnosis of covid- were . , . , . , and . , respectively. moreover, we included the two best-performing indicators, crp and nlr, in the binary logistic regression analysis, and the equation was nlr þ . Â crp. we found that when we combined crp with nlr, the diagnostic accuracy was even higher (auc ¼ . , % ci: . - . ), suggesting that the combined detection of nlr and crp can improve the diagnostic performance compared to the detection of only one of these markers ( figure and table ). the present study of cases of covid- patients showed that the lymphocyte percentage of covid- patients was lower than that of healthy controls. although an association between viral infection and lymphocytosis has long been established [ ] , lymphopenia occurring in covid- patients has been reported by previous studies [ ] [ ] [ ] , and this phenomenon was also observed in sars [ ] . direct invasion by sars-cov viral particles damages the cytoplasmic component of the lymphocyte and causes its destruction [ ] ; indirect mechanisms such as vascular cell adhesion molecule- (svcam- ), soluble fas ligand (sfasl) or intense cytokine storms can induce apoptosis in lymphocytes [ ] . recently, the nlr has been proposed as a novel predictor of mortality in various diseases, such as heart failure and several types of cancer [ , ] ; however, the use of the nlr in the differential diagnosis of pneumonia is rare [ ] . in this study, we found that the neutrophil to lymphocyte ratio was significantly higher in covid- patients than in healthy controls. to the best of our knowledge, this is the first study to investigate the nlr in sars-cov- infections. moreover, our study found that patients with higher severity of pneumonia may have lower lymphocyte percentages and higher nlr, and logistic regression analysis showed that both lymphocyte percentage (or ¼ . , % ci: . - . , p < . ) and nlr (or ¼ . , % ci: . - . , p < . ) were independent risk factors predicting sars-cov- infection. the crp was significantly higher in patients infected with sars-cov- , and we found that the crp in the severely ill groups (severe, critical, and death group) was significantly higher than that in the moderate group or healthy controls, which was consistent with the findings of a previous study [ ] . higher blood crp levels, as a non-specific inflammation marker, play an instructive role in the acquired immune response as an innate recognition lectin [ ] , and elevated crp levels have also been associated with acute dyspnea due to pneumonia and bronchitis [ ] . our study showed that crp (or ¼ . , % ci: . - . , p ¼ . ) was an independent risk factor predicting covid- . subsequently, we analyzed the diagnostic performance of the parameters mentioned above. roc curves showed that lymphocyte percentage, nlr, and crp had good diagnostic efficiency (auc: . , . , . ). moreover, when the nlr and crp were combined, the auc increased to . , with a sensitivity of . % and a specificity of %. in conclusion, the outbreak of pneumonia infected with sars-cov- has had extensive influence around the world, which requires scientists, clinicians and governments around the world to work swiftly to combat covid- . in concert with recent studies [ ] , the similarities between the clinical features of covid- and those of previous beta coronavirus infections have been noted. in our study, we found that the lymphopenia and elevated crp found in covid- patients mimicked those of patients with sars-cov infection. this could be caused by the phylogenetic homogeneity between sars-cov- and other beta coronaviruses. in addition, our study further suggested that the nlr was an obvious independent risk factor predicting sars-cov- infection, and when combined with crp, the diagnostic efficiency for sars-cov- infection improved. given that this study was limited by its sample size, more comprehensive studies are required to help establish the role of these parameters in predicting covid- . epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china covid- ) situation report the species severe acute respiratory syndrome-related coronavirus: classifying -ncov and naming it sars-cov- world health organization. laboratory testing for coronavirus disease (covid- ) in suspected human cases: interim guidance the sars-cov- outbreak: diagnosis, infection prevention, and public perception clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china clinical features of patients infected with novel coronavirus in wuhan china medical treatment expert group for covid- . clinical characteristics of coronavirus disease in china role of neutrophil to lymphocyte and monocyte to lymphocyte ratios in the diagnosis of bacterial infection in patients with fever neutrophil-to-lymphocyte ratio as a prognostic marker in infective endocarditis: in-hospital and long-term clinical results a manual of laboratory and diagnostic tests who: clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected clinical manifestations, laboratory findings, and treatment outcomes of sars patients clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study mechanisms of lymphocyte loss in sars coronavirus infection neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are predictors of heart failure the role of the systemic inflammatory response in predicting outcomes in patients with operable cancer: systematic review and meta-analysis the neutrophillymphocyte count ratio in patients with community-acquired pneumonia the instructive role of innate immunity in the acquired immune response hematological and biochemical factors predicting sars fatality in taiwan no potential conflict of interest was reported by the author(s). key: cord- -vt zwfr authors: semmekrot, b. a.; croonen, e. a.; weijers, g.; van wieringen, p. m. v.; holl, r. a.; hendriks, j. c. m.; gerrits, g. p. j. m. title: vermindering van diagnostiek en overbehandeling bij rs-virus-bronchiolitis na geprotocolleerde behandeling date: journal: tijdschr kindergeneeskd doi: . /bf sha: doc_id: cord_uid: vt zwfr purpose: evaluating the guideline ‘diagnosis and treatment of respiratory syncytial (rs) virus bronchiolitis’ on the number of chest x-rays, c-reactive proteïn (crp) counts, leukocyte counts, and antibiotic prescriptions in infants admitted to hospital with rs bronchiolitis. design: retrospective ‘before-after’ cohort study. location: canisius-wilhelmina hospital, nijmegen, the netherlands. patients: infants admitted with proven rs virus infection. methods: guidelines, including sound restriction of performance of x-rays, crp and leukocytes, were introduced in february . data from infants admitted with rs virus infection during - (cohort a) were compared with those admitted from - april (cohort b) results: there were infants in cohort a and in cohort b. implementation of guidelines led to significant reductions of crp and leukocyte determinations: . % and . %, respectively (both p< . ) and x-rays: . % (p= . ). numbers of antibiotic prescriptions decreased with % (p< . ). the chance of antibiotic prescription increased significantly when x-rays (or= . ), crp (or= . ), or leukocytes (or= . ) were done. after implementation of the guidelines, the median stay in hospital decreased significantly from . to . days (p< . ; ranges - days and - days, respectively). performing x-ray, crp or leukocytes, or antibiotic prescription did not significantly alter the total duration of hospital stay. conclusion: implementation of the guidelines led to significant decreases in numbers of x-rays, crp and leukocytes determinations, and antibiotic prescriptions. our data support the restrictive use of chest x-rays, crp and leukocyte determinations in infants, admitted to hospital with rs virus bronchiolitis. het respiratoir syncytieel (rs-)virus is bij jonge kinderen het belangrijkste respiratoire pathogeen en het veroorzaakt in ongeveer % van de gevallen een bronchiolitis. [ ] [ ] [ ] ongeveer % van alle kinderen raakt tijdens het eerste levensjaar geïnfecteerd met het rs-virus. [ ] [ ] [ ] [ ] naar schatting moeten van de kinderen jonger dan een jaar met rs-infectie worden opgenomen. op de leeftijd van - jaar heeft bijna % van de kinderen antilichamen tegen het rs-virus ontwikkeld. [ ] [ ] [ ] [ ] [ ] [ ] rs-virusinfecties zijn seizoensgebonden en treden vooral op van eind oktober tot april. besmetting geschiedt door direct contact via handen, voorwerpen en door druppelcontact. de infectie begint meestal met rhinorroe, faryngitis, matige koorts, vaak vergezeld met hoesten en niezen. [ ] [ ] [ ] [ ] indien het virus door aspiratie de onderste luchtwegen bereikt, ontstaan klachten van droge hoest, tachypneu, subcostale en intercostale intrekkingen, eindinspiratoir crepiteren, piepen (vooral expiratoir), tachycardie, apneu en/of cyanose. [ ] [ ] [ ] differentiaaldiagnostisch moet worden gedacht aan een infectie met rinovirus, influenzavirus, para-influenzavirus type - , coronavirus of adenovirus, die een soortgelijk beeld kan geven. , sinds de ontdekking in door nederlandse onderzoekers moet hierbij ook het humane metapneumovirus (hmpv) genoemd worden. van het hmpv is inmiddels duidelijk dat het een belangrijke rol speelt bij bovenste en onderste luchtweginfecties op de kinderleeftijd met sterk op rs-virus gelijkende epidemiologische en klinische kenmerken. , het klinische beeld van een rs-virusinfectie varieert van mild tot ernstig. bij een ernstige infec-a r t i k e l e n samenvatting doel: evalueren of invoering van een protocol 'diagnostiek en behandeling van rs-virus-bronchiolitis' leidt tot minder thoraxfoto's, minder c-reactieve proteïne (crp-) en leukocytenbepalingen en minder antibioticavoorschriften bij opgenomen kinderen met respiratoir syncytieel (rs-)bronchiolitis. opzet: retrospectieve 'vóór-ná'-cohortstudie. plaats: canisius-wilhelmina ziekenhuis, nijmegen. patiënten: opgenomen kinderen met bewezen rs-virusinfectie. methoden: het protocol, met duidelijke restricties voor wat betreft het maken van een thoraxfoto en het bepalen van crp en leukocyten, werd in februari ingevoerd. data van kinderen met rsvirusinfectie opgenomen in de periode t/m (cohort a) werden vergeleken met die van kinderen opgenomen van t/m april (cohort b). resultaten: cohort a omvatte kinderen en cohort b . na invoering van het protocol nam het aantal crp-en leukocytenbepalingen af met respectievelijk , % en , % (beide p< , ) en het aantal thoraxfoto's met , % (p= , ). antibioticatoediening nam af met % (p< , ). de kans op het krijgen van antibiotica nam significant toe zodra een thoraxfoto werd gemaakt (or= , ), een crp-bepaling werd gedaan (or= , ) of een leukocytenbepaling werd verricht (or= , ). de mediane opnameduur nam na invoering van het protocol significant af van , naar , dagen (p< , ; range - dagen en - dagen, respectievelijk). het verrichten van crp-en leukocytenbepalingen, het maken van een thoraxfoto of antibioticatoediening hadden geen significante invloed op de opnameduur. conclusie: invoering van het protocol leidde tot significante afname van het aantal thoraxfoto's, crp-en leukocytenbepalingen en antibioticavoorschriften. onze gegevens ondersteunen een restrictief beleid met betrekking tot het verrichten van thoraxfoto's, crp-en leukocytenbepalingen bij in het ziekenhuis opgenomen kinderen met rs-virus-bronchiolitis. tie heeft het kind koorts en maakt het een zodanig zieke indruk, dat gedacht wordt aan een bacteriële (super)infectie. dit nodigt uit tot het verrichten van aanvullende onderzoeken zoals c-reactieve proteïne (crp), leukocyten met differentiatie en thoraxfoto. het probleem dat zich voordoet is dat afwijkingen die dan worden gevonden, niet specifiek zijn voor bacteriële superinfectie, maar ook bij 'gewone' rs-bronchiolitis kunnen passen. het verrichten van deze onderzoeken leidt zo gemakkelijk tot onterechte antibiotische behandeling indien de afwijkingen worden geïnterpreteerd als passend bij bacteriele pneumonie. literatuurgegevens laten zien dat de kans op een bacteriële superinfectie erg klein is, namelijk ongeveer %. , persisterend hoge koorts is de belangrijkste aanwijzing voor de aanwezigheid van een bacteriële superinfectie. [ ] [ ] [ ] het op onze afdeling in ingevoerde protocol 'diagnostiek en behandeling van rs-virus-bronchiolitis' gaat uit van terughoudendheid in het verrichten van aanvullend onderzoek (crp, leukocyten, thoraxfoto) en het geven van antibiotica, omdat het immers om een virale aandoening gaat. in dit onderzoek willen wij aantonen dat het volgen van een protocol leidt tot minder diagnostische bepalingen, afname van antibiotische behandeling en (mogelijk) afname van de opnameduur. het protocol 'diagnostiek en behandeling van rs-virus-bronchiolitis' is gebaseerd op het hoofdstuk bronchiolitis uit het werkboek kinderlongziekten. het protocol is desgewenst bij de auteurs op te vragen (via e-mail). doel van het protocol is het waarborgen van een optimale behandeling met minimale inzet van (diagnostische en therapeutische) middelen. bij verdenking op een rs-virusinfectie wordt een rs-sneltest afgenomen. dit is een immunochromatografische test voor opsporing van het rs-virus in het nasofaryngeale secreet. een kind dat met verdenking op een rs-virusinfectie wordt opgenomen, krijgt direct een rs-sneltest (binnen kantooruren). bij opname buiten kantooruren wordt uitsluitend onmiddellijk een rs-sneltest verricht indien dit consequenties heeft voor isolatie of plaatsing voor opname. in overige gevallen wordt deze meteen de volgende dag verricht. de uitslag is doorgaans bin-nen twee uur bekend. indien de eerste test negatief is wordt er een tweede afgenomen. binnen de cohorten werden patiënten onderverdeeld in drie leeftijdsgroepen: < maanden, - maanden en > maanden. uit onderzoek blijkt namelijk dat kinderen jonger dan twee maanden het grootste risico op aan het rs-virus geassocieerde apneu hebben. zekerheidshalve namen wij drie maanden als leeftijdsgrens. de grens van maanden komt voort uit het feit dat % van de kinderen al tijdens het eerste levensjaar een rs-infectie heeft doorgemaakt en deze zich na die tijd dus minder frequent zal voordoen. het onderzoek kan dan tevens informatie geven over de vraag of leeftijd van invloed is op het beloop en behandeling van kinderen met een rs-virusinfectie. exclusiecriteria waren: -geen rs-virus aangetoond tijdens opname, maar kind wel als zodanig behandeld; -kind overgeplaatst van/naar een ander ziekenhuis; -complicatie door andere infectie (niet pulmonaal) of opname om andere reden. overplaatsing naar een ander ziekenhuis vond plaats wegens respiratoire insufficiëntie of plaatsgebrek in het eigen ziekenhuis. als gevolg in tabel staan de demografische gegevens, de diagnostiek en de behandeling van de twee cohorten weergegeven. er was geen significant verschil in de verdeling tussen het aantal jongens en meisjes tussen de twee cohorten. de ratio jongens-meisjes bedroeg , : . de mediane opnameduur voor de rs-virusinfectie daalde significant van , dagen in cohort a naar , dagen in cohort b (p< , , range - dagen en - dagen, respectievelijk). nagegaan werd of de leeftijd een effectmodificator is voor de verschillen in diagnostiek tussen de protocollen, middels het toetsen van de interactieterm tussen protocol en leeftijdsgroep (< , - , > maanden) op statistische significantie in het multivariate lineaire model. het zou kunnen dat de afname zich bijvoorbeeld alleen afspeelt in de jongste leeftijdsgroep. de interactieterm bleek nergens significant te zijn (p= , - , ), wat betekent dat de verschillen tussen de protocollen in alle leeftijdsgroepen vergelijkbaar groot zijn. diagnostiek en behandeling tabel laat zien dat in cohort b significant minder diagnostiek en significant minder behandeling plaatsvond. tabel toont de geadjusteerde oddsratio met % betrouwbaarheidsinterval van de diagnostische tests voor de kans op het krijgen van antibiotica, met behulp van multivariate logistische regressie. zoals de tabel laat zien, verhoogt het verrichten van crp, x-thorax en leukocyten de kans op het gebruik van antibiotica. dit effect is vergelijkbaar groot in beide cohorten. wel is er in cohort b in vergelijking met cohort a een statistisch verlaagde kans op gebruik van antibiotica. ten aanzien van de leeftijdsgroepen zijn er geen significante verschillen in de kans op gebruik van antibiotica. de kans op gebruik van antibiotica is niet significant verschillend voor de leeftijdsgroepen. er zijn zowel voor crp, x-thorax als voor leukocytenbepaling geen statistisch significante verschillen in de opnameduur (tabel ). de mediane opnameduur is in cohort a met bijna een kwart verlengd in vergelijking met cohort b ( % met %-bi - %). bovendien is de mediane opnameduur in de leeftijdsgroepen < maanden en - maanden statistisch significant langer dan boven de maanden (respectievelijk %, %-bi - %, en %, %-bi - %) en deze verschillen zijn vergelijkbaar in beide protocollen (tabel ). rs-infectie ging in beide cohorten niet gepaard met mortaliteit. in deze studie werden de effecten van de invoering van een protocol voor diagnostiek en behandeling van rs-virus-bronchiolitis bestudeerd. we wilden vooral weten wat de invloed is van het verrichten van crp en x-thorax op het verstrekken van antibiotica. hiertoe werden cohorten vergeleken vóór en na invoering van het protocol. rs-opnamen betroffen vaker jongens dan meisjes ( , : ), overeenkomend met eerder retrospectief onderzoek. voorkeur voor jongens wordt verklaard door hogere vatbaarheid bij jongens door een geslachtsspecifieke respons op een rs-virusinfectie en/of achterlopende groei van de luchtwegen ten opzichte van het longparenchym bij jongens. het aantal kinderen bij wie een thoraxfoto werd gemaakt, nam significant af met %. eerdere studies met een vergelijkbare studieopzet, waarin kinderen jonger dan één jaar werden opgenomen met een eerste episode van bronchiolitis, toonden een significante afname (p< , ), , respectievelijk een niet-significante afname , van het aantal verrichte thoraxfoto's voor en na invoering van het protocol. in ons onderzoek leidde het maken van een thoraxfoto tot een significant hogere kans op antibiotica (p< , ). dit werd ook in eerdere onderzoeken gezien. het aantal crp-bepalingen nam met bijna de helft af (p< , ). een crp-bepaling kan niet differentiëren tussen een virale en bacteriële pneumonie en is onvoldoende sensitief en specifiek om een infiltraat op een thoraxfoto en een bacteriële etiologie van onderste luchtweginfecties uit te sluiten. crp-bepaling is dus geen goede gids voor antibiotische behandeling. wij stellen dan ook dat er geen toegevoegde waarde is van het gebruik van crp-bepalingen bij bewezen rs-virus-bronchiolitis. het aantal leukocytenbepalingen daalde met % (p< , ). in eerder onderzoek werd leukocytose-en crp-verhoging waargenomen bij ongeveer % van de kinderen met rs-virus-bronchiolitis zonder bacteriële (super)infectie. ons onderzoek toont aan dat crp-bepaling leidt tot een significant hogere kans op antibiotica, wat de opnameduur kan verlengen. het laatste kwam in ons onderzoek niet significant naar voren, wellicht doordat de totale opnameduur na invoering van het protocol significant afnam (zie verder). het aantal kinderen met antibiotica nam na invoering van het protocol significant af met %. dit komt niet overeen met eerdere studies, waarin een niet-significante afname van %, res-pectievelijk geen significant verschil werd gevonden. in een andere studie vond men aanvankelijk geen significant verschil in antibioticagebruik tussen twee met onze studie vergelijkbare cohorten ( - en ) , maar een significante afname (p< , ) in een vervolgstudie, mogelijk doordat hier werd vergeleken met een groter cohort ( ) ( ) ( ) . de afname van het antibioticagebruik in ons onderzoek schrijven we toe aan gedragsveranderingen bij de artsen ten gevolge van het ingevoerde protocol. de gemiddelde opnameduur nam na de invoering van het protocol significant af met %. eerdere studies toonden afnamen van % (p< , ), , % (p= , ) of geen significant verschil. , de gemiddelde opnameduur in die studies was echter met - dagen veel lager dan in ons onderzoek. internationale variatie in opnameduur werd eerder gerapporteerd en lijkt samen te hangen met risicofactoren zoals zuurstofondersaturatie, jonge leeftijd en prematuriteit. wij vonden geen significante invloed van het maken van een thoraxfoto en het op basis hiervan geven van antibiotica op de opnameduur, dit kwam overeen met een eerdere studie. de mediane tijd voor herstel ( dagen) verschilde in die studie niet significant tussen kinderen met en zonder thoraxfoto. , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) , ( , - , ) merk op: elke horizontale indeling is één tweevoudig variantieanalysemodel en de interactieterm tussen beide was nergens significant. geadjusteerd: geadjusteerd voor de andere variabele in het model; bi: betrouwbaarheidsinterval; crp: c-reactieve proteïne. plaatst naar een academisch ziekenhuis in verband met behoefte aan intensieve zorg. eventueel hierdoor ontstane selectie gold echter voor beide groepen die bovendien uit hetzelfde algemene ziekenhuis voortkwamen. wij achten daarom het effect van selectie gering. wij includeerden ook kinderen met risicofactoren voor een ernstiger beloop, zoals prematuriteit (< weken), chronische longziekte en congenitale hartziekte (zie tabel ). deze kinderen kregen significant vaker een infuus en antibiotica. omdat meer kinderen met risico in cohort b zaten dan in cohort a, zouden de gevonden verschillen ten gunste van groep b bij homogene verdeling wellicht groter zijn geweest. deze studie toont aan dat diagnostiek en behandeling van kinderen met rs-virus-bronchiolitis met een gericht protocol effectief kunnen worden gereduceerd. het verrichten van een thoraxfoto, en bepalingen van crp of leukocyten werken (onterechte) antibioticatoediening in de hand. wij bepleiten dan ook terughoudendheid met betrekking tot het verrichten van aanvullende diagnostiek bij patiënten met rs-bronchiolitis. dit zal tevens tot kostenreductie leiden. de auteurs zijn dank verschuldigd aan mw. m.l. brouwer, kinderarts-kinderpulmonoloog, voor het kritisch doorlezen van het manuscript gerrits, kinderartskinderpulmonoloog, dhr. dr. b.a. semmekrot, kinderarts-neonatoloog, afdeling kindergeneeskunde, canisius-wilhelmina ziekenhuis correspondentieadres: dr. b.a. semmekrot, afdeling kindergeneeskunde, canisius-wilhelmina ziekenhuis, postbus , gs nijmegen viral lower respiratory tract infection in infants and young children schilte ppm (red.). werkboek kinderlongziekten recent trends in severe respiratory syncytial virus (rsv) among us infants lage incidentie van nosocomiale infecties met respiratoir syncytieel virus onder kinderen jonger dan c-reactive proteïn (crp) counts, leukocyte counts, and antibiotic prescriptions in infants admitted to hospital with rs bronchiolitis. design: retrospective 'before-after' cohort study. location: canisius-wilhelmina hospital ) and x-rays: . % (p= . ). numbers of antibiotic prescriptions decreased with % (p< . ). the chance of antibiotic prescription increased significantly when x-rays (or= . ), crp (or= . ), or leukocytes (or= . ) were done. after implementation of the guidelines, the median stay in hospital decreased significantly from . to . days (p< . ; ranges - days and - days, respectively). performing x-ray, crp or leukocytes, or antibiotic prescription did not significantly alter the total duration of hospital stay. conclusion: implementation of the guidelines led to significant decreases in numbers of x-rays, crp and leukocytes determinations, and antibiotic prescriptions. our data support the restrictive use of chest x-rays, crp and leukocyte determinations in infants, admitted to hospital with rs virus bronchiolitis infectie met respiratoir syncytieel virus en mogelijkheden voor preventie rhinovirus and the lower respiratory tract reducing the impact of viral respiratory infections in children a newly discovered human pneumovirus isolated from young children with respiratory tract disease human metapneumovirus in paediatric patients diagnosis and testing in bronchiolitis: a systematic review risk of secondary bacterial infection in infants hospitalised with respiratory syncytial viral infection risk factors for respiratory syncytial virus associated apnoea risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections concurrent serious bacterial infections in infants and children hospitalized for treatment of respiratory syncytial virus lower respiratory tract infection clinical profile of pediatric patients hospitalized with respiratory syncytial virus infection. clin pediatr gender analysis in acute bronchiolitis due to respiratory syncytial virus sex and gender differences in lung development and their clinical significance evaluation of an evidence-based guideline for bronchiolitis sustaining the implementation of an evidencebased guideline for bronchiolitis impact of a bronchiolitis guideline: a multisite demonstration project effect of rsv bronchiolitis practice guideline on resource utilization randomised controlled trail of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children clinical items not helpful in differentiating viral from bacterial lower respiratory tract infections in general practice assendelft wjj. diagnostic value of c-reactive protein in infections of the lower respiratory tract: systematic review diagnostiek en behandeling van kinderen met acute bronchiolitis door infectie met respiratoir syncytieel virus; resultaten van een enquête onder alle nederlandse kinderartsenpraktijken in standardizing the care of bronchiolitis international rsv study group. international variation in the management of infants hospitalized with respiratory syncytial virus key: cord- -xwjwt be authors: ruppert, christoph; kaiser, lars; jacob, lisa johanna; laufer, stefan; kohl, matthias; deigner, hans-peter title: duplex shiny app quantification of the sepsis biomarkers c-reactive protein and interleukin- in a fast quantum dot labeled lateral flow assay date: - - journal: j nanobiotechnology doi: . /s - - - sha: doc_id: cord_uid: xwjwt be fast point-of-care (poc) diagnostics represent an unmet medical need and include applications such as lateral flow assays (lfas) for the diagnosis of sepsis and consequences of cytokine storms and for the treatment of covid- and other systemic, inflammatory events not caused by infection. because of the complex pathophysiology of sepsis, multiple biomarkers must be analyzed to compensate for the low sensitivity and specificity of single biomarker targets. conventional lfas, such as gold nanoparticle dyed assays, are limited to approximately five targets—the maximum number of test lines on an assay. to increase the information obtainable from each test line, we combined green and red emitting quantum dots (qds) as labels for c-reactive protein (crp) and interleukin- (il- ) antibodies in an optical duplex immunoassay. cdse-qds with sharp and tunable emission bands were used to simultaneously quantify crp and il- in a single test line, by using a single uv-light source and two suitable emission filters for readout through a widely available bioimager device. for image and data processing, a customized software tool, the multiflow-shiny app was used to accelerate and simplify the readout process. the app software provides advanced tools for image processing, including assisted extraction of line intensities, advanced background correction and an easy workflow for creation and handling of experimental data in quantitative lfas. the results generated with our multiflow-shiny app were superior to those generated with the popular software imagej and resulted in lower detection limits. our assay is applicable for detecting clinically relevant ranges of both target proteins and therefore may serve as a powerful tool for poc diagnosis of inflammation and infectious events. [image: see text] sepsis, a life-threatening syndrome following a dysregulated host response to infection, frequently leads to organ dysfunction; it is a major public health concern because of its high mortality rates [ ] . because unspecific pathologies pose difficulties in diagnosis, the definition of sepsis has developed over time. the most recent international consensus on the definition of sepsis and septic shock, sepsis- , was published in and defines diagnostic guidelines including hypotension, a decreased respiratory rate and a decrease in lactate levels. the quick sequential organ failure assessment (qsofa) score was further introduced for fast identification in patients at high journal of nanobiotechnology *correspondence: kohl@hs-furtwangen.de; dei@hs-furtwangen.de medical and life sciences faculty, furtwangen university, jakob-kienzle str. , villingen-schwenningen, germany full list of author information is available at the end of the article risk [ ] . distinguishing sepsis from systemic inflammatory response syndrome (sirs), which is not caused by a microbial insult, remains difficult, but this distinction is essential to determine proper treatment. for example, if a non-microbial event, such as trauma or necrosis, is the cause of inflammation, administration of antibiotics may cause unnecessary stress and increased mortality [ ] . sepsis leading to organ failure frequently involves the so-called cytokine storm, which also leads to complications in patients with covid- [ ] . therefore, to achieve efficient therapeutic approaches, there is a major clinical need for biomarker assays with a fast turnaround time of ≤ min to diagnose sepsis and guide therapy. currently, no single biomarker can be used for the diagnosis of sepsis. however, evidence suggests that combined determination of multiple biomarkers might compensate for the low sensitivity and specificity of single marker molecules [ ] . c-reactive protein (crp), the clinically most important acute-phase protein, and interleukin- (il- ) are both early biomarkers that can provide valuable information for distinguishing non-microbial sirs from sepsis [ , ] . the kda pentamer of crp binds polysaccharides in pathogens and subsequently activates the complement pathway [ , , ] . under normal conditions, crp levels are approximately . mg/l ( nm) and do not exceed mg/l ( nm). elevated crp levels are indicative of an inflammatory process [ ] ; these levels can rise to up to mg/l ( , nm) in severe cases. the proinflammatory cytokine il- was chosen as the second target, because it is observed very early after noxious events and is produced almost instantly by b and t cells in response to bacterial pathogens. il- weighs approximately kda, and normal levels are lower than ng/l ( . pm). in noxious events, the il- levels can rise as high as µg/l ( pm) [ ] . indeed, crp and il- levels both substantially differ between non-septic and septic patients, as well as between septic patients and patients with sirs, thereby allowing for no sepsis, sepsis and sirs to be differentiated [ , ] . furthermore, accurate quantification of crp and il- in sepsis and covid- may be crucial for predicting outcomes, thus potentially enabling early therapeutic interventions and therapy control, e.g., in response to mechanical ventilation or tocilizumab treatment [ ] [ ] [ ] . indeed, several other molecules, such as procalcitonin, are frequently described as potential biomarkers for sepsis [ , ] and therefore may be included in further development of lateral flow assays, to increase the specificity of such point of care (poc) devices. a combination of crp and il- in poc devices would have numerous potential areas of application. for example, combined quantification of crp and il- might be useful for the detection of periprosthetic hip infections [ ] . furthermore, different concentration ranges for crp, as well as for il- , have been shown to serve as risk indicators for coronary artery disease [ ] [ ] [ ] . the relevant detection range of both crp and il- is, however, highly dependent on the intended application. lateral flow immunoassays (lfias) are simple, rapid, robust and cost-effective devices with demonstrated potential to simplify and accelerate diagnostics in laboratory settings as well as in resource-poor environments; therefore, lfias are a preferable choice for poc diagnostics. furthermore, the desired concentration ranges can easily be adjusted by varying the applied sample volumes or adding competing unlabeled antibodies, thus rendering lfias highly flexible. in addition, different design approaches can be used in lateral flow assays, such as sandwich assays (fig. ) or a competitive design to enable detection of small molecules [ , ] . in competitive design, if antigen is present in the sample, bioprobes consisting of an antibody conjugated to a dye particle will be saturated and unable to bind the test line (see fig. a ). if no or little analyte is present in the sample, the bioprobe binds at the test line (see fig. b ). saturated probes are captured at the control line by secondary antibodies, thus indicating that the test is valid [ , ] . a positive assay shows one test line. the information obtained from each test line can be multiplied by using bioprobes tagged with distinct colors; accordingly, more distinct parameters can be investigated in one lateral flow assay (lfa). to date, mixing different colors at one test line has been achieved only with chromogenic bioprobes [ ] [ ] [ ] . a mixture of fluorescent bioprobes has been used only with readout on separate test lines [ ] . for detection, antibodies to crp and il- were conjugated to green and red emitting semiconductor nanocrystals, so-called quantum dots (qds). qds can be excited simultaneously by a single uv-light source, emit narrow, sharp peaks of a distinct color, are very resistant to photodegradation and have high fluorescence intensities, which makes qds a very favorable and effective label for duplex or multiplex approaches in bioassays like lfas [ , ] . for synthesis of qd labeled antibody conjugates, we used amine modified candot seriesa qds (em. max. and em. max. ) purchased from can (hamburg, germany) and carboxyl modified qds (qdot itk, qdot itk) from thermo fischer scientific (waltham, usa). two anti-human il- antibodies (polyclonal host: goat; monoclonal host: mouse), two anti-human-c-reactive protein antibodies (polyclonal host: rabbit; monoclonal host: mouse) and recombinant human il- were obtained from peprotech (hamburg, germany). secondary anti-mouse (polyclonal host: goat; anti-heavy and light chain igg, iga and igm) antibodies for generation of the control lines were purchased from sigma aldrich (st. louis, usa). buffers and reagents were purchased from sigma aldrich. human crp was purchased from life diagnostics (west chester, usa). biotinylated il- and crp were provided by r-biopharm (darmstadt, germany). all buffers and reagents were prepared with milliq water (≥ mΩ). pur-a-lyzer midi ( kda mwco) dialysis tubes and vivaspin ( kda mwco) columns were purchased from sigma aldrich (st. louis, usa). lateral flow test strips with a streptavidin test line and anti-mouse-antibody control line were provided by r-biopharm. cn and cn lateral flow membranes were obtained from sartorius (goettingen, germany). amine qd (candot- -anti-crp and candot- -anti-il- ) antibody conjugates were prepared with the following protocol. for activation of qds (candots series a, amine) µl stock solution ( µm) was diluted in µl × pbs ( mm edta, ph . ), and µl of smcc ( µm in milliq water) was added. the mixture was incubated on a horizontal shaker at °c for h. the solution was then dialyzed ( kda mwco) against × pbs ( mm edta, ph ) for min to remove excess smcc linker. after dialysis, the volume was adjusted to µl with × pbs ( mm edta, ph . ). for antibody activation, µl of antibody (anti il- or crp; . mg/l in milliq water) was dissolved in µl × pbs ( mm edta, ph ). then µl of traut's reagent ( -iminothiolan, . µm, tenfold excess) was added to a final volume of μl. the mixture was incubated for h at rpm and °c. excess traut's reagent was removed with a centrifugal concentrator (vivaspin , kda mwco), and the antibodies were washed twice with µl pbs ( mm edta, ph ). antibodies were then re-dispersed in µl × pbs ( mm edta) and combined with the activated qd-solution. the reaction mix was incubated for min at rpm and °c. then µl % bsa in milliq water was added to the solution to a final volume of µl, and the conjugates were stored at °c overnight. carboxyl qds (qdot- -anti-crp-conjugate and qdot- -anti-il- -conjugate) antibody conjugates were prepared with the following protocol. a total of µl of qdot itk stock solution ( µm) was dissolved in µl mes buffer ( mm, ph . ). then µl edc ( mg/ml in milliq water) and µl sulfo-nhs ( mg/l in milliq water) were added; the mixture was incubated for min at rpm and °c. then µl of mes buffer (ph . ) and µl of antibody solution ( . µg/ml in pbs, ph . ) were added to a final volume of µl; the mixture was incubated for min at rpm and °c. then µl hepes buffer ( mm, . % tween and % bsa, ph . ) was added to a final volume of µl, and the conjugates were stored at °c overnight. qd (carboxylated) conjugates were characterized by fluorescence emission spectra, agarose gel electrophoresis and dynamic light scattering to verify successful conjugation (additional file : section s . ). fluorescence spectra measurements were collected with a tecan infinite pro plate reader from tecan group ltd. (männedorf, switzerland). briefly, the prepared conjugates were diluted in ddh o to µl. afterward, qds were excited at nm, and the fluorescence emission between and nm for qd , or and nm for qd , was recorded. emission peaks were normalized to the peak maximum by dividing the emission values by the maximum emission value. agarose gel electrophoresis of qds before and after conjugation to the corresponding antibodies was performed with . % (w/v) agarose gel electrophoresis in × tris-acetate-edta buffer. electrophoresis was performed at v/cm for min, and pictures were taken with a gel ix imager device (intas, göttingen, germany). dynamic light scattering measurements were performed with a zetasizer nano instrument (malvern, worcestershire uk). three different systems were used in the development of the duplex lfa for detection of crp and il- through optical duplex detection: after printing, the lateral flow membranes were dried overnight in a desiccator at room temperature. the membranes were then affixed to absorbent filters (whatman) with adhesive tape and cut into mmwide lfa-strips. for all lateral flow tests, running buffer (bis-tris mm, % triton x- and . % bsa, ph . ) was used. sample proteins were dissolved in × pbs with a content of % (streptavidin assay), % (sandwich assay) or % (clinical range assay) human serum. for the streptavidin assay, biotin-labeled target proteins were used. the volume for one lateral flow test sample preparation was μl or µl, consisting of - µl qd-conjugates of each color, µl or µl target protein solution, and or µl running buffer. the sample mixture was prepared in ml flat bottomed reaction vessels and incubated for min. then test strips were placed upright in the prepared vessels for either or min to allow the sample mixture to flow through the membranes. after the run, the test strips were placed on a benchtop to dry for min and then imaged. sample preparations for different assays are summarized in table . images of test strips were acquired with a bioimager streptavidin and sandwich assays) or × binning (for clinical range assays). depending on the experimental setup, as well as the analyzed qd, illumination times between and s were chosen to achieve images with clearly visible test and control lines but no oversaturation of the lines, which has been demonstrated to have a negative influence on the readout of auc values in imagej or the developed multiflow-shiny app, thus leading to flat readout peaks (oversaturated peaks). illumination times were kept constant for each experimental setup and the corresponding qd conjugates used. a detailed list of the imager settings used is shown in additional file : section s . . for image processing and data collection, we programmed readout software based on several packages of r statistical software for analysis of bioassay data, which was implemented in our multiflow-shiny app [ ] [ ] [ ] [ ] . we processed all acquired image datasets with our app and with the imagej (v . i) gel analyzer tool and compared the acquired key measures such as limit of blank (lob), limit of detection (lod) and limit of quantification (loq) [ , ] . our data processing multiflow-shiny app can be used to process colorimetric data lists from auc values acquired with other software, such as imagej, or can be used as an all-in-one solution for image readout with automated generation of a results sheet. the software allows for cropping, segmentation and background correction of the images to generate the background corrected intensity values for the bands. it combines the intensity data with experimental data, can average technical replicates and computes linear calibration curves. furthermore, an .html report is generated, including full details about the calibration analysis. the development version of our r packages including the multiflow-shiny app can be downloaded from https ://githu b.com/ stama ts/multi flow. further details on the multiflow app and an illustrated users guide for the use is available from https ://stama ts.githu b.io/multi flow/multi flow.html; a video tutorial is available from https ://www. youtu be.com/playl ist?list=plrgo zxm l z gv ojts c n gsxo vran. in the app, imported image files of lfa-strips were first cropped and segmented to select the area of interest and to include a visual control with the test and control lines being properly positioned to enable subsequent background subtraction through otus's method and readout of line intensity values [ ] . the acquired values were merged with the experimental information and exported as a .csv file, which was used to calculate concentration values derived from the duplex crp/il- lfa. the app allowed us to create custom calibration profiles for strip based bioassays and generate .html reports with the results of the calibration analysis as well as the key measures lob, lod and loq. the objective of the experiments was to evaluate whether two analytical targets could be quantitatively detected at the same test line by using two different fluorescent labels. therefore, biotinylated analytes (biotinylated crp and biotinylated il- ) in combination with two different qd-antibody conjugates (candot- -anti-crp and candot- -anti-il- ) were used. after binding of biotinylated targets to the corresponding antibody-qdconjugates, the complex was bound on the streptavidin test line (fig. a) . conjugates without target did not bind the test line but were captured on the control line containing secondary antibodies. we first intended to use the system as a competitive immunoassay, in which the added target proteins, crp/ il- without a biotin label, would compete for antibody binding, thus decreasing the fluorescence signal intensity on the test line with increasing target concentration. however, the competitive assay did not show a quantitative correlation after evaluation of the data obtained via imagej (additional file : s . ). we assume that this result was due to high amounts of target competing for the antibody as well as biotin/streptavidin binding sites. indeed, evaluation with our own data processing mul-tiflow-shiny app revealed a concentration dependent decrease in test line signal intensity (additional file : s . ). however, the variability and linearity remained poor, as indicated by the low coefficient of determination. therefore, we switched to a sandwich immunoassay approach, decreasing the number of required components. after demonstrating that the system generated quantitative data in the streptavidin assay, whereas the competitive assay format was unsuccessful, we designed a new lfa setup based on a sandwich immunoassay format. the test line was composed of anti-crp and anti-il- antibodies, and qd- -anti-crp and qd- -anti-il- antibodies were used with unlabeled crp and il- proteins as targets. initially, we decided to use similar concentration ranges for both analytes to evaluate the linearity at comparable intensities. because the relevant concentration ranges for both analytes differed by several orders of magnitude, we initially decided to use concentrations between and nm for both analytes. indeed, when we used the data obtained from imagej as well as from our multiflow-shiny app, the sandwich immunoassay format clearly showed a concentration dependent signal increase for both analytes in the range of - nm. nevertheless, the variability in the intensities obtained from imagej analysis still remained poor. additional analysis with our multi-flow-shiny app, however, showed significantly lower variability and enhanced the limit of detection and of quantification ( fig. and table ). this result was probably due to the automated intensity measurement in combination with background correction in the multi-flow-shiny app; in contrast, in classical imagej analysis, these parameters are defined by the user. figure shows the calibration curves for the range of - nmol/l for crp and il- . the r -values were clearly better for data acquired with the multiflow-shiny app ( . and . ) than with imagej ( . and . ). overall, data processing through the multiflow-shiny app provides a benefit over imagej, a popular, widely used standard tool for quantification of laboratory data. the multiflow-shiny app is a user-friendly solution for readout and data processing of functional lfas that can be used not only for qd labeled antibodies but also for any kind of lfa, in principle containing an arbitrary number of bands with one or more color labeled antibodies. as described in "introduction", the relevant clinical range of crp is between and nm, whereas the clinical range of il- is much lower, between . and pm. because our initial sandwich immunoassay was developed by using a range between and nm, the assay needed to be adjusted to better reflect the relevant concentration ranges observed during inflammatory events such as sepsis or bacterial/viral infections. therefore, the detection limit of il- was decreased to below pm through increasing the sample amount used per lfa from to µl; using a slow wicking, high sensitivity lateral flow membrane; and decreasing the amount of qdot- -anti-il- -conjugate to decrease the background fluorescence. to compensate for low emission, we decreased the resolution of the ccd-camera from a maximum of mp resolution to × binning settings, thus allowing for a fast acquisition time of s while maintaining the brightness of the test lines to be detected. the crp concentration in blood samples is of interest if it exceeds nm; therefore, the detectable concentration needed to be adjusted to accommodate higher amounts. this was achieved by dilution of the qdot- -anti-crp conjugates with additional anti-crp antibodies, which competed with the qd-conjugates for the target protein (the sample composition of all three assay types can be found in table ). using these simple modifications, we were able to adjust the crp/il- assay to the clinically relevant range (examples of test strips in fig. ; linear calibration models of both analytes in fig. and key measures in table ), thus enabling the immediate applicability of our assay. the multiflow-shiny app provides an all in one solution for the analysis of images taken from lfas that may include up to six lines, a restriction we chose since we are not aware of any lfa having more than six lines. it works for grayscale as well as color images and can handle images that include several well aligned strips in one batch. overall, it clearly speeds up the analysis process compared to other image analysis software such as imagej. it provides various tools for processing the images, handling the intensity and the experimental data, conducting a calibration analysis by arbitrary linear models and generating automatic.html reports of the calibration analysis. furthermore, the app offers various options to start the analysis. instead of starting with the raw images, one can also start with already existing intensity data (e.g. from imagej) or further preprocessed intensity data (e.g. after averaging technical replicates). the results of the multiflow-shiny app are also well reproducible, since the analysis is fully automatic except for the cropping of the images. we found that the app especially outperforms the manual analysis with imagej when the analyzed lfas contain very weak signal intensities or broad and blurred lines and consequently leads to better calibration with higher measures of determination. figure shows screenshots of the user interface of the multiflow-shiny app. the presented lfas were designed to detect the sepsis biomarkers crp and il- simultaneously on one test line, by using two different qds as labels. we calibrated the lfas (streptavidin, sandwich assay and clinical range assay) by using linear models, and we demonstrated that optical duplex imaging using emission filters for signal separation did not indicate any mutual disturbance between different qd-dyed antibody probes. the results therefore indicated that the presented setup is suitable for quantitative readout. data processing with our multiflow-shiny app with automated report generation significantly increased the test performance relative to that of a general-purpose standard software solution, such as imagej. this improvement was particularly evident in the detection of lfa lines with very weak signal intensities or wide and blurred lines. accordingly, we not only achieved but exceeded the sensitivity required for the detection of crp in clinical diagnostics. we furthermore demonstrated that, with simple adjustments (e.g., varying the sample volume, amount of probes applied, addition of unlabeled antibodies and different lateral flow membranes), this method can be made suitable for detecting clinically relevant concentration ranges, the influence of a change in septic shock definitions on intensive care epidemiology and outcome: comparison of sepsis- and sepsis- definitions the 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c-reactive protein and interleukin- may be useful to detect periprosthetic hip infection high-sensitivity c-reactive protein and cardiovascular disease across countries and ethnicities the impact of c reactive protein on global cardiovascular risk on patients with coronary artery disease elevated serum interleukin- is predictive of coronary artery disease in intermediate risk overweight patients referred for coronary angiography lateral flow (immuno) assay: its strengths, weaknesses, opportunities and threats. a literature survey multiplexed lateral flow biosensors: technological advances for radically improving point-of-care diagnoses dual-quantum-dots-labeled lateral flow strip rapidly quantifies procalcitonin and c-reactive protein multiplexed dot immunoassay using ag nanocubes, au/ag alloy nanoparticles, and au/ag nanocages multicolored silver nanoparticles for multiplexed disease diagnostics: distinguishing dengue, yellow fever, and ebola viruses traffic light" immunochromatographic test based on multicolor quantum dots for the simultaneous detection of several antibiotics in milk multiplexing in bioassays selection of quantum dot wavelengths for biomedical assays and imaging r: a language and environment for statistical computing. vienna: r foundation for statistical computing shiny: web application framework for r shinyimage: image manipulation, with an emphasis on journaling multiflow: multiplex lateral flow assays limit of blank, limit of detection and limit of quantitation method validation essentials, limit of blank, limit of detection, and limit of quantitation threshold selection method from gray-level histograms publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations support from bundesministerium für bildung und forschung (multiflow project: fh px and flowarray project: fh px ) is gratefully acknowledged. we thank weronika schary and filip paskali for their support in developing and testing the shiny app. we thank r-biopharm (darmstadt germany) and especially steffen rameil for their support. thus providing a highly useful poc assay. similar approaches should be feasible for other targets. the setup presented, with its optimization to clinical parameters, has potential for increased number of analytical targets and optimized readout workflow through our app. together with the downsizing of readout equipment, the assay has promise as a robust, inexpensive and rapid poc sensing system for sepsis and other diagnostic challenges. supplementary information accompanies this paper at https ://doi. org/ . /s - - - .additional file . supplementing information of material characterization, imaging hardware settings and results of data processing for the streptavidin and clinical range assay. authors' contributions cr performed most of the experiments, performed analysis of data through imagej and wrote this article. lk performed particle characterization experiments and contributed to writing and editing of this article. ljj performed streptavidin assay pre-experiments. mk performed statistical data analysis, programmed r-packages and apps, and contributed to writing of data processing parts. sl and hpd revised the manuscript and contributed to editing. all authors read and approved the final manuscript. open access funding provided by projekt deal. multiflow-shiny app download: https ://githu b.com/stama ts/multi flow manual at: https ://stama ts.githu b.io/multi flow/multi flow.html video tutorial: https ://www.youtu be.com/playl ist?list=plrgo zxm l z gv ojts c n gsxo vran additional charts and tables referred to in the text are available in additional file . not applicable. not applicable. the authors declare no conflicts of interest. medical and life sciences faculty, furtwangen university, jakob-kienzle str. , villingen-schwenningen, germany. institute of precision medicine, furtwangen university, jakob-kienzle str. , villingen-schwenningen, key: cord- -vb nx authors: liu, kuan-ting; lin, tzeng-jih; chan, hon-man title: characteristics of febrile patients with normal white blood cell counts and high c-reactive protein levels in an emergency department date: - - journal: the kaohsiung journal of medical sciences doi: . /s - x( ) - sha: doc_id: cord_uid: vb nx fever is one of the more common chief complaints of patients who visit emergency departments (ed). many febrile patients have markedly elevated c-reactive protein (crp) levels and normal white blood cell (wbc) counts. most of these patients have bacterial infection and no previous underlying disease of impaired wbc functioning. we reviewed patients who visited our ed between november and july . the wbc count and crp level of patients over years of age who visited the ed because of or with fever were recorded. patients who had normal wbc count ( , – , /ml) and high crp level (> mg/l) were included. the data, including gender, age and length of hospital stay, were reviewed. underlying diseases, diagnosis of the febrile disease and final condition were recorded according to the chart. within the study period, , patients visited our ed. of , febrile adults, ( . %) had elevated crp level and normal wbc count. the major cause of febrility was infection ( . %). most of these patients were admitted ( . %). there were patients with malignant neoplasm, nine with liver cirrhosis, with diabetes mellitus and with uremia. there were no significant differences in age and gender between patients with and those without neoplasm. however, a higher inhospital mortality rate and other causes of febrility were noted in patients with neoplasm. it was not rare in febrile patients who visited the ed to have a high crp level but normal wbc count. these patients did not necessarily have an underlying malignant neoplasm or hematologic illness. factors other than malignant neoplasm or hematologic illness may be associated with the wbc response, and crp may be a better indicator of infection under such conditions. examine febrile patients. sometimes, they have significant symptoms and signs, and the diagnosis can be made by suitable examination. on other occasions, however, patients do not have obvious symptoms and signs, although physicians need an indicator to avoid a failure to diagnose severe disease. in febrile patients, white blood cell (wbc) count is a common examination. in addition, procalcitonin, c-reactive protein (crp) and interleukin- levels will be elevated in cases of severe infection [ ] [ ] [ ] [ ] [ ] [ ] [ ] . some studies suggest that these examinations could help to differentiate between less threatening fever and septic patients. crp is a common available examination item in taiwan's hospitals. in practice, however, wbc count and crp are not always elevated at the same time [ ] [ ] [ ] . some obviously septic patients do not have elevated wbc count but their crp is markedly elevated. such a condition can also be found in some patients with hematologic disease and neoplasm [ , ] . we found that many patients without hematologic disease and neoplasm have normal wbc count and markedly elevated crp. these patients usually have obvious infection or inflammation. therefore, we analyzed the characteristics of these patients, and then compared them with those of patients with malignancy. we retrospectively reviewed patients who visited the ed of kaohsiung medical university hospital between november and july because of fever or high body temperature (tympanic temperature > . °c). because the period of study was within year of the severe acute respiratory syndrome (sars) outbreak, all febrile patients received blood examinations including wbc count and crp level. adult patients (> years) who had normal wbc counts ( , - , /μl) and high crp levels (> mg/l) were included for further analysis. patient characteristics including gender and age were recorded. underlying diseases including diabetes mellitus, end-stage renal disease, liver cirrhosis and malignant neoplasm were recorded by history taking and examination in hospital. the diagnosis and final condition on discharge from hospital were determined according to the chart records filled in by the doctor in charge of the ward or ed. student's t test was used to compare age and days of hospitalization between patients with and those without underlying malignant neoplasm and/or hematologic disease. χ and fisher's exact tests were used to examine the correlation between gender, cause of fever, hospitalization, type of infection and mortality with underlying malignant neoplasm and/or hematologic disease. within the study period, , patients visited our ed. of , febrile adults, ( . %) had an elevated crp level and normal wbc count. the age of these patients ranged from to years. the characteristics of these patients are shown in table . there were patients with malignant neoplasm, nine with liver cirrhosis, with diabetes mellitus and with uremia. the major cause of febrility was infection ( . %). pneumonia and urinary tract infection were the leading diagnoses of infection ( table ) . most of the patients *data presented as mean ± standard deviation or n (%). were admitted ( . %). there were no significant differences in age and gender between patients with and those without neoplasm (table ). however, a higher inhospital mortality rate and other causes of febrility were noted in patients with neoplasm. febrile patients who have normal wbc counts and elevated crp levels usually have infection ( . %). crp is an acute-phase reactant produced by the liver that can increase markedly in response to infection or inflammation. in a previous study [ ] , markedly increased crp level (> mg/l) was highly associated with severe sepsis. this makes it possible to distinguish pyelonephritis from cystitis, bacterial pneumonia from acute bronchitis, acute bronchitis from uncomplicated acute or chronic obstructive pulmonary disease, and bacterial meningitis from aseptic meningitis. however, the range of elevation is large: the higher the crp level, the more sensitivity there is to an association with sepsis. for this reason, a cutoff point of mg/l was selected in this study for its higher ability to detect the factor results in normal wbc counts in those patients. in putto et al's study [ ] , crp of > mg/l could detect % of bacterial infection with % specificity. however, crp of - mg/l has been recorded in both viral and bacterial infections. many studies found that crp was more sensitive than wbc counts in distinguishing bacterial infection [ , ] . many studies have focused on the use of crp in patients with malignancy, hematologic disease or neutropenia, because these patients do not have normal wbc response to infection [ , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . such studies have shown that crp could help to diagnose sepsis in such patients. in a study of children with cancer, santolaya et al [ ] showed that patients with crp level > mg/l had bacterial infection (sensitivity of %, specificity of . %). arber et al [ ] found that levels of crp in sepsis were higher than in graft-versushost disease. although crp is elevated in cancer itself, fever with elevated crp could still reveal infection. most of the patients in our study did not have malignancy or hematologic disease, but wbc count did not increase in those with infections. although some of these patients had chronic disease, further study is needed to determine the cause of impaired wbc response in these patients. other biomarkers like crp may be more suitable to detect infection in such patients. in our study, there were no differences in age and gender between patients with and those without malignancy. although most causes of febrility were infection in both types of patients, patients with malignancy still had higher incidences of causes of febrility other than infection. the inhospital mortality rate was higher in patients with malignancy. our data did not attribute the mortality to the difference in severity of infection or underlying malignancy. the patients with malignancy had a greater possibility of having a rare infection or multiple site infection. as fever is one of the most common complaints of patients who visit the ed, it is very important to [ , , , , ] . although studies have shown the value of these examinations, the majority, except for crp and wbc count, are unavailable in the ed of most hospitals. most infections can be diagnosed by clinical symptoms and signs, but diagnosis may be difficult in patients who cannot express their symptoms well, such as children. accordingly, crp could be used in febrile children [ , , , , [ ] [ ] [ ] [ ] to distinguish bacterial infection. furthermore, the causes of febrility may be difficult to distinguish in some situations including trauma [ ] and bone marrow transplantation [ ] . the crp level test has value in such cases. furthermore, many infectious or inflammatory diseases have no specific symptoms; marked elevation of crp has significant diagnostic value in such cases as well. there are several limitations to this study. first, the major goal of the study was to analyze the characteristics of febrile patients with normal wbc count and high crp level. we lacked the data to confirm the roles in differential sepsis in this study. secondly, this study did not determine whether crp itself affects the disposition of the doctors. further study is necessary to determine if doctors tend to suggest that patients with high crp level be hospitalized. finally, this study analyzed the data in an ed, so the results can be applied to patients in an ed, but it did not determine if these patients had normal wbc counts throughout the course of disease or whether some patients developed high crp levels during the course of the disease. it was not rare for febrile patients who visited the ed to have high crp level but normal wbc count. these patients usually had significant infection or inflammation and needed hospitalization and further treatment, but they did not necessarily have an underlying malignant neoplasm or hematologic illness. this suggests that some factors other than malignant neoplasm or hematologic illness may be associated with the wbc response, and that crp may be a better indicator of infection under such conditions. further studies are needed to elucidate what these factors may be. we believe that it is reasonable to check crp level in addition to wbc count for patients who visit the ed due to fever. bedside procalcitonin and c-reactive protein tests in children with fever without localizing signs of infection seen in a referral center correlation between serum interleukin and c-reactive protein concentrations in patients with adenoviral respiratory infection c-reactive protein and erythrocyte sedimentation rate in differential diagnosis between infections and neoplastic fever in 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'# / $:;<= key: cord- - t prfkr authors: bhargava, ashish; fukushima, elisa akagi; levine, miriam; zhao, wei; tanveer, farah; szpunar, susanna m; saravolatz, louis title: predictors for severe covid- infection date: - - journal: clin infect dis doi: . /cid/ciaa sha: doc_id: cord_uid: t prfkr background: covid- is a pandemic disease caused by a novel coronavirus, severe acute respiratory syndrome coronavirus (sars-cov- ). predictors for severe covid- infection have not been well defined. determination of risk factors for severe infection would enable identifying patients who may benefit from aggressive supportive care and early intervention. methods: we conducted a retrospective observational study of patients with confirmed covid- infection admitted to a tertiary academic medical center. results: of hospitalized patients, the mean (sd) age of the cohort was . ( . ) years, ( . %) were male and ( . %) were black. severe covid- infection was noted in ( . %) patients, requiring intubation. patients aged above were significantly more likely to have severe infection. patients with severe infection were significantly more likely to have diabetes, renal disease, chronic pulmonary disease and had significantly higher white blood cell counts, lower lymphocyte counts, and increased c-reactive protein (crp) compared to patients with non-severe infection. in multivariable logistic regression analysis, risk factors for severe infection included pre-existing renal disease (odds ratio [or], . ; % ci . - . ), oxygen requirement at hospitalization (or, . ; % ci, . - . ), acute renal injury (or, . ; % ci . - . ) and initial crp (or, . ; % ci, . - . ). race, age and socioeconomic status were not identified as independent predictors. conclusions: acute or pre-existing renal disease, supplemental oxygen at the time of hospitalization and initial crp were independent predictors for the development of severe covid- infections. every unit increase in crp increased the risk of severe disease by . %. a c c e p t e d m a n u s c r i p t in december , the first pneumonia cases of unknown origins were identified in wuhan city, hubei province, china [ ] . the pathogen was identified as a novel coronavirus (ncov), now called severe acute respiratory syndrome coronavirus (sars-cov), with the disease termed covid- [ ] . because of its rapid spread, the world health organization has declared -ncov as pandemic [ ] . as of april , , a total of , , confirmed cases had been reported in at countries [ ] . sars-cov- infections have been described among asymptomatic (who never developed symptoms) as well as pre-symptomatic patients (who are not yet symptomatic) [ ] [ ] [ ] [ ] [ ] [ ] . the clinical spectrum from the largest cohort of symptomatic covid- patients from china ranged from mild to critically ill cases [ ] . age was described as a strong risk factor for severe disease, with the highest case fatalities occurring in those years and older [ ] [ ] [ ] . preliminary data from the united states (u.s.) also suggested that adverse outcomes were most frequent among persons years of age and older, but it also recognized that severe infections could occur in adults of any age group [ , ] . comorbid conditions of hypertension, diabetes, chronic lung and renal disease were also associated with severe infections and adverse outcomes [ ] [ ] [ ] . medications such as non-steroidal antiinflammatory drugs (nsaids), angiotensin-converting enzyme (ace) inhibitors or angiotensin receptor blockers (arbs) were suggested to increase the severity of infection [ ] , but currently there are no data to suggest a link between these medications and adverse outcomes. the determination of risk factors for severity in covid- infection would enable identification of high-risk patients who may benefit from close monitoring, aggressive supportive care and early intervention. a c c e p t e d m a n u s c r i p t to address this question, we collected clinical data from a cohort of hospitalized patients with the aim of identifying predictors for developing severe covid- infections. obesity and severe obesity were defined according to cdc definitions [ ] . fever was defined as an axillary temperature of . °c or higher. lymphocytopenia was defined as a lymphocyte count of less than cells per cubic millimeter. thrombocytopenia was defined as a platelet count of less than , per cubic millimeter. acute renal injury or elevated creatinine on admission was defined as increase in serum creatinine by ≥ . mg/dl (≥ . micromol/l) within hours or increase in serum creatinine to ≥ . times baseline, which is known or presumed to have occurred within the prior seven days [ ] . patients with pre-existing renal disease were on dialysis, had a history of renal transplant, had uremic syndrome, or had a creatinine > mg/dl in prior admissions. using the nine-digit zip code, the area deprivation rank for each individual patient was also obtained. the area deprivation index (adi) is a measurement of healthcare deprivation based upon where a person lives; it correlates with socioeconomic status [ ] . a higher adi means more deprived. on a national level the adis are ranked from to ( = least deprived, = most deprived) and on a state level it is from to ( = least deprived, = most deprived). a c c e p t e d m a n u s c r i p t statistical analysis was performed using spss v. . (armonk, ny). descriptive statistics were generated to characterize the study population. continuous variables were described as the mean with standard deviation or median with interquartile range. univariable analysis was done using student's t-test, analysis of variance followed by multiple pairwise comparisons using the bonferroni correction of the p-value, the mann-whitney u test and chi-squared analysis. variables that were found to be significant (p < . ) predictors of severity were then entered a multivariable logistic regression model using a forward likelihood ratio algorithm. when two variables were measuring the same underlying factor, the variable with the highest univariable measure of association was used in the model. results from the regression are reported as odds ratios with % confidence intervals. all there was no significant association found between race and severity (p - . ). to examine this further, we also assessed the association between the median state adi rank with both race and severity of disease. although there was a significant association between race and median state adi rank (white median state rank . (iqr: . , ) vs. black median rank . (iqr: , . )), (p -< . ), there was no association between median state adi rank and severity of disease. the most common symptoms at the onset of illness in the studied cohort were cough ( including higher white blood cell counts, lower lymphocyte and platelet counts, and increased c-reactive protein (crp) levels compared with those patients with non-severe infection. although patients with severe infection had significantly elevated procalcitonin levels, which raises concern for the presence of secondary bacterial infection, these patients also had acute renal injury on admission which may have caused the elevated procalcitonin. has become pandemic. while little has been reported regarding the predictors for severe covid- infections, much is known regarding the risk factors and predictors for mortality [ , ] . in our study we report pre-existing renal disease, supplemental oxygen requirement at admission, acute renal insufficiency, and initial crp value as independent predictors of severe covid- infections. it is also interesting that acute renal insufficiency (whether in patients with chronic kidney disease or normal baseline renal function) was associated with adverse outcome. sars-cov- is strongly suspected to use angiotensin converting enzyme (ace ) as its receptor, and ace binding affinity has been shown to be one of the most important determinants of sars-cov infectivity [ ] . perhaps acute renal insufficiency reflects more efficient binding of sars-cov- to ace given the location of ace expression. interestingly, ace inhibitors and angiotensin ii type- receptor blockers (arbs), increase ace expression, yet our analysis did not detect an association between ace or arb use, or hypertension or diabetes, and disease severity. persons taking ace or arb at home but presenting with renal insufficiency generally have those medications held upon admission. while sars-cov- enters cells by binding to ace , ace also reduces inflammation [ ] . if one hypothesizes that ace expression decreases inflammation, and that withholding drugs that increase its expression was done mainly in patients with acute renal insufficiency, perhaps a proinflammatory reaction to drug withdrawal could contribute to unfavorable outcome in such patients. the need for supplemental oxygen for baseline hypoxia was an independent factor for severe disease in our study. a recently published study showed oxygen saturation below % despite oxygen supplementation was a powerful predictor for fatal outcome [ ] . given that ace is expressed in lung epithelium, hypoxia may represent more avid binding to sars-cov- in those hosts. interestingly, ace is also expressed by endothelial cells, which represent one third of lung cells [ ] . the endothelium functions to promote vasodilation, fibrinolysis, and anti-aggregation; thus, endothelial damage may lead to a hypercoagulable state [ ] . accumulation of coagulation factors in lungs can drive ards through activation of a c c e p t e d m a n u s c r i p t protease activated receptors. microvascular permeability from endothelial injury can also facilitate viral invasion [ ] . thus, direct effect of viral invasion and indirect effects thorough endothelial damage lead to severe hypoxia. initial c-reactive protein (crp) level also associated with severe infection. every unit increase in crp increased the risk of severe disease by . %. crp is a homopentameric acute-phase inflammatory protein. baseline crp values are influenced by age, gender, smoking status, weight, lipid levels, and blood pressure, and by genetics [ ] . recent studies have reported that cases of sever covid- exhibit increased plasma levels of interleukin (il) , il , il , il , granulocyte colony-stimulating factor (gcsf), tumor necrosis factor (tnf) alpha, and others [ ] . il- is the main inducer of crp gene expression, with il- and tnf-alpha also playing a role [ ] . elevated crp may reflect severe disease as an indirect marker of elevated il- and tnf-alpha. crp not only reflects inflammation, it also enhances the immune response. crp can be irreversibly dissociated into monomeric subunits termed monomeric or modified crp (mcrp) at either high concentrations of urea or elevated temperatures in the absence of calcium, and mcrp promotes monocyte chemotaxis and recruitment of circulating leukocytes to areas of inflammation. modified crp also binds immunoglobulin g (igg) fc receptors in an interaction leading to release of proinflammatory cytokines [ ] . thus, elevated crp at admission may both reflect significant inflammation and itself drive further inflammation. and given that elevated levels of urea promote formation of mcrp, it fits that acute and chronic kidney disease may be associated with adverse outcomes. in our data, having a known sick contact was associated with lower risk of severe disease. perhaps some of those patients with a sick contact knew they were at risk of a c c e p t e d m a n u s c r i p t exposure and therefore were already attempting to minimize that risk through hand-hygiene, masks, or physical isolation or using separate bathrooms, thus decreasing the potential amount of virus to which they were exposed. this would, however, only account for patients where someone else was symptomatic or exposed soon enough for the patient to be able to take precautions. patients with known sick contacts may also have presented sooner due to a heightened suspicion of having contracted covid- , and thus received care more rapidly [ ] . recall bias may also have contributed. one other potential explanation is that the sickest patients were more confused or were intubated rapidly and therefore could not provide a history of sick contact, which would have impacted the recording of a sick contact in the electronic medical record and thus our results. patients over years old were significantly more likely to have severe infection. in multivariable analysis, however, age, was not found to be an independent predicting factor for the severe infection. this may reflect that the occurrence of kidney disease tends to be higher in older people and kidney disease was the stronger predictor in the model. older age has been significantly associated with death in previous studies [ , ] . this might be related due to less robust immune responses as older age has been linked with declined of comorbid conditions including significant elevation in creatinine on admission than those not admitted to icu [ ] . thus, age in our studied cohort might have been a confounding factor to elevated serum creatinine and c-reactive protein. during the covid- pandemic, racial and ethnic minorities especially blacks, have been reported to be severely or disproportionately impacted. our study did not show a disparity in severity by race, so we also investigated the relationship by adi (as a proxy for socioeconomic status). no association was found between adi and severity or between race and severity after controlling for adi. our study has several limitations. this was a single institution study among all the admitted patients which makes generalization of interpretations difficult. because of the retrospective nature of the study design, all variables in the studied patients were not available. therefore, the role of some of these variables in predicting severity of the infection could have been underestimated. last but not the least, the small sample size of our study and a predominantly black and overweight/obese cohort could have limited the generalizability of interpretation for some of the findings (for eg: race). nonetheless our study did involve a population of black patients in the detroit area and can provide valuable information on which factors are most significant predictors of severe disease in that population. pneumonia of unknown cause -china genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding world health organization home page evidence of sars-cov- infection in returning travelers from wuhan, china clinical characteristics of asymptomatic infections with covid- screened among close contacts in nanjing clinical outcome of asymptomatic cases at the time of hospital admission infected with sars-coronavirus- in shenzhen presumed asymptomatic carrier transmission of covid- asymptomatic and presymptomatic sars-cov- infections in residents of a long-term care skilled nursing facility -king characteristics of and important lessons from the covid- ) outbreak in china: summary of a report of cases from the chinese center for disease control and prevention clinical characteristics of coronavirus disease in china clinical characteristics of hospitalized patients with novel coronavirus-infected pneumonia in wuhan, china severe outcomes among patients with coronavirus disease (covid- ) -united states characteristics and outcomes of critically ill patients with covid- in washington state clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study novel coronavirus pneumonia emergency response epidemiology t covid- pathophysiology: a review fibrinolytic abnormalities in acute respiratory distress syndrome (ards) and versatility of thrombolytic drugs to treat covid- role of c-reactive protein at sites of inflammation and infection transcriptomic characteristics of bronchoalveolar lavage fluid and peripheral blood mononuclear cells in covid- patients journey of a thai taxi driver and novel coronavirus risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease clinical course and outcomes of critically ill patients with sars-cov- pneumonia in wuhan, china: a single-centered, retrospective, observational study abbreviations: n: number, or: odds ratio, ci: confidence interval, acei: angiotensin converting enzyme inhibitor, arbs: angiotensin ii receptor blockers a c c e p t e d m a n u s c r i p t a c c e p t e d m a n u s c r i p t key: cord- -x zvx fp authors: ohta, yoshinori; miyamoto, kyohei; kawazoe, yu; yamamura, hitoshi; morimoto, takeshi title: effect of dexmedetomidine on inflammation in patients with sepsis requiring mechanical ventilation: a sub-analysis of a multicenter randomized clinical trial date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: x zvx fp background: administration of dexmedetomidine has been reported to improve inflammatory response in animals. we explored the effects of administering dexmedetomidine on the levels of c-reactive protein (crp) and procalcitonin, and thus on inflammation, in patients with sepsis enrolled in a randomized clinical trial. methods: the desire trial was a multicenter randomized clinical trial in which adult patients with sepsis were sedated with (dex group) or without (non-dex group) dexmedetomidine while on mechanical ventilators. as a prespecified sub-analysis, we compared crp and procalcitonin levels during the first days of treatment between the two groups. the -day mortality rate, albumin level, and the number of patients with disseminated intravascular coagulation (dic) were also assessed. we used generalized linear models to estimate the differences in these outcomes between groups. we also used the kaplan-meier method to estimate the -day mortality rate and the log-rank test to assess between-group differences. results: our study comprised patients: in the dex group and in the non-dex group. crp and procalcitonin levels were lower in the dex vs. non-dex group during the -day treatment period [crp—range, . – . vs. . – . mg/dl (p = . ); procalcitonin—range, . – . vs. . – . ng/ml (p = . )]. albumin levels were higher in the dex group (range, . – . g/dl) than in the non-dex group (range, . – . g/dl; p = . ). the percentage of patients with dic did not significantly differ between the groups (range, – % and – % for the dex and non-dex groups, respectively; p = . ). the -day mortality rates in the dex and non-dex groups were and %, respectively (p = . ). conclusion: sedation using dexmedetomidine reduced inflammation in patients with sepsis requiring mechanical ventilation. trial registration: clinicaltrials.gov, nct . registered on january . the inflammatory response has catastrophic consequences in patients with sepsis, including multiple organ failure and death [ ] . leukocytes secrete inflammatory mediators such as interleukin (il)- and tumor necrosis factor (tnf)-α during critical illness. these mediators can cause endothelial dysfunction, which affects vascular permeability, as well as thrombin activation, leading to hypotension, metabolic acidosis, tissue damage, and eventual organ failure [ , ] . il- and tnf-α concurrently stimulate the production of c-reactive protein (crp) and procalcitonin (pct), which are the most widely used inflammatory biomarkers in patients with sepsis in clinical practice [ , ] . although crp is a marker of the acute inflammatory response, rather than of the infection that caused the sepsis, it is used to assess the severity and progression of sepsis-induced inflammation [ ] . pct levels rise in response to a variety of proinflammatory stimuli, especially those of bacterial origin. they closely correlate with the severity of systemic inflammation and can be used to monitor the course of sepsis [ , ] . dexmedetomidine is a highly selective α -adrenergic agonist widely used for sedation of patients during mechanical ventilation [ ] . several studies have shown that it also suppresses the inflammatory response [ ] [ ] [ ] . administration of dexmedetomidine decreases il- and tnf-α levels in animals with severe inflammation [ , ] and il- , tnf-α, and crp levels in humans undergoing surgery [ ] . whether it also reduces inflammation in patients with sepsis is not known. to investigate the effect of administering dexmedetomidine on sepsis-induced inflammation, we compared the outcomes of patients with sepsis who were treated with or without dexmedetomidine for days as part of the desire clinical trial [ ] . this analysis was prespecified in the study protocol for the desire trial before patient enrollment began. the desire trial was a multicenter, open-label, randomized clinical trial that compared the sedation strategies of administering dexmedetomidine (dex group) versus not administering dexmedetomidine (non-dex group) in terms of mortality and ventilator-free days during a day period [ ] . the trial was registered at clinical-trials.gov (identifier: nct ). a total of patients were enrolled from eight intensive care units (icus) in japan between february and january , all of whom had sepsis requiring mechanical ventilation for more than h [ ] . the flow of participants through the trial is shown in the supplemental figure ( see additional file ). in the trial, sepsis was defined as systemic inflammatory response syndrome (sirs) criteria due to infection [ ] . the enrolled patients satisfied the sepsis-iii criteria due to having received mechanical ventilation and having a sequential organ failure assessment (sofa) score of or more [ ] . patients in the dex and non-dex groups received other sedatives as needed to achieve the sedation target and analgesics if necessary. in both groups, the targets of sedation depth were a richmond agitation-sedation scale score of (calm) during the day and − (lightly sedated) during the night [ ] . the treatment protocol for sepsis was based on the guidelines developed by the japanese society of intensive care medicine for sepsis management [ ] . the present study was approved by the institutional review boards at each participating center. additional study protocols, inclusion and exclusion criteria, and informed consent are described in the supplemental methods (see additional file ). to evaluate the acute phase of inflammation, this sub-analysis compared the inflammatory status of the dex and non-dex groups during the first days after the randomization. the primary outcome in this analysis was inflammation as indicated by crp and pct levels. the secondary outcomes were -day mortality, albumin (alb) level, and sepsis-associated coagulopathy. the alb level served as a marker of vascular permeability [ ] . the disseminated intravascular coagulation (dic) score, as defined by the japanese association for acute medicine, was used to assess sepsis-associated coagulopathy [ ] . the dic score comprises platelet (plt) counts, the patient/normal prothrombin time (pt) ratio, the levels of fibrin/fibrinogen degradation products (fdps), and the number of sirs characteristics. the scoring system for dic is summarized in the supplemental table (see additional file ). crp, pct, alb, and fdp levels, plt counts, and pt ratios were measured throughout the -day observation period. we also determined the number of patients with three or more sirs characteristics and/or dic (as based on the dic score) on days , , , , , , , and . primary and secondary outcomes were analyzed according to the intention-to-treat principle. continuous variables were presented as means with standard deviations (sds) or medians with interquartile ranges, and categorical variables were presented as numbers and percentages. to compare patient characteristics between the groups, we used t tests or wilcoxon rank sum tests for continuous variables and chi-square tests or fisher's exact tests for categorical variables. we used a generalized linear model (the genmod procedure) to examine the effect of administering dexmedetomidine on crp, pct, alb, and fdp levels, plt counts, and pt ratios and to account for repeated measurements in the same patient. we used a generalized linear model (the genmod procedure with logit) to determine the effect of administering dexmedetomidine on the number of patients with three or more sirs characteristics and/or dic. the variables describing patient status were the dependent variables, and treatment allocation was the independent variable with a repeated variable of patient. the cumulative incidence of mortality over the -day treatment period was estimated via the kaplan-meier method, and differences between the groups were assessed using the log-rank test. all statistical analyses were performed using jmp version . . (sas institute inc.), and sas version . (sas institute inc.) software. a two-sided p value < . was considered statistically significant. among the patients in our study, ( %) were men, and the mean age was years (sd, years) ( table ). the median acute physiology and chronic health evaluation ii score was , and the median sofa score was . there were patients in the dex group and in the non-dex group; the characteristics of the groups were well balanced. on the first day after randomization, the median and highest crp levels were . and . mg/dl in the dex group and . and . mg/dl in the non-dex group, respectively. the number of patients with a pct level of more than . ng/ml was ( %) in the dex group and ( %) in the non-dex group. the mean alb level was . g/dl in the dex group and . g/dl in the non-dex group; the number of patients with hypoalbuminemia (alb of . mg/dl or less) was ( %) in the dex group and ( %) in the non-dex group. forty ( %) patients in the dex group and ( %) in the non-dex group had dic on day . crp and pct levels in the dex and non-dex groups during the -day observation period are shown in fig. a and b . the crp level was highest on day in both the dex ( . mg/dl) and the non-dex ( . mg/ dl) groups (fig. a) . it was significantly lower in the dex group (range, . - . mg/dl) than in the non-dex group (range, . - . mg/dl) over the -day observation period (p = . ). pct levels were measured on days , , , and and were highest on day in both the dex ( . ng/ml) and non-dex ( . ng/ml) groups (fig. b) . the pct level was significantly lower in the dex group (range, . - . ng/ml) than in the non-dex group (range, . - . ng/ml) over the -day observation period (p = . ). the alb levels in the dex and non-dex groups during the days after randomization are shown in fig. c . the alb level was lowest on days - in the dex group and on days - in the non-dex group. alb levels were reduced to a lesser extent in the dex group (difference, − . g/dl) than in the non-dex group (difference, − . g/dl). the alb level was significantly higher in the dex group (range, . - . g/dl) than in the non-dex group ( . - . g/dl) over the -day treatment period (p = . ). the levels of the coagulation biomarkers and the number of patients with three or more sirs characteristics during the -day observation period are shown in the supplement table (see additional file ). plt counts were lowest on day in both groups and overall did not differ significantly between groups (range, - × /l in the dex group and - × /l in the non-dex group; p = . ). fdp levels were also similar in both groups (range, . - . mcg/ml in the dex group and . - . mcg/ml in the non-dex group; p = . ). the pt ratio was highest in both groups on day but overall was lower in the dex group (range, . - . ) than in the non-dex group ( . - . ; p = . ). the percentage of patients with three or more sirs characteristics did not differ significantly between the dex vs. non-dex group (range, - vs. - %; p = . ). the levels of the dic-associated variables were similar in both groups with the exception of the pt ratio (supplement table ). the percentage of patients with dic was also similar in both groups (range, - % in the dex group and - % in the non-dex group; p = . ). among the patients in our study, ( %) died during the days after randomization. the mortality rates in the dex and non-dex groups were % ( patients) and % ( patients), respectively (p = . ) (fig. ). we analyzed data derived from a randomized clinical trial and found that the administration of dexmedetomidine to patients with sepsis on ventilators improved crp and pct levels during the first days in the icu. it also reduced the incidence of hypoalbuminemia, but not of dic. the -day mortality rate was also % lower in the dex group than in the non-dex group, but this reduction was not significant. the original desire trial did not find statistically significant superiority of administering dexmedetomidine in terms of mortality, but the findings implied an % reduction in the -day mortality rate in patients with sepsis [ ] . because the different use of sedatives did not account for the reduction of mortality, the mechanism of the effect of administering dexmedetomidine on mortality should be explored. dexmedetomidine is a unique sedative: unlike aminobutyric acid receptor agonists, it has analgesic [ ] and anti-inflammatory [ ] [ ] [ ] effects. the latter may reflect its ability to inhibit the expression of inflammatory molecules when bound to α -adrenergic receptors on macrophages [ ] and/or to increase the concentration of norepihephrine (which suppresses the immune response) when bound to synaptic α -adrenergic receptors in the central nervous system [ ] [ ] [ ] . other possible mechanisms include the modulation of cytokine production by macrophages and monocytes; the inhibition of apoptosis and the toll-like receptor and myeloid differentiation factor /mitogen-activated protein kinase/nuclear factor-κb signaling pathways; and the stimulation of the cholinergic anti-inflammatory pathway [ ] [ ] [ ] [ ] [ ] [ ] . although the anti-inflammatory mechanisms through which the administration of dexmedetomidine suppresses inflammation remain to be fully elucidated, previous studies suggest that administration of dexmedetomidine decreases the levels of pro-inflammatory cytokines such as il- and tnf-α in patients with sepsis [ ] , as well as the levels of pro-inflammatory cytokines and crp in patients undergoing surgery while under anesthesia [ ] . in the present study, the use of dexmedetomidine for sedation reduced both crp and pct levels in patients with sepsis. this result indicates that the administration of dexmedetomidine alleviates infection-induced inflammation. we also aimed to determine whether administration of dexmedetomidine improved hypoalbuminemia and sepsis-associated coagulopathy, both of which are associated with severe inflammation. systemic inflammation increases vascular permeability, which is a major cause of hypoalbuminemia in patients with sepsis [ ] . most of the patients in our study had low albumin levels on the first day after randomization. thereafter, however, albumin levels were higher in patients treated with versus without dexmedetomidine. this finding presumably reflects reduced inflammation rather than improved nutrition: during the acute phase of inflammation, levels of albumin, which has a half-life of days, are more influenced by vascular permeabilization caused by inflammation-induced injuries to the endothelium than by nutrition [ , ] . sepsis-associated coagulopathy, which can lead to dic, is thought to result from crosstalk between the inflammation and coagulation systems; inflammation triggers coagulation, which in turn promotes inflammation [ , ] . in this study, the administration of dexmedetomidine did not affect the incidence of coagulation or dic. suppression of inflammation by administering dexmedetomidine might be insufficient for preventing coagulopathy. the administration of dexmedetomidine has been shown to reduce not only plasma inflammatory cytokine concentrations but also mortality in rats with endotoxininduced shock, and these effects were reported to be dose-dependent [ ] . a recent database study reported that mortality differed according to the time after diagnosis of sepsis; phases were categorized in that study as phase (days to ), phase (days to ), and phase (days to ) [ ] . deaths during phase and phase accounted for . % of mortality in patients with sepsis or septic shock [ ] , and one cause of the early peak in mortality was severe inflammation [ ] . therefore, we focused on both inflammation status and mortality in a -day period. crp levels correlate positively with the risk of organ failure and mortality; hence, monitoring these levels may aid in assessing the response to therapy in patients with sepsis [ , ] . pct has greater diagnostic accuracy than does crp because it differentiates infectious versus non-infectious causes of inflammation [ ] . crp is a risk factor for mortality in patients with sepsis when levels are elevated and the clearance rate is low [ ] . hypoalbuminemia has been shown to predict -day mortality in critically ill patients [ ] . the doses of dexmedetomidine ranged from . to . mcg/kg/h in this study; these are the standard approved doses in japan. although these doses are lower than those typically administered in western countries, the administration of dexmedetomidine at these lower doses successfully decreased crp and pct levels and increased albumin levels when administered to patients with sepsis for days. these changes were considered to reflect the improvement of inflammation in the first days after sepsis onset; hence, it might be associated with decreased mortality. as noted above, a point estimate of % reduction in mortality at day was observed in our study, although a level of statistical significance was not reached. one possible reason for this non-significant reduction in mortality could be due to the relatively small sample size or the lower doses of dexmedetomidine. as the anti-inflammatory effects of administering dexmedetomidine are reportedly dosedependent [ ] , a greater reduction in mortality might be observed if higher doses are used. further research should clarify the effect of administering dexmedetomidine with higher doses on patient mortality and potential adverse effects in patients with sepsis. there are two limitations in this study. first, it was an open-label study, and the endpoints were assessed by a physician at discharge. awareness of the treatment assignment (dexmedetomidine or no dexmedetomidine) may have influenced some of the management protocols. however, crp, pct, and alb levels, -day mortality rates, and sepsis-associated coagulopathy would not be affected by the judgments of physicians. although preparations containing alb can increase albumin levels, the physicians in charge followed the guidelines regarding such preparations when treating patients with sepsisassociated hypoalbuminemia [ ] . second, because our study was a subcomponent of the desire trial, sample sizes with sufficient power to detect clinically meaningful differences were not calculated and thus may have been inadequate in some cases, especially in those involving sepsis-associated coagulopathy. moreover, multiple endpoints in sub-analyses should be treated with caution owing to inflated alpha errors. however, the consistency of our findings (lower crp and pct levels and higher alb level in the dex group) attest to their validity. the administration of dexmedetomidine significantly improved crp, pct, and alb levels in patients with sepsis requiring mechanical ventilation. because the anti-inflammatory effects of administering dexmedetomidine were not associated with the reduction of mortality in patients with sepsis at days, further studies with larger sample sizes or administering higher doses of dexmedetomidine are 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sepsis markers of inflammation and infection in sepsis and disseminated intravascular coagulation dose-and timerelated effects of dexmedetomidine on mortality and inflammatory responses to endotoxin-induced shock in rats the late phase of sepsis is characterized by an increased microbiological burden and death rate c-reactive protein levels correlate with mortality and organ failure in critically ill patients failure to reduce creactive protein levels more than % in the last hours before intensive care unit discharge predicts higher in-hospital mortality: a cohort study serum procalcitonin and c-reactive protein levels as markers of bacterial infection: a systematic review and meta-analysis serum procalcitonin and procalcitonin clearance as a prognostic biomarker in patients with severe sepsis and septic shock clinical usefulness of c-reactive protein to albumin ratio in predicting -day mortality in critically ill patients: a retrospective analysis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank the following investigators in the desire trial: tomonori yamamoto, md (osaka city university, osaka, japan); akihiro fuke, md (osaka city general hospital, osaka, japan); atsunori hashimoto, md (hyogo college of medicine, nishinomiya, japan); hiroyuki koami, md (saga university hospital, saga, japan); satoru beppu, md (national hospital organization kyoto medical center, kyoto, japan), and makoto itoh, md (yamaguchi grand medical center, yamaguchi, japan). authors' contributions yo and tm had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. all authors read and approved the final manuscript. this multicenter randomized clinical trial was supported in part by a noncontractual research grant to wakayama medical university from hospira japan. the present study was supported by jsps kakenhi grants to yo (jp k , jp k , jp , and jp k ) and tm (jp , jp , jp , jp , and jp ). the funding sources had no role in the study design; collection, analysis, or interpretation of data; writing of the report; or decision to submit the manuscript for publication. the data that support the findings of this study are available from the corresponding author upon reasonable request.ethics approval and consent to participate this study was approved by the institutional review boards of wakayama medical university and each participating institution. written informed consent was obtained from the patient or patient's family before randomization. not applicable. dr. ohta has no conflicts of interest. dr. miyamoto received lecture fees from becton dickinson and pfizer japan. dr. kawazoe received lecture fees from hospira japan and pfizer japan and a scholarship from hospira japan. dr. yamamura received lecture fees from hospira japan, nipro, and asahi kasei and educational consulting fees from toray industries, csl behring, teijin pharma, and nihon pharmaceutical. dr. morimoto received lecture fees from bayer, daiichi sankyo, japan lifeline, kyocera, mitsubishi tanabe, novartis, and pfizer japan; a manuscript fee from pfizer japan; and consulting fees from asahi kasei, bristol-myers squibb, and boston scientific. key: cord- -hgnz fkv authors: wyse, c.; o'malley, g.; coogan, a.; smith, d. title: seasonal and daytime variation in multiple immune parameters in humans: evidence from , participants of the uk biobank cohort date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: hgnz fkv abstract [ words] background: seasonal disease outbreaks are perennial features of human infectious disease but the factors generating these patterns are unclear. in animal studies, seasonal and circadian (daily) rhythms in immune function generate periodicity in vulnerability to disease, although it is not known whether the same applies to humans. making use of extensive data from the uk biobank cohort, we investigate seasonal and daytime variability in multiple immune parameters (inflammatory markers, white blood cell counts and antibody titres), and test for associations with a wide range of environmental and lifestyle factors. methods and findings: markers of inflammation (crp), and white blood cell counts were measured between am and pm over a -year time period in , participants in uk biobank. individual-level data were linked to other factors that vary over seasonal and daily cycles, including changes in day length, outdoor temperature and vitamin d at the time the blood sample was collected. analyses were further adjusted for potentially confounding lifestyle factors. seasonal patterns were evident in lymphocyte and neutrophil counts, and crp, but not monocytes, and these were independent of lifestyle, demographic and environmental factors. all the immune parameters assessed demonstrated significant daytime variation that was independent of confounding factors. conclusions: at a population level, human immune parameters vary across season and across time of day, independent of multiple confounding factors. both season and time of day are fundamental dimensions of immune function that should be considered in all studies of immuno-prophylaxis and disease transmission. strategic alignment of human activities to seasons and times of the day when we are less susceptible to infection could be an important additional tool for limiting population-level impacts of infectious diseases. annual cycles in vulnerability to infectious disease are an established feature of human epidemiology: most respiratory viruses cause winter-time infection and polio is principally a summer-time disease. childhood infectious diseases (meningitis, mumps, pertussis and varicella) and many of the contagious diseases that affect domestic animals , are seasonal as are relapses in autoimmune diseases. , the factors that mediate this seasonality are poorly understood and circannual patterns are simply an assumed component of the dynamics of infectious diseases. in addition to seasonality, animals and humans are more susceptible to infectious disease during the resting phase of their daily cycle, adding a further circadian dimension to disease vulnerability. the axial and orbital rotations of the earth generate predictable seasonal and daily rhythms of light and darkness. these conditions in turn generate circadian and seasonal oscillations in ambient temperature, food availability, predation and risk of infection. evolution has equipped animals with innate timing mechanisms, or "clocks", that synchronise physiology to these recurring periods of increased risk. the circadian clock is generated by a series of interconnected transcription-translation feedback loops that regulate the expression of a panel of clock-controlled genes. most mammalian cells contain a molecular clock and overall rhythmicity is maintained by a master clock located in the suprachiasmatic nuclei of the hypothalamus, conferring time dependence on most physiological parameters through hormonal and neural signals. the mechanisms driving seasonality in humans are unclear, but in animals, the seasonal clock is generated by changes in thyroid hormones in the brain that respond to day length signalled by the pineal hormone melatonin. the circadian clock is entrained by the -hour photoperiod, while the seasonal clock entrains to day length patterns in northern latitudes and to seasonal patterns in rain and food availability in tropical regions, where day length is constant. , this is analogous with aspects of seasonality of the human immune system, where viral infection and immune cell numbers are associated with day length (e.g. winter peak in influenza) in northern clines and with climatic changes in tropical regions. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] together, the seasonal and circadian clock synchronise physiology in two dimensions of time, optimising homeostasis by anticipating changes in the environment. for example, plants , fish , birds and mammals , all align their immune defence with the time of day that pathogenic and physical challenge are most likely. this conservation across the biological kingdoms is strong evidence that temporal modulation of immune function is an ancient and fundamental mechanism that has evolved to optimise survival in variable environmental conditions. laboratory experiments corroborate epidemiological evidence of circadian and seasonal rhythms in disease susceptibility. for example, mice are more resilient to experimental inflammatory, , , infectious - and physical challenges delivered at night (their active circadian phase) or in summer. importantly, these daily cycles in vulnerability persist in constant conditions (photoperiod, temperature, or humidity) , and are absent in animals lacking a circadian clock, , demonstrating clock-mediated regulation that is not driven by current environmental conditions. similar to rodents, humans are more resistant to the effects of inflammatory or infectious challenge , delivered during their active circadian phase (day-time), or in summer. circulating white blood cell counts are known to oscillate across h under basal conditions, reflecting distribution of cells between tissues and the periphery. importantly, these rhythms persist in constant conditions and are absent in animals with ablated clock function , indicating that they are mediated via innate circadian timing mechanisms. the extensive data collection within uk biobank represents an unprecedented opportunity to assess seasonal and time-of-day variation in levels of human immune parameters. here we provide new evidence of endogenous seasonal and daytime variability in human immune function at a population level and we demonstrate that these patterns are independent of a wide range of demographic, environmental and lifestyle factors. the study sample were participants of uk biobank, a general population cohort study that recruited over half a million uk residents continuously between and , at assessment centres located across the uk (ukb handbook). eligible participants who lived within travelling distance of one of uk assessment centres were identified through national health service patient registers and invited to participate by mail, resulting in a . % response rate. participants were invited to attend the assessment centre at a pre-booked provisional appointment time between am- pm; they did not self-select the time of day of attendance but were free to reschedule if required. baseline information was collected at the assessment centre using a questionnaire and an interview, and blood samples and physical measurements were taken. information on the demographic status of the participants included age at baseline, sex (male/female), ethnicity (white, black, mixed, chinese, asian, other). participants were self-categorised as morning or evening chronotype using the question, "do you consider yourself to be: definitely a morning person; more a morning than evening person; more an evening than a morning person; definitely an evening person; or don't know". the self-reported level and duration of usual physical activity was used to derive total physical activity, measured as metabolic equivalents (met.hours/week). a proxy of sedentary behaviour was derived from the total number of self-reported hours spent driving, using a computer and watching television each day. smoking status was self-reported and categorized as "never smoker," "current smoker" and "former smoker." the frequency and volume of alcohol intake were self-reported. body mass index (bmi was measured by trained uk biobank staff using standardized methods and instruments. habitual sleep duration was self-reported in hours per h. blood samples were collected at the end of the assessment centre visit, and the time was immediately recorded on computerised system by swiping the unique barcode on the collection tube. blood cell counts were performed within hours using an lh haematology analyser (coulter, beckman coulter, brea, ca, usa) to determine the total number of white blood cells, plus the numbers of neutrophils, lymphocytes and monocytes, which were expressed as a percentage of the total white blood cell count. vitamin d was measured using a chemiluminescent direct competitive immunoassay (diasorin). serum c reactive protein (crp) was measured using a high-sensitivity immunoturbidimetric assay performed on a beckman coulter clinical chemistry analyser. a subset of participants (n= ) were chosen at random for assessment of blood levels of antibodies against infectious agents (see tables s - for details of antigens). antibody levels were measured using a luminex high-throughput platform following validation against gold-standard assays and independent reference sera. results of analyses were expressed as median fluoresce intensity for each antigen, and seropositivity status based on suggested thresholds. full details of the participant measures and analysis procedures are available at www.ukbiobank.co.uk. latitude and longitude were derived from the postcode of residence at km resolution using open source geographic information system software (qgis open source geospatial foundation project, http://qgis.osgeo.org). these data were combined with information on the date of attendance at the assessment center to derive the length of daylight on that day for each participant using vectorial algorithms in r-software [r version] in the 'insol' package (insol: solar radiation). daylight was approximated over the hours ( am- pm) of the diurnal dataset by calculating the mean zenith angle of the sun at each time and assessment centre location using the r-package "geolight". the derived data were verified using information provided by the global monitoring division of the us government national oceanic and atmospheric administration. outdoor temperature was averaged for the weeks preceding the date of attendance from data provided by the uk meteorological office for the weather station nearest to each assessment center. seasonal and daily variation were assessed by plotting mean values of white blood cell and crp values against month or hour of sample collection, fitting models to describe annual and daily variation, and then investigating whether any variation was independent of confounding factors and directly related to day length. seasonal patterns were analyzed by fitting a linear regression model for each outcome of interest that included a sine and a cosine term of transformations of the time variable, taken as month: where y is t is time (months), and m, β and γ were predicted by regression, above. the acrophase (Φ) and amplitude (a) was predicted using equations and , with m predicted from equation ( ) above. the intercept (m) was the mean level of the curve and thus an estimate of the annual mean of each outcome variable. the amplitude (a) was the distance from the mean to the acrophase or the nadir, providing an estimate of the magnitude of seasonality. the acrophase (Φ) is the peak x axis value of the curve, whereas the nadir is the trough. seasonality was indicated by statistical significance of the estimated cosinor (sine and cosine) regression coefficients. variation of the markers over the daily time course of sample collection was modeled using linear methods since the absence of nighttime samples precluded assumption of circadian patterns. although assessment centre appointments started at am, the blood sample was collected at the end of the -minute assessment, so the am time point was excluded due to small sample numbers at this time. the relationship between time of day and the immune parameters was represented by a series of linear regression lines connected at breakpoints where the slope of each line changed. this analysis was implemented using the r package / "segmented" to predict the times of breakpoints during the test period for each analyte. the statistical significance of the segmented regression model was assessed using the davies test to test the null hypothesis that a breakpoint does not exist, and that the difference in slope parameter (߰) of the segmented relationship is zero. the breakpoints and slopes of each segment indicate peaks and troughs in wbc and crp levels over time, as well as the rate and direction of any changes. if seasonal and daily variation were indicated, we next investigated if these patterns were related to day length, and to time of day, and if any relationships were independent of lifestyle and environmental factors. the daytime data were modelled as a series of linear splines to account for the non-linear relationships between time of day and the immune parameters. three multiple linear regression models were run that included an increasing number of covariates and progressively adjusted for sociodemographic, disease, lifestyle and environmental (temperature and day length) factors, with results reported as point estimates and % confidence intervals. potential confounders included as covariables were age; sex; ethnicity; townsend areadeprivation score; physical activity and sedentary behaviour; alcohol intake and smoking status; outdoor temperature; blood analyser; vitamin d; sleep duration; chronotype and uk biobank assessment centre. all analyses were performed using r version . , stata statistical software (statacorp lp) and values of p < . were considered to represent statistical significance. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; https://doi.org/ . / . . . doi: medrxiv preprint / the exclusion criteria for this study resulted in the removal of , study participants. the remaining cohort was mostly white ( %), with the other ethnic groups poorly represented (< % participants). summary data that describes the demography and lifestyle of the , participants that were eligible for inclusion are given in table . mean values for wbc percentage and crp were plotted against month and time of day for all participants, and annual and daily variation was evident on visual inspection and univariate analysis (figures - ) , but there was no seasonal or diurnal variation in the titre levels of any antigen (table s - ) . the probability of seropositive status to any of the antigens analysis was not associated with the month or time of day of analysis (data not shown). summary data for white blood cell count, antigen titre, vitamin d and crp levels at all time points are shown in supplementary data (tables s - ). mean and % confidence intervals for monthly data with fitted cosinor models for lymphocyte, monocyte, neutrophil, and crp are shown in figure - . cosinor analysis showed that the seasonal patterns were statistically significant for a -month assumed periodicity for crp, and wbc counts ( table ) . crp levels were higher in the winter months, peaking in december, with lowest levels in july. the seasonal pattern of neutrophil counts was similarly higher in winter, peaking in jan with lowest levels recorded in summer (july). the seasonal pattern of lymphocyte counts peaked in spring (march) and troughed in autumn (october) ( table ; figure ). there was no significant seasonal pattern in monocyte counts. multiple linear regression was next applied to investigate whether the immune parameters were associated with day length and, if so, whether these were independent of other lifestyle and environmental factors that could confound associations via unrelated seasonality. crp levels, and neutrophil and lymphocyte counts were found to be significantly associated with day length, independent of demographic, lifestyle and environmental factors ( table ) including outdoor temperature, and vitamin d. the relationship between vitamin d and crp was found to be dependent on bmi, and an interaction term to account for this effect was included in the crp regression model. interaction was also detected between vitamin d and sex for all wbc markers, and these interaction terms were added to the regression models (supplementary data tables s - ). in the fully adjusted model, neutrophil count and crp showed significant negative associations with day length, while lymphocyte count was positively associated, as also shown in cosinor analysis. monocyte count was not significantly associated with day length in the fully adjusted model (model ). segmented linear regression analysis of crp and wbc counts over the daily time course showed significant daytime variation that was represented by segmental regression lines ( figure ). the peaks and trough, (breakpoints) for each marker are shown in table . all white blood cells showed significant daily variation, with counts lowest in the early morning and increasing as the day progressed. neutrophil count reached a plateau at pm. crp levels were highly variable, peaking at pm, and decreasing thereafter (table ) . linear regression analysis demonstrated that the daytime changes in wbcs and crp were in most cases independent of lifestyle and environmental factors ( table ). the morning ascending segment of the crp daily curve was the only section of any of the curves that did not retain statistical significance after adjustment. however the daily crp curve showed a / significant relationship with time of day for the later parts of the day, after the breakpoint at pm. the human immune system is not constant over h or across the seasons and the time of exposure to pathogens is an important consideration in determining risks of infection that is relevant to public health interventions (such as movement restrictions) during epidemics. here we report seasonal and daytime patterns in immune cells and inflammatory markers within a large sample of the uk population. importantly, we demonstrate that these patterns are independent of multiple demographic, lifestyle and local environmental variables, supporting the existence of endogenous seasonal and daytime patterns in human immune parameters. these findings highlight the importance of future studies to understand the time dimensions of immune function and their implications for preventing and controlling outbreaks of infectious disease. the greatest seasonal and daytime changes in this study were seen in lymphocyte numbers, with high-amplitude variation over seasons and days. lymphocytes were lower during the early parts of the day, increasing as the day progressed, consistent with previous reports that lymphocytes circulating in blood are lower during the respective active phase of humans , , , , and rodents. , , circadian rhythms in the homing and egress of lymphocytes through the lymphatic system and other tissues underlies these diurnal changes of lymphocyte numbers in blood. , , since the lymph nodes contain the interaction between lymphocytes and antigen, longer accumulation times increase antigen encounters and potentiate the adaptive immune response. , consequently, lymphocyte numbers in the periphery drop as trafficking to the tissues increases, along with increased tissue surveillance and resistance to infection. , circadian rhythms of lymphocyte trafficking to the periphery are abolished by genetic ablation of clock function and persist in constant conditions , confirming their regulation by the innate circadian clock in mice. these endogenous rhythms are associated with time-of-day dependent changes in adaptive immunity, including amplified response to induction of autoimmunity (experimental autoimmune encephalomyelitis), immunisation and viral infection (influenza) during the active phase. thus the time of day that pathogenic challenge occurs affects the adaptive immune response generated days later, one of the mechanisms through which lymphocyte trafficking might modulate seasonal and circadian vulnerability to infection. in agreement with previous findings, , lymphocytes were positively associated with day length in our study; cell numbers were lower in autumn and peaked in spring. these findings of lower peripheral lymphocyte counts in winter and in the early active phase suggest that adaptive immune defences might be augmented in summer and during the day, and that humans might have retained some capacity for seasonal regulation of lymphocyte trafficking that might contribute to our increased susceptibility to infection in winter. previous studies have reported seasonal and circadian patterns in antibody titres in humans, igm , often discovered serendipitously in the course of other investigations. leucocytes collected at different times of year showed decreased ex vivo response (thymidine incorporation, cytokine release) to activation in winter time in humans and rats [ ] [ ] [ ] , and diurnal patterns in antibody titres and in ex vivo response to stimulation of pbmcs , have been reported in humans. this study in uk biobank is the first to investigate circadian and seasonal patterns in antibody titres to common infectious agents at a population level. despite our comparatively large sample size, we found no evidence for seasonal or daily variation in antibody titres or in the probability of testing immunopositive to any of the antigens investigated in this study. however, the antibody response to vaccination or viral infection and subsequent decay is subject to wide variation between individuals, which is not accounted for by the cross-sectional design of the present study. longitudinal experiments are required to establish if antibody titres vary by season or time of day and how this might impact on response to vaccination or infection. daytime variation in antibody titres could confound studies of the efficacy of vaccination that use antibody response as an outcome variable, , , and future investigations within individuals and with multiple sample time points are warranted to understand basal variation in antibody titres. blood neutrophil counts were lowest in early morning in the uk biobank participants, increasing thereafter to plateau after pm. previous studies demonstrated comparable circadian rhythms in peripheral neutrophil counts that were low in the rest phase, and that increased over the active phase in both humans and mice. , neutrophils have a half-life less than h, and circadian rhythmicity is regulated through clock-controlled oscillations in chemokine pathways that drive release of young cells in the active phase, and clearance of aged neutrophils from the periphery in the resting phase. , these rhythms in neutrophil tissue migration were shown to underlie increased resistance to infection (candidia albicans), during the active phase in mice and to diurnal variation in bactericidal function ex vivo in human neutrophils. neutrophil counts were negatively associated with day length in our study, in agreement with previous studies in humans living at temperate latitudes. , we extend these findings to demonstrate high peripheral neutrophil counts in winter time at a population level that were related to annual photoperiod, independent of participant lifestyle, local environmental conditions and vitamin d. in addition to total counts, previous studies have demonstrated seasonality of functional aspects of neutrophil immune function, including adhesive capacity, cd b/cd expression and ros production, resulting in augmented bactericidal properties of neutrophils collected in summer. the seasonal and daytime patterns in neutrophil count reported here, and in previous studies support evidence from animal studies that time-dependent cycles of tissue migration could contribute to neutrophil-mediated resilience to infection during the active phase, and relative vulnerability to infection in winter time. , monocyte counts were lower in the morning compared to evening in uk biobank participants, consistent with previous reports that monocytes increase during the active phase in mice and humans. the acute phase protein, crp showed a weak daily pattern in this study, with levels higher in daytime, again corroborating previous reports of diurnal patterns of crp humans , , , circadian rhythms in circulation and tissue migration of monocytes in mice are regulated through an innate cell-intrinsic clock mechanism and their oscillation coincides with an enhanced inflammatory response when monocytes are decreasing at the beginning of the rest phase and increased lethality of endotoxic challenge at this time. in agreement, human volunteers show a heightened response to endotoxic challenge in the evening. , this increased inflammatory response in the active phase might maximise innate immune defence at a time when pathogenic challenge is most likely, but could also leave animals vulnerable to the toxic effects of augmented inflammation. monocyte counts are higher in winter in some but not all previous studies. there was no evidence of a seasonal pattern in uk biobank participants, and monocytes were not associated with day length in the fully-adjusted model. while peripheral counts are not always seasonal, monocyte function shows strong seasonality ex vivo, with an augmented proinflammatory response to activation in summer time. , we found a weak seasonal pattern in the acute phase protein, crp in uk biobank, with levels higher in the winter months. peripheral crp and other proinflammatory markers were higher in winter in many studies in humans, , , and this is thought to contribute to seasonal prevalence of cardiovascular disease seasonality of human viral infections is generally and intuitively thought to be driven by annual changes in temperature or humidity, but there is increasing evidence that innate variation in host disease susceptibility is an important contributor. in support of this, many diseases are seasonal in tropical regions where temperature and humidity are constant. , furthermore, outbreaks of influenza occur annually and simultaneously at latitudes that are oceans apart despite variations in local climatic conditions and human behaviour. recurrent seasonality is a feature of the epidemiology of infectious disease in animals that do not share human winter time behaviours such as increased time indoors, crowding or school terms. the prevalence of human respiratory viruses does not correspond with the prevalence of the respiratory disease they cause; remarkably, detection of viral infection is relatively low in the months that respiratory disease is highest. vitamin d is suspected to contribute to disease seasonality due to known associations with immune function and highly seasonal serum levels, but this postulation is not corroborated by models that compared serum vitamin-d with influenza transmission in population based studies. , our findings in uk biobank showed that seasonal changes in white blood cells and crp were related to day length independent of vitamin d levels, in agreement with evidence that circulating vitamin d was not responsible for seasonality in the proinflammatory functions of human monocytes. finally, evidence of widespread seasonal regulation of transcription of genes regulating immune function and of reversed expression patterns in northern and southern hemispheres strongly supports endogenous regulation of seasonality in human immune function. seasonality of human infectious disease may be driven by an endogenous circannual rhythmicity in host immunity that generates cycles of enhancement and suppression of immune function and windows of vulnerability to infection, as proposed by dowell ( ) . this study in uk biobank is the largest investigation of the seasonal and daytime patterns in human immune cells, inflammatory markers and antibody titres at population level, but our results are subject to many important limitations. in general, the uk biobank does not truly represent the uk population, as participation was voluntary, uptake rates were low, and ethnic diversity was poorly represented. furthermore, uk biobank specifically recruited participants aged - years, so our findings may not apply to younger people. some of the data that we analysed were self-reported, including ethnicity, physical activity, health status and chronotype, and mis-classification errors are possible. the participants denied chronic disease, but we cannot exclude the presence of acute infection at the time of assessment. the study design was cross sectional, and a single blood sample was available from each participant so the influence of within subject variation cannot be assessed. we were unable to assess circadian patterns since there were no night-time blood sample collections, and our results are limited to analysis of daytime variation. nevertheless, the daily patterns we report in over , participants are consistent with the results of previous studies where blood was withdrawn at regular timepoints over h under experimental conditions. we present results of total cell counts only, and further studies are required to investigate subtypes of lymphocytes and neutrophils. the immune parameters that we report are affected by a multitude of factors related to interactions between host, pathogen and the environment. it is not possible to consider all of these in a population-based study, and the mechanisms driving the associations with day length and time of day that we report require investigation under controlled experimental conditions. furthermore, the effect sizes we report are small, and likely to be of clinical significance for population-level disease control, rather than for the health of individuals. the strengths of this study are the large sample size and that the times of sample collection were randomly allocated to each participant. it is also a strength that we were able to investigate the effects of day length and time of day on immune parameters while adjusting for other factors thought to affect seasonal and daytime variability including physical activity, vitamin d and outdoor temperature. seasonality in the epidemiology of infectious disease is considered to be generated by environment and pathogen related factors, and innate variability in host susceptibility to infection is rarely considered. our findings of seasonal and daytime variability in multiple immune parameters in a large sample of the uk population under basal, free living conditions that were independent of environmental conditions, support the contribution of innate mechanisms to variability in disease susceptibility. future research should focus on whether elective restriction of human activity at times of increased vulnerability to infection through night time and winter curfews could control the spread of infectious disease by minimising exposure to pathogens during susceptible periods. this is exactly the function that has driven the evolution of temporal regulation of the immune system and harnessing this innate attribute could optimise our resilience to covid- and future pandemics. annual variation in total monocytes, neutrophils, lymphocytes and crp. data are mean (bars) and % confidence intervals (boxes), with fitted cosinor curves (dotted line). daylength is indicated by the box colour gradients all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; daytime variation in monocytes, neutrophils, lymphocytes and crp. data are mean (bars) and % confidence intervals (boxes), with fitted segmented regression lines (dotted black lines). the colour gradient represents mean zenith angle of the sun at each timepoint is given to indicate daylight all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted october , . ; https://doi.org/ . / . . . doi: medrxiv preprint table : associations between day length and crp, lymphocyte, neutrophil and monocyte count. 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intervals in parentheses. model was adjusted for age, sex, ethnicity, deprivation, model was adjusted for bmi, physical activity, sedentary behaviour, sleep duration, chronotype, smoking, alcohol model was adjusted for model + day length key: cord- -mneil gn authors: aronen, matti; viikari, laura; kohonen, ia; vuorinen, tytti; hämeenaho, mira; wuorela, maarit; sadeghi, mohammadreza; söderlund-venermo, maria; viitanen, matti; jartti, tuomas title: respiratory tract virus infections in the elderly with pneumonia date: - - journal: bmc geriatr doi: . /s - - -z sha: doc_id: cord_uid: mneil gn background: in children suffering from severe lower airway illnesses, respiratory virus detection has given good prognostic information, but such reports in the elderly are scarce. therefore, our aim was to study whether the detection of nasopharyngeal viral pathogens and conventional inflammatory markers in the frail elderly correlate to the presence, signs and symptoms or prognosis of radiographically-verified pneumonia. methods: consecutive episodes of hospital care of patients years and older with respiratory symptoms (n = ) were prospectively studied as a cohort. standard clinical questionnaire was filled by the study physician. laboratory analyses included pcr diagnostics of nasopharyngeal swab samples for respiratory viruses, c-reactive protein (crp) and white blood cell count (wbc). chest radiographs were systematically analysed by a study radiologist. the length of hospital stay, hospital revisit and death at ward were used as clinical endpoints. results: median age of the patients was years (range – ). pneumonia was diagnosed in / ( %) of the studied episodes. one or more respiratory viruses were detected in / ( %) episodes and in / ( %) episodes also diagnosed with pneumonia. pneumonia was associated with a wbc over × ( )/l (p = . ) and a crp value over mg/l (p < . ). a virus was detected in % of pneumonia episodes and in % of non-pneumonia episodes, but this difference was not significant (p = . ). the presence of a respiratory virus was associated with fewer revisits to the hospital (p < . ), whereas a crp value over mg/l was associated with death during hospital stay (p < . ). respiratory virus detections did not correlate to wbc or crp values, signs and symptoms or prognosis of radiographically-verified pneumonia episodes. conclusion: among the elderly with respiratory symptoms, respiratory virus detection was not associated with an increased risk of pneumonia or with a more severe clinical course of the illness. crp and wbc remain important indicators of pneumonia, and according to our findings, pneumonia should be treated as a bacterial disease regardless of the virus findings. our data does not support routine virus diagnostics for the elderly patients with pneumonia outside the epidemic seasons. electronic supplementary material: the online version of this article ( . /s - - -z) contains supplementary material, which is available to authorized users. the number of over -year-old patients with weaning immune system is rising rapidly in western societies, but the clinical significance of respiratory virus infections among this group remains unclear. the burden of pneumonia among the elderly is high as it includes significant morbidity, mortality and costs around the world [ ] . in the united states alone, about % of the deaths caused by pneumonia or influenza occur in the age group of years and older, and in , in the health care of patients of all ages, more than . billion dollars were spent on pneumonia [ ] . as polymerase chain reaction (pcr) and rapid antigen detection tests are increasingly available for respiratory virus detection [ ] , currently in to % of lower respiratory tract infections among the elderly, a virus has been implicated [ , ] . in the age group of years and older, influenza virus (flu), respiratory syncytial virus (rsv) and parainfluenza virus (piv) are the leading viral causes of respiratory morbidity and mortality [ ] [ ] [ ] , while other viral causes include rhinovirus (rv) and coronaviruses (cov) [ ] . however, in contrast to pediatric data, there are only a few reports concerning the usefulness of respiratory virus diagnostics in the elderly, and virus diagnostics have shown only limited value in reducing antibiotic use and the length of hospital stay [ , ] . while influenza detection is seen as an important diagnostic tool by the physicians, the detection of other viruses is seen less useful [ ] . among the elderly, the all-cause mortality rate associated with respiratory viral infection increases with age and is approximately - % among the over -year-old subjects [ ] . this may, however, be an underestimate due to a general bias towards predominantly recording influenza as a death course, while neglecting other virus infections. other common risk factors of a severe respiratory viral infection among the elderly include underlying medical conditions and poor response to influenza vaccine [ , ] . in adults, mixed infections with a respiratory virus and a bacterial pathogen, especially rhinovirus with pneumococci, have been shown to associate with more severe pneumonia and longer hospitalization period [ ] [ ] [ ] [ ] . c-reactive protein (crp) value and white blood cell count (wbc) seem to be insufficient methods in differentiating sole bacterial, mixed and sole virus pneumonias, although no unambiguous methods exist [ , ] . all of the aforementioned findings support a clinically meaningful role of virus diagnosis among the frail elderly. thus, the aim of this study was to investigate how viral pathogens detected in the nasopharynx and conventional inflammatory markers (wbc and crp) correlate to signs, symptoms and prognosis of pneumonia among the age group of years and over. we hypothesized that virus detection could give clinically relevant information in addition to conventional inflammatory markers and chest radiograph findings in treating frail elderly patients. this prospective follow-up study investigated the association between virus detection and predefined clinical outcomes in elderly hospitalized patients. strobe criteria were respected. the study was carried out in geriatric wards of the turku city hospital between july and april as part of a previously introduced study [ ] . consecutive turku residing patients of over years of age suffering from respiratory symptoms requiring hospital admission were recruited in this study. patients were excluded from the study if they were in extremely poor condition, had severe dementia or had been quarantined. the patient or his/her trustee was informed about the study both orally and in a written form. patient's previously named trustee was approached if patient's ability to independent decision making was deteriorated. a written consent from the patient or his/her trustee was required to participate in the study. the study protocol was approved by the ethics committee of the turku university hospital and it complies with the ethical rules for human experimentation stated in the declaration of helsinki. patients were considered to have respiratory symptoms if they had coryza, cough, sore throat, hoarseness or nasal stuffiness. in pneumonia episodes, the need for oxygen was considered as a sign of dyspnea. at study entry patients or their trustees were interviewed using a standardized questionnaire (additional file : "questionnaire"), which included questions concerning the form of living before hospitalization, the hospital unit the patient was coming from, chronic diseases, influenza vaccination status, height, weight, smoking habits and physical activity. hospital records were reviewed for the clinical history and gender of the patient. having one or more of the following conditions was defined as having other diseases: dementia, depression, diabetes, rheumatic disease or history of cancer. the length of the hospital stay, hospital revisit and death during the hospital stay were used as clinical outcomes of this study. patient was discharged from the ward when the illness no longer required hospital treatment. a new episode of hospital care between weeks and six months from the last visit was considered a revisit; earlier visits were considered prolonged illness and later a separate episode. for this study only hospital revisits in which respiratory symptoms were present were recorded. treatment-related chest radiographs taken in the study hospital were systematically analysed in a blinded fashion by a study radiologist. the presence of interstitial infiltrate and/or lobar atelectasis in the chest radiograph was considered pneumonia after congestive heart failure as an etiology was excluded. from all patients meeting the inclusion criteria, nasopharyngeal swab samples were collected (sterile flocked swab, cs , copan, brescia, italy) by study physicians within h of admission. the swabs were then stored in dry tubes in a refrigerator for a maximum of h before transportation to the laboratory where they were stored at − °c. the swab samples were analysed at the department of virology, university of turku, turku, finland by a multiplex reverse-transcriptase (rt-)pcr test (seeplex rv ace detection; seegene, seoul, korea) for adenovirus, coronavirus nl and oc , human bocavirus, human metapneumovirus (mpv), influenza a and b, and piv - , and by using an 'in-house' rt-pcr test for rsv, rv -including rhinovirus type c -and enteroviruses (evs) [ ] . based on our previous experiences in amplicon sequencing, if the in-house pcr test could not distinguish enteroviruses from rhinoviruses, the result was considered rhinovirus positive [ , ] . hbov infections were serologically confirmed to be acute infections at the department of virology, university of helsinki, helsinki, finland. blood samples for crp and wbc analysis were routinely collected from all the patients as part of hospital treatment. the serum samples were stored at − °c and analyzed by the hospital laboratory. the highest values measured during the hospital stay were used in statistical analysis. in basic statistics, two sample t-test, χ test and fischer exact test (when counts < ) were used when appropriate. logistic regression with full model was used to analyse the association between clinical outcomes and virus etiology, pneumonia, chronic illnesses (cardiovascular diseases, respiratory diseases, other diseases), age, gender and laboratory findings (wbc, crp). statistical significance was established at the level of p < . . for statistics sas enterprise guide . (sas institute inc., cary, nc, usa) was used. a total of episodes of hospital care were screened ( fig. ). of those screened episodes of hospital care fulfilled the initial study requirements of age years or over, hospitalization-needing disease, respiratory symptoms and a signed consent to participate in the study. a swab and serum samples were collected from the patients of these episodes. of the episodes, a chest radiograph was available for episodes. in of the episodes the patient was diagnosed from a chest radiograph finding as having pneumonia. in ( %) of these pneumonia episodes the patient had pneumonia with dyspnea and in ( %) pneumonia without dyspnea. the characteristics (age, gender, presence of chronic illnesses, smoking status) of patients who had respiratory symptoms but no chest radiograph available, were not different from the included subjects (p > . , data not shown). mean age of the patients in the study was . (sd . ) years (table ) . a diagnosis of cardiovascular disease was present in % and respiratory disease in % of the study episodes. there were more men ( %) in the group diagnosed with pneumonia than in the group not diagnosed with pneumonia ( %) (p = . ). the weight of the patients seemed to be lower in the group diagnosed with pneumonia (p = . ), whereas heart dysrhythmia seemed to be more common among patients not diagnosed with pneumonia (p = . ). in connection with the study episodes without pneumonia, in % the patient had a history of a stroke or transient ischemic attack (tia) and in % the patient smoked, compared to . and % of the study episodes diagnosed with pneumonia, respectively. these differences were, however, not statistically significant (p = . and p = . , in the same order). otherwise cardiovascular, respiratory and other diseases were equally common in the study episodes diagnosed with pneumonia and the study episodes not diagnosed with pneumonia (all p > . ). a respiratory virus was detected in / ( %) nasopharyngeal swabs of the study episodes (table ) . overall, rhinovirus and influenza virus were the two most common viruses detected, both present in ( %) study episodes, followed by parainfluenza in ( %), coronavirus in ( %), rsv in ( %), mpv in ( %) and adenovirus in ( %) cases. during one study episode, prolonged bocavirus shedding was found in the nasopharynx of the patient, but serology did not confirm an acute infection. in % of the study episodes diagnosed with pneumonia a respiratory virus was also detected, whereas the same was true for % of the study episodes not diagnosed with pneumonia. this association was, however, not statistically significant (p = . ). virus detection was also found not to be associated with dyspnea (p > . ), nor were there virus-specific differences found between study episodes diagnosed with pneumonia and with dyspnea, and study episodes diagnosed with pneumonia but without dyspnea (p > . ). the mean wbc value was . × /l in study episodes with pneumonia and . × /l in study episodes without pneumonia, but this difference was not statistically significant (p = . , table ). as a categorical variable, wbc over × /l was associated with study episodes diagnosed with pneumonia (p < . , table ). the mean crp value was mg/l in study episodes with pneumonia and mg/l in study episodes without pneumonia (p < . ). as a categorical variable, a crp value over mg/l, or even over mg/l, was associated with a pneumonia finding in the chest radiograph (p < . for both, table ). when comparing study episodes diagnosed with pneumonia and with one or more respiratory viruses, and study episodes diagnosed with pneumonia but without respiratory viruses, no differences between wbc or crp values were found (p > . , table ). corresponding effects of the most common viruses (rhinovirus, influenza virus, coronavirus, rsv and parainfluenza virus) were also tested separately, and no differences were found (p > . ). a clinical outcome was available for of the study episodes. of the study episodes with clinical outcome available, in , the patient stayed in the hospital for more than nights, in , the patient had a revisit and in , the patient died during the hospital stay (table ). in study episodes diagnosed with pneumonia, the presence of a respiratory virus was neither associated with clinical outcomes (i.e. over -night hospital stay, number of revisits or death at ward) nor with wbc values over × /l or crp values over mg/l (all p > . , table ). similar results were also seen with lower wbc and crp cutoff values of × /l and mg/l, respectively (data not shown). also in connection with study episodes diagnosed with pneumonia, there was no association between the above mentioned clinical outcomes and laboratory findings (wbc over × /l/l or crp over mg/l) (p > . ). in study episodes diagnosed with pneumonia and with dyspnea, death at ward was seen in % of the study episodes, whereas in connection to study episodes diagnosed with pneumonia but without dyspnea, the same was true in . % of the study episodes, although this difference was not statistically significant (p = . ). however, study episodes diagnosed with pneumonia and with dyspnea lasted longer than study episodes diagnosed with pneumonia but without dyspnea (p = . ). no difference in the number of deaths at ward was seen between study episodes diagnosed with pneumonia and study episodes not diagnosed with pneumonia. a negative association was found between hospital revisit and virus detection; a revisit was less probable when a virus was present than when a virus was not present; ( %) revisits occurred among the virus-positive study episodes and ( %) revisits among the virus-negative study episodes (p < . , table ). finally, a crp value over mg/l was associated with death at ward; of the ( %) deceased patients had crp values over mg/l (p = . . table ). the study shows three main findings. firstly, radiologically confirmed pneumonia was not associated with respiratory virus detection. moreover, in the studied episodes of hospital care diagnosed with pneumonia, the presence of a respiratory virus was associated neither with clinical outcomes, nor with wbc or crp values. against our study hypothesis, all the studied episodes of hospital care in which the patient was diagnosed with one or more respiratory viruses were, in fact, associated with a less severe clinical course in terms of the number of hospital revisits. secondly, radiologically confirmed pneumonia was associated with the indicators of a severe bacterial infection, wbc over × /l and crp over mg/l. thirdly, a crp value over mg/l was associated with death at ward. our finding, namely that % of the study patients diagnosed with pneumonia also had a respiratory virus present in nasopharynx, is in line with recent studies executed on adults that suggest that even one third of pneumonia cases are associated with a respiratory virus [ , , ] . in our study, rhinovirus was the most common virus present in the study episodes diagnosed with pneumonia, followed by coronavirus and influenza virus. treanor et al. anticipated in their study that the role of these common cold viruses, coronavirus and rhinovirus, among the elderly will rise in the future, although piv, rsv and influenza are still considered the most harmful viruses among the elderly [ ] [ ] [ ] . our findings also support this idea of a rising clinical significance of common cold viruses, especially rhinovirus, among the elderly [ , , ] . an association between elevated disease severity and dual infection, especially rhinovirus/pneumococcal infection, in the adult population have been reported previously [ , ] . our analyses, however, showed no differences in the severity of the study episodes diagnosed with pneumonia regardless of whether there was a respiratory virus present or not. frailty, immunologic weakening and cardiopulmonary diseases are understood to predispose to pneumonia when a viral infection occurs [ ] . in our study, a respiratory virus was found in no less than % of the elderly patients who suffered from respiratory symptoms but were not diagnosed with pneumonia. at the same time, the risk of a hospital revisit in all the studied episodes of hospital care seemed to be lower when a virus was present than when no virus was fund. these findings support the idea that respiratory viruses are merely innocent bystanders in patients with pneumonia [ ] . our study strengthens the idea that high crp and wbc values are associated with pneumonia in patients with respiratory symptoms but have limited value as independent predictors [ ] . in adult populations, only relatively high crp values have been shown useful in predicting the presence of pneumonia, and a cut-off value of mg/l is mentioned in some studies [ ] . krueger et al. concluded in their capnetz-study with patients aged ± years that wbc and crp are higher in typical bacterial than in atypical or viral etiology community-acquired pneumonias [ ] . gao et al. showed in their study that high levels of crp were induced as well as correlated with the complement activation in patients infected with severe influenza a [ ] . in our study, we saw no difference in inflammatory markers according to virus etiology. according to our data, among the elderly, a respiratory disease that elevates crp to over mg/l could be linked to death on the count of that in such cases pneumonia is probable. lee et al. showed similar results in their study with patients aged . +/− . years [ ] . interestingly, they also showed that in addition to crp the albumin level was associated with a -day mortality in hospitalized patients with a community-acquired pneumonia. on the other hand, ortqvist et al. saw no association between high crp and mortality in hospital-treated pneumonia patients and krueger et al. stated in the capnetz-study that wbc in contrast to crp increased with the severity of a community-acquired pneumonia [ , ] . the strengths of our study include prospective design, large sample size and sensitive virus-detection methods. also, pneumonia was radiologically confirmed. however, there are some limitations to our study as well. as the study observed hospitalization-requiring episodes among frail geriatric patients, the results cannot be generalized as such to treating outpatients. also, the swab samples were collected from the upper airways and thus infections solely in the lower airways may have been missed. further, as the virus samples were collected in - , they naturally give specific information concerning those years only. the study was carried out ten years ago and in one center which limits the generalizability of the results. many respiratory viruses exhibit a seasonal variation in temperate climates. however, at species level annual virus epidemics are relatively stable in climates with defined winter seasons like in finland [ ] . we used modern pcr diagnostics that have been in routine use ever since. we believe that nearly a -year recruitment period with samples gives a relatively good picture of virus epidemics at species levels in our area. this study has prospective design and gives information about the effect of common respiratory virus infections, even though there is some annual variation in circulating viruses. due to many chronic diseases in the elderly, virus-induced respiratory symptoms may be difficult to distinguish from other symptoms. however, for dyspnea, we used an objective criterion based on oxygen saturation. this study gives valuable information about the significance of virus findings in nasopharynx and inflammatory markers among frail elderly patients with respiratory symptoms. in elderly patients, the presence of respiratory viruses in the nasopharynx seems to have limited value in assessing the severity and the short-time prognosis of the disease. multivariable logistic regression analysis was used crp 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characteristics, and illness severity bronchiolitis: age and previous wheezing episodes are linked to viral etiology and atopic characteristics acute viral infections of upper respiratory tract in elderly people living in the community: comparative, prospective, population based study of disease burden uncommon(ly considered) manifestations of infection with rhinovirus, agent of the common cold severe human rhinovirus outbreak associated with fatalities in a long-term care facility in ontario community-acquired viral pneumonia what is the real role of respiratory viruses in severe community-acquired pneumonia? evaluating the evidence for the implementation of c-reactive protein measurement in adult patients with suspected lower respiratory tract infection in primary care: a systematic review biomarkers in lower respiratory tract infections inflammatory parameters predict etiologic patterns but do not allow for individual prediction of etiology in patients with cap: results from the german competence network capnetz c-reactive protein mediating immunopathological lesions: a potential treatment option for severe influenza a diseases albumin and c-reactive protein have prognostic significance in patients with communityacquired pneumonia diagnostic and prognostic value of interleukin- and c-reactive protein in communityacquired pneumonia occurrence of respiratory virus: time, place and person we thank md heli ylä-outinen and md henriikka langen for active patient recruit, sample collection and patient monitoring, laboratory assistant heidi jokinen for sample storage and analysis coordination, biostatistician tero vahlberg for assistance in biostatistics and colleagues of the geriatric department of the turku city hospital for co-operation regarding the study. in addition, we thank anna eskola, for language editing.funding tyks foundation, turku and the sigrid jusélius foundation, helsinki, finland. the granting agencies played no role in study design, execution or analysis. the datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. if a virus is found, it may in fact indicate a clinical situation with a better prognosis. in this study, not one respiratory virus correlated with the presence, signs and symptoms or prognosis of radiographically-verified pneumonia among the elderly. however, this study did find that a crp over mg/l and a wbc over × /l were linked to pneumonia and a crp over mg/l to elevated mortality during hospital stay. all in all, this study shows that pneumonia should be treated in elderly people as a bacterial disease regardless of virus findings. the study protocol was approved by the ethics committee of the turku university hospital and it complies with the ethical rules for human experimentation that are stated in the declaration of helsinki. the patient or his/her trustee was informed about the study both orally and in a written form. patient's previously named trustee was approached, if patient's ability to independent decision making was deteriorated. a written consent from the patient or his/her trustee was required to participate in the study. not applicable. key: cord- -i bs s authors: cheng, chao-wen; chien, ming-hsien; su, shih-chi; yang, shun-fa title: new markers in pneumonia date: - - journal: clinica chimica acta doi: . /j.cca. . . sha: doc_id: cord_uid: i bs s abstract pneumonia is one of the most common causes of death from infectious diseases worldwide, and the most common fatal infection acquired in hospitals. despite advances in prevention strategies, such as antibiotic therapies and intensive care, significant improvement in the mortality rate is still lacking. this high mortality is largely due to the limitations in current clinical practices and laboratory tests, which delay the timing of adequate antibiotic therapy. in recent years, many indicators (biomarkers) are present in scenarios where infectious pathogens invade into the body. these biomarkers, as reflected in specific biological responses to infections, have been reported to demonstrate the ability to facilitate the diagnosis, risk stratification, and management of pneumonia. this review provides a schematic overview of these new potential biomarkers based on the categories of ( ) microorganisms and their derivatives, ( ) inflammation mediators, ( ) inflammation response proteins, and ( ) stress-sensing proteins. in addition, approaches to identifying new biomarkers are also briefly introduced. although no current biomarker can solely achieve a definitive diagnosis, many of them can be complemented, rather than replaced outright, in routine clinical practices to improve decision-making processes regarding pneumonia. acquired outside of hospitals; hap describes infections acquired in the hospital setting; vap is a subtype of hap that occurs when receiving mechanical ventilation; nhap is defined as infection acquired in an extended-care facility. in the united states, an estimated . million patients are diagnosed with cap annually, with . million requiring hospital admission. the mortality rate of cap outpatients is in the range of %- %, with % of patients requiring hospitalization, and as much as % of patients requiring admission to intensive care units (icus) [ , ] . although the clinical presentations are often similar, pneumonia can also be classified into typical or atypical types according to the differences in pathogens. the typical type of pneumonia is usually caused by bacteria such as streptococcus and staphylococcus, while the atypical type is caused by the influenza virus, mycoplasma, chlamydia, legionella, adenovirus, or other unidentified microorganisms [ ] . ideally, as an early and definitive diagnosis can be achieved by verifying the specific pathogens involved, subsequent treatment with specific antibiotics can improve the prognosis of pneumonia. however, a rapid and accurate diagnosis of pneumonia remains challenging. the common clinical symptoms of pneumonia patients include cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain [ ] . depending on the various types of pathogens involved, pneumonia may be accompanied with different features. according to the clinical guidelines, the gold standard for diagnosing pneumonia involves the use of chest radiography to detect the presence of pulmonary infiltrates. however, chest radiography is not sensitive enough for detecting specific pulmonary infiltrates and the early course of the disease. up to one-third of possible pneumonia diagnoses may be missed when using chest radiography [ ] . in addition, certain chronic diseases, such as congestive heart failure, chronic obstructive pulmonary disease, and malignancy, can also interfere with the results. laboratory tests, including leukocyte count, sputum gram stain, sets of blood cultures, and urine antigens, can also help provide a definitive diagnosis and guide therapeutic decision making. however, the results of these tests on patients with suspected cap vary because of the uncertain quality of specimens and the use of antimicrobial drugs. a positive blood culture may have no correlation with the severity of the illness or outcome [ ] . such uncertainty and time-consuming limitation may obscure accurate diagnoses and delay the beginning of treatment. therefore, innovative approaches for identifying the indicators of biological state of pneumonia are eager to be achieved. the term "biomarker" is defined as a biological molecule found in blood, other body fluids, or tissues that is a sign of a normal or abnormal process, or of a condition or disease. a biomarker may be used to see how well the body responds to a treatment for a disease or condition [ ] . according to this definition, a qualified biomarker of pneumonia should be used to accomplish at least one or more of the following tasks: perform a rapid and accurate diagnosis and less affected by other diseases, identify the types of pathogenic microorganisms for specific antibiotics treatment, and reflect the status of successful prognosis therapy or remain elevated with the infectious stimulus [ , ] . consequently, the potential biomarkers in pneumonia exist in the specific biological responses to infections and the scenario where the infectious pathogens invade in the host body. noteworthily, most of the potential markers in pneumonia are also described in the sepsis. therefore, biomarkers in pneumonia can fall into four categories: ( ) microorganisms and their derivatives; ( ) inflammation mediators; ( ) inflammation response proteins; and ( ) stress-sensing proteins (table ) . in the progress of pneumonia, pathogenic bacteria that undergo host respiratory colonization and growth can be detected and characterized by performing conventional laboratory tests. although these methods are highly specific, the result is affected by the usage of antimicrobial drugs and the sensitivity is poor. the application of polymerase chain reaction (pcr) in species-specific genes and conserved bacterial dna sequence-based diagnostic tests has been developed [ , ] . in contrast to negative sputum cultures, most samples from patients infected with streptococcus pneumoniae and receiving antibiotics can still be accurately evaluated by applying pcr [ ] . examination by using a real-time (rt) pcr technique can reduce the time consumption associated with culture methods and permit early diagnosis. in a prospective study in denmark, a quantitative multiplex pcr method was evaluated by detecting s. pneumoniae, haemophilus influenzae, and neisseria meningitidis in bronchoalveolar lavage fluids (balf) and cerebrospinal fluids (csf). both the sensitivities and specificities for s. pneumoniae and h. influenzae can reach %- % in a cut-off of genomic copies/ml for clinical positivity. in a previous study where patients had taken antibiotics prior to sampling, % of s. pneumoniae infections and % of h. influenza infections could be detected using pcr, whereas only % and %, respectively, could be detected in culture. in addition, identifying the s. pneumoniae and n. meningitidis in csf can achieve % sensitivity and specificity [ ] . pathogens detected by pcr are not found by using the culture methods, and vice versa, suggesting that pcr can provide additional information compared to current culture methods [ , ] . pcr results may show the existence of specific infectious pathogens, which, however, is not considered the "illness" of pneumonia. vap is the main infection acquired in an icu and with the use of antibiotics. the microbiologic flora associated with vap encompasses multidrug-resistant bacteria. up to % of vap cases are caused by gram-negative bacteria, which contain abundant endotoxins in the outer membrane. the concentration of endotoxins in balf has exhibited a relationship with the quantity of gram negative bacteria in vap. an amount greater than or equal to eu/ml can be used to distinguish patients with gram-negative or -positive bacterial pneumonia (sensitivity, %; specificity, %; positive predictive value, %; negative predictive value, %). determining the concentration of endotoxins in balf can facilitate the diagnosis of gram-negative pneumonia for further antibiotic therapies, although a gram stain of balf can provide the same information [ , ] . once the infectious pathogen invades and begins growing, the host rapidly releases a cohort of inflammatory cytokines, such as interleukin (il)- β, il- , tumor necrosis factor (tnf)-α, and il- , in response to the infection. however, these proinflammatory cytokines have not met the criteria for clinical applications because of their short half-life and low specificity, as well as the existence of natural inhibitory factors in the serum [ , ] . in a study of patients with cap, il- and tnf-α were detected in most of the patients on admission and decreased significantly thereafter, and il- presented as a prognostic marker in correlation with the acute physiology and chronic health evaluation ii (apache ii) scores on admission. based on an evaluation, high levels of both il- and il- increase the risk of mortality in cap [ , ] . conway-morris et al. found that balf il- β, il- , granulocytemacrophage colony-stimulating factor (gm-csf), and macrophage inflammatory protein (mip)- α were significantly higher in the vap patients. in patients with balf il- β lower than pg/ml, the posttest probability of vap was only . %, whereas a level of il- greater than ng/ml corresponded to a % probability of vap being present. in addition, the cytokines could be detected within h and showed a significant impact on clinical decision making [ , ] . the innate immunity system is the first line of host defense against pathogens and comprises both cellular and soluble compartments. the major components in soluble compartments are pattern recognition proteins, demonstrating the abilities to recognize pathogen-associated molecular patterns (pamp), such as collectins, ficolins, and pentraxins, in initiating an immune response. pentraxins are a family of acutephase reactants that are highly conserved in biological classes from arachnids to mammals. based on the primary structure, pentraxins are divided into two groups: short and long pentraxins. c-reactive protein (crp) and the serum amyloid p component (sap) are prototypic short pentraxins, and long pentraxin (ptx ) is the prototypic long pentraxin [ , ] . plasma pentraxins, which are barely detectable under normal conditions but rapidly increasing while counteracting with the infections, represent invaluable diagnostic indicators in pneumonia. crp was first identified in from the serum of pneumonia patients. crp has been observed to disappear in recovering patients and not detectable in healthy people [ , ] . in the presence of calcium, crp can recognize and bind to several pamps present in bacteria, fungi, and parasites, and become involved in the clearance of microorganisms. crp is synthesized in hepatocytes through the induction of il- , although other cytokines, such as tnf-α and il- β, are also involved. in healthy human adults, the concentration of crp is lower than mg/l [ ] , and the secretion of crp starts from between and h after stimulation, doubling every h, and reaching the maximum value after - h. in the existence of stimuli, crp production can still be evaluated at even more than -fold of the reference value. once the stimulus is removed, the crp value falls rapidly with a half-life of h [ , ] . serum crp has been reported in some studies regarding its role in identifying patients with pneumonia. the elevation of crp levels is both sensitive and specific for predicting pneumonia, and its diagnostic performance is superior to white blood cell counts or erythrocyte sedimentation rates [ ] . in a prospective hospital-based cap study, serum crp levels were elevated above mg/l in all of the patients and above mg/l in % of the patients on the day of hospital admission. patients who had received antibiotics prior to hospital admission exhibited significantly lower crp levels [ ] . in radiologically confirmed pneumonia, the specificity of crp at a cut-off value of mg/l in predicting pneumonia can reach . % [ ] . serum crp values are significantly higher in cap patients, compared to healthy controls and suspected cap patients, and high crp values are suggestive of severity in determining the appropriateness of inpatient care. in addition, serum crp levels have been demonstrated to be greatly increased by most severe bacterial infections, but only modestly increased by viral respiratory tract infections [ , ] . high crp values are especially present in patients with pneumonia caused by s. pneumonia or legionella pneumophila [ ] . the single parameter of crp concentration greater than mg/l appears to be highly specific for a bacterial infection. combination with other markers did not improve the diagnostic accuracy in differentiating patients with a bacterial or viral lower respiratory tract infection (lrti), compared with crp alone [ ] . by contrast, some previous studies have inferred that crp lacks specificity for bacterial infection, and a high crp level could be due to other inflammatory conditions [ ] . the serum level of crp may largely depend on the status of systemic inflammatory responses rather than the direct outcomes of the disease. the general characteristics of patients, such as age and sex, may also strongly influence serum crp values. alternatively, assessment results of relative variations may provide more information about the course of infection than that of absolute variations can. the serial measurements of crp in a patient may represent the progression of the clinical course and also help assess the response to antibiotic therapy. in a cohort study of hap patients, the crp ratios of day to the admission day could separate the "good" and "poor" responses at % and % mortality rates, respectively [ ] . in a multicenter prospective observational study of community-acquired sepsis, póvoa et al. indicated that, as early as day onward, the crp concentrations of survivors decrease to a level that was significantly lower than that of non-survivors [ ] . póvoa et al. also suggested that, after - h of antibiotic therapy, the crp value of severe cap survivors should decrease by %- % from the admission day. patients with consistent decreasing crp ratios usually have a more favorable response to antibiotic therapy [ ] . . . . . long pentraxin . ptx , similar to the short pentraxins, is an acute-phase reactant that plays a crucial role as a soluble innate immune pattern recognition receptor in the activation of innate immunity. however, ptx exhibited different features from short pentraxins in its structure, gene location, and cellular source, inducing stimuli and ligand recognition. the structure of ptx is related to crp and sap, but contains an unrelated long amino-terminal domain coupled to the carboxyl-terminal pentraxin domain [ ] . the genes of short pentraxins are located on chromosome , whereas ptx is located on chromosome q . unlike crp that is produced in the liver by the stimulation with the secondary cytokine, il- , ptx is induced by the toll-like receptor engagement and primary cytokines, tnf-α and il- β, in various cell types, particularly mononuclear phagocytes, dendritic cells, fibroblasts, endothelial cells, and epithelial cells [ , ] . il- does not induce ptx production. taken together, these findings imply that the serum ptx level may directly reflect the severity of infections and is less affected by other inflammatory conditions. the levels of ptx , which are low under normal conditions (b ng/ml in human), have been examined in several clinical settings for infectious diseases, thus revealing a correlation with severity and mortality. a cohort study consecutive critically ill patients admitted to the icu with systemic inflammatory response syndrome, sepsis, or septic shock showed that ptx was elevated with a gradient from systemic inflammatory response syndrome to septic shock. ptx levels not only correlated with clinical scores but also reflected the severity of disease, and higher levels of ptx were associated with an unfavorable outcome [ ] . in severe leptospirosis patients, the plasma ptx levels were also associated with the severity and mortality of diseases, while crp levels could not be used to differentiate the severe from the severest cases [ ] . in studies on patients with meningococcal disease, high plasma concentrations of ptx were seen at admission and correlated to patients with shock, whereas crp level at admission was negatively correlated. ptx level was not correlated with mortality or days spent in the icu [ ] . in bacteremia patients, ptx values on days - were markedly higher in non-survivors compared to survivors and showed % sensitivity and % specificity for fatal disease at a cut-off level of ng/ml. ptx showed a higher prognostic value compared to crp in the prognostic stratification of bacteremia patients [ , ] . in our recent data on cap, ptx and crp levels were both decreased after antibiotic treatment. the plasma concentration of ptx was correlated with the severity of cap and the length of hospital stay. calcitonin gene peptides, including procalcitonin (pct), ct generelated peptides, and adrenomedullin (am), are a superfamily of endocrine cell-produced hormones with systemic activities. the classical production of calcitonin gene peptides is mainly carried out by the neuroendocrine cells. in addition, calcitonin gene peptides can also be expressed in the various parenchymal cells and are released by the microbial toxins or pro-inflammatory cytokine stimulation. the systemic release of calcitonin gene peptides occurs in a cytokinelike manner and is considered a prototype of hormokines. the serum levels of calcitonin gene peptides may be applied as indicators for the status of infections. . . . . procalcitonin. procalcitonin (pct), a thyroidal parafollicular cell-produced prohormone ( kda), is low in serum (b . ng/ml) of healthy people, whereas circulating pct levels, primarily derived from non-thyroidal tissues, can increase by several -fold in patients with sepsis [ ] . in the process of microbial infection, lipopolysaccharide (lps), il- β, il- , and tnf-α can promote calc-i gene expression and increase the release of pct into circulation from parenchymal tissues, such as the liver and peripheral blood mononuclear cells. after a septic stimulus, pct protein production of parenchymal cells can be detected after h with a half-life of approximately - h [ , ] . in addition, the production of pct may also be markedly increased under noninfectious conditions such as trauma, surgery, burns, heat stroke, and rejection after transplantation [ , ] . pct levels are attenuated by the cytokines released in response to a viral infection. the prohormone requires further post-translational processing to form a mature type of hormone, and may demonstrate distinct biological activities. in a hamster septic model, the concentration of pct was rapidly evaluated and peaked at h after induction of sepsis. because the exogenous pct significantly increased the mortality rate, a prophylactic blockade of pct attenuated the lethal effects of sepsis. the increase in circulation of pct levels may exacerbate the mortality rate, and diminishing the production of pct increases the survival [ ] . it inferred that pct may play a detrimental role in systemic inflammation. in addition, the changes in circulating pct levels may represent the severity of infections and may be used as a prognostic marker. therefore, the circulating pct level has been examined to monitor the progression of severe sepsis, septic shock, and the response to antimicrobial therapy [ ] . two commercial pct detection assays that demonstrate high sensitivity, low detection limitations, and a fast readout are currently available. several studies have reported the value of using pct levels in managing cap. it has been suggested that rising pct can facilitate early identification of the risk of mortality in critically ill patients [ ] . from the results of two randomized prospective studies, in cap patients from a total of patients with suspected lower respiratory tract infections, pct presented a higher diagnostic accuracy in differentiating cap from other diagnoses than did crp or the total leukocyte count. the pct levels also demonstrated higher accuracy in predicting bacteremia and the severity of cap [ ] . in a vap cohort study with sequential measurement of pct and crp levels, both pct and crp levels were significantly higher in patients with confirmed vap, and pct demonstrated higher accuracy. however, the pct and crp levels in balf cannot help differentiate between confirmed and non-confirmed vap [ ] . in addition to discriminating the accurate diagnosis of pneumonia, pct levels demonstrated their prognostic value in cap patients [ , ] . in a study where the pct, crp, wbc, and crb- scores in cap patients were all determined on admission and followed-up for days to ascertain mortality, a similar prognostic accuracy of the crb- score showed that pct levels on admission can predict the severity and outcome of cap. pct levels show a higher prognostic accuracy than do those of crp or leukocyte count, and provide independent identification of patients at low risk of death [ ] . by using pct levels, christ-crain et al. reduced antibiotic exposure in patients with cap from a median of to days in a randomized trial investigating the guidance of antibiotic treatment duration in cap [ ] . the dynamic levels of pct may present a guide for the choice and duration of the antibiotic therapies. pro-adrenomedullin. the adrenomedullin (am) gene encodes a -amino acid preprohormone, which can be generated into a -amino acid peptide pro-am with removal of the signal peptide and further processed to form the active peptides am and pamp (define pamp) [ ] . am is expressed in many tissues including the adrenal medulla, atrium, lung, pancreas, and small intestine [ ] . in addition to its potent vasodilating activities, am can modulate the complement activation to perform bactericidal activities [ ] . in cultured vascular smooth-muscle and endothelial cells, am production can be largely induced by lps, tnf, and il- stimulation. by contrast, am also suppresses il- β-induced tnf-α secretion and gene transcription in swiss t fibroblasts [ , ] . the regulation of am production may be involved in a feedback loop during inflammatory responses. the serum am levels might reflect the severity of infections. however, am is rapidly cleared from circulation. determining the level of pro-am can alternatively represent the levels of the rapidly degraded active peptide am [ ] . pro-am levels are helpful for individual risk assessment and outcome prediction in sepsis. a previous study demonstrated that, the median pro-am level was . nm ( . - . ) in healthy people, . nm ( . - . ) in those with sepsis, . nm ( . - . ) in those with severe sepsis, and . nm ( . - ) in patients with septic shock. on admission, it was also significantly higher in non-survivors than in survivors [ ] . in a prospective observational study, pro-am levels were correlated with the severity of cap and could predict the mortality on admission. combining the psi and pro-am levels increased the prognostic accuracy to predict the risk stratification of cap patients [ ] . in pediatric cap patients, the pro-am level was also related to the development of complications during hospitalization [ ] . although pro-am level can help distinguish the severity and risk of cap, it shows a high coverage of the concentration ranges, and the cut-off values in pneumonia still need to be evaluated. the triggering receptor expressed in myeloid cell- (trem) is a member of immunoglobulin superfamily receptors expressed at high levels in neutrophils and monocytes that infiltrate human tissues infected with bacteria. in microbial sepsis patients and an animal model of lps-induced shock, trem was upregulated in the peritoneal neutrophils [ , ] . silencing of trem in vivo in a fecal peritonitis mouse model blunted the inflammatory response and increased mortality. these effects occur with an impairment of bacterial clearance that was related to marked inhibition of the neutrophil oxidative burst [ ] . raising trem expression levels may promote neutrophil activities in eliminating microorganisms. once the trem binds to its ligand and is activated through the association with the adapter protein, dap , it can further induce the secretion of inflammatory cytokines, such as il- , monocyte chemotactic protein- , and tnf-α to induce neutrophil degranulation in response to infections [ ] . trem is highly expressed in neutrophils caused by staphylococcus aureus, bartonella henselae, and aspergillus fumigatus infections. this phenomenon has not been observed in samples from patients under non-infectious inflammatory conditions [ ] . this indicates that the upregulation of the membrane-bound and the soluble form (s-trem) of trem may be specifically involved in infectious diseases. because the increased expression of trem is found in the infiltrated neutrophils and monocytes, the s-trem levels in balf may be of diagnostic value in pneumonia. in a prospective study of suspected cap and vap patients, the presence of balf s-trem by itself was more accurate than any clinical findings or laboratory values in identifying the presence of bacterial or fungal pneumonia, suggesting that the balf s-trem may serve as an independent predictor of pneumonia [ ] . by contrast, in a study that was conducted to evaluate the usefulness of s-trem in balf of icu patients as a rapid diagnostic test for vap, the s-trem levels in balf could not discriminate for vap, although the confirmed vap patients exhibited higher concentrations of s-trem in balf than did the unconfirmed vap patients [ ] . in another prospective cohort study, the mean s-trem concentration was higher in confirmed vap patients, but this finding lacks statistical significance. patients with alveolar hemorrhage had the greatest values for s-trem concentration, while a cut-off value for s-trem greater than pg/ml yielded a diagnostic sensitivity of . % and a specificity of . % for definite vap [ ] . in addition to being measured in balf, the serum levels of s-trem were also reported with significant elevation in pneumonia, copd, and asthma exacerbations [ ] . the levels of s-trem may correlate with an inflammation condition but appear less accurate as a sole marker for pneumonia. therefore, s-trem levels must be further combined with other markers for accurate evaluation. in sepsis, the innate immune system releases multiple inflammation mediators and related proteins in response to the pathogens. in this period, the uncontrolled secretion of mediators, outgrowth of pathogens, and the release of endotoxin can all cause detrimental physiological stresses such as tissue edema, organ failure, and shock, to affect the vital signs. the neuroendocrine system hypothalamo-pituitary-adrenal (hpa) axis regulates many of the physical processes to appropriately react to stress through the release of corticotropin-releasing hormones (crhs). in the co-stimulation of crh, another stressor, arginine vasopressin (avp), induces adrenocorticotropic hormone (acth) secretion and further controls the adrenal cortex to produce cortisol. in this cascaded process, the circulation levels of avp and cortisol may be used as indicators for the severity of a particular illness [ , ] . the level of circulating avp is difficult to measure because it is released in a pulsatile manner, unstable in plasma, and bound to platelets [ ] . active avp is derived from a larger precursor peptide, the amino-acid preprovasopressin, which consists of a signal peptide, avp, neurophysin ii, and copeptin [ ] . copeptin is a glycosylated peptide with a leucine-rich core segment that is simultaneously released with avp during precursor processing, and considered as an alternative indicator for avp concentration. in addition, copeptin is stable for days after blood withdrawal and can be quickly and easily measured [ , ] . the increase in copeptin levels has shown the positive association of copeptin with the severity and outcome of illness, such as sepsis, hemorrhagic shock, and stroke [ ] . in a study on lower respiratory tract infection (lrti) patients, copeptin levels were significantly increased in lrti patients, and the highest levels of copeptin were observed in patients with cap [ ] . the copeptin level was also associated with the severity of cap, and the non-survivors exhibited significantly higher copeptin levels on admission. copeptin levels are a powerful predictor of short-term and long-term risk stratification of patients with cap [ , ] . in addition to cap, copeptin levels are also an indicator for the severity and mortality of vap [ , ] . the circulating copeptin level represents an accurate marker for early risk stratification and can be applied to management of pneumonia patients. the activation of the hpa axis is characterized by an increase in cortisol levels, thus indicating that cortisol, as copeptin, is essential for survival and parallels the degree of stress. the majority of circulating cortisol in human serum is bound to proteins; however, the free cortisol, rather than the protein-bound fraction, is responsible for the physiologic functions. although the total cortisol level more accurately reflects the intensity of activation in the hpa axis, the free cortisol concentrations can still represent an indicator of critically ill patients [ , ] . both total and free forms of cortisol have been reported to increase with the increasing severity of cap and have been observed to be significantly higher in non-survivors [ , ] . cortisol shows the potential for predicting the mortality and critical disease in cap patients, independently from clinical scores and inflammatory biomarkers. as mentioned, the potential biomarkers in pneumonia may exist in the scenario where infectious pathogens invade into the body, as reflected in specific biological responses to infections. in addition to the pneumonia markers that have been discussed, other biomarkers, such as pro-atrial natriuretic peptide [ , ] , b-type natriuretic peptide [ ] [ ] [ ] , and red cell distribution width [ ] , have been examined and demonstrated to have the ability to improve the diagnosis and prognosis of pneumonia. with advances in proteomic research on developing d gel electrophoresis, mass spectrometry, and bioinformatic analysis, global protein analysis can be applied as an inventory for identifying potential pneumonia markers. because of the deduction of cost, higher resolution, and fast performance, the proteomic technology can be used at the stage of large clinical intervention trials [ ] . yip et al. applied protein chip array profiling analysis to identify biomarkers that might be useful in monitoring the clinical course of severe acute respiratory syndrome patients. they identified the concentration of serum amyloid a protein, a short pentraxin, as a biomarker potentially useful in monitoring the extent of pneumonia [ ] . a research group in taiwan applied d gel electrophoresis and mass spectrometry to identify the differential levels of haptoglobin, immunoglobulin kappa chain, apolipoprotein a-i, and transthyretin in the plasma protein profiles of children with different severities of pneumococcal pneumonia [ ] . in addition to proteomic studies, metabolomics is a rapidly expanding field of identifying and quantifying the changes in the levels of all metabolites within a biofluid, such as blood, saliva, and urine. in a study aiming to compare s. pneumonia with other microbemediated pneumonia, the urinary metabolomic profile of pneumococcal pneumonia patients was significantly different from that of patients with viral and other bacterial forms of pneumonia [ ] . the results from a metabolomic analysis of severe childhood pneumonia in gambia also clearly distinguished severe pneumonia patients from community controls. those identified metabolites are related to the host response to infection through antioxidant, inflammatory, and antimicrobial pathways, as well as the energy metabolism [ ] . these findings indicate that nmr-based analysis of metabolites in urine may provide new information for the diagnosis and etiology of pneumonia. pneumonia is the leading cause of severe sepsis, which is present with a cohort of processes from the entry of pathogens to host defense responses. these potential biomarkers may provide different clinical values in detecting pneumonia according to their original biological features. first, identifying microorganisms and their derivatives can help ascertain the etiology of pneumonia. second, evaluating the inflammation mediators and response proteins can provide information on the degree of immunity to combat pulmonary pathogens that cause the disease, and can facilitate pneumonia management. finally, the circulating stress-sensing proteins that reflect the condition of illness can be useful in stratifying risks and predicting prognosis. however, due to the heterogeneity of pneumonia patients, who vary in age, sex, comorbid conditions, and the development of complications, the clinical cut-off value of these potential biomarkers must be determined further. in conclusion, the implication of these biomarkers should be 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pilot study key: cord- - zmtky authors: esposito, susanna; di gangi, maria; cardinale, fabio; baraldi, eugenio; corsini, ilaria; da dalt, liviana; tovo, pier angelo; correra, antonio; villani, alberto; sacco, oliviero; tenero, laura; dones, piera; gambino, monia; zampiero, alberto; principi, nicola title: sensitivity and specificity of soluble triggering receptor expressed on myeloid cells- , midregional proatrial natriuretic peptide and midregional proadrenomedullin for distinguishing etiology and to assess severity in community-acquired pneumonia date: - - journal: plos one doi: . /journal.pone. sha: doc_id: cord_uid: zmtky study design: this study aimed to evaluate the diagnostic accuracy of soluble triggering receptor expressed on myeloid cells- (strem- ), midregional proatrial natriuretic peptide (mr-proanp) and midregional proadrenomedullin (mr-proadm) to distinguish bacterial from viral community-acquired pneumonia (cap) and to identify severe cases in children hospitalized for radiologically confirmed cap. index test results were compared with those derived from routine diagnostic tests, i.e., white blood cell (wbc) counts, neutrophil percentages, and serum c-reactive protein (crp) and procalcitonin (pct) levels. methods: this prospective, multicenter study was carried out in the most important children’s hospitals (n = ) in italy and otherwise healthy children hospitalized for radiologically confirmed cap were enrolled. among cases for whom etiology could be determined, cap was ascribed to bacteria in ( . %) children and to one or more viruses in ( . %) children. a total of ( . %) children had severe disease. results: crp and pct had the best performances for both bacterial and viral cap identification. the cut-off values with the highest combined sensitivity and specificity for the identification of bacterial and viral infections using crp were ≥ . mg/l and ≤ . mg/l, respectively. when pct was considered, the cut-off values with the highest combined sensitivity and specificity were ≥ . ng/ml for bacterial cap and ≤ . ng/ml for viral cap. for the identification of severe cases, the best results were obtained with evaluations of pct and mr-proanp. however, in both cases, the biomarker cut-off with the highest combined sensitivity and specificity (≥ . ng/ml for pct and ≥ . pmol/l for proanp) had a relatively good sensitivity (higher than %) but a limited specificity (of approximately %). conclusions: this study indicates that in children with cap, strem- , mr-proanp, and mr-proadm blood levels have poor abilities to differentiate bacterial from viral diseases or to identify severe cases, highlighting that pct maintains the main role at this regard. community-acquired pneumonia (cap), with viruses and bacteria as its main causes, is one of the leading causes of morbidity and mortality in young children worldwide [ ] . early detection of bacterial cases that have the potential for a rapid negative evolution is essential to guide clinical management and to avoid prolonged hospitalization and the risk of death [ ] . furthermore, the differentiation of viral from bacterial cap is necessary for the rational use of antibiotics and the consequent reduction in the emergence of bacterial resistance and drug-related adverse events [ ] . unfortunately, both these goals are difficult to achieve, particularly in younger children in whom the collection of respiratory samples is difficult or impossible to obtain [ ] . clinical signs and symptoms and radiological findings are frequently similar in cases of viral and bacterial disease [ ] . moreover, in most cases, the results from routine laboratory tests, such as white blood cell (wbc) count and c-reactive protein (crp) serum level determination, tend to overlap, making the differentiation impossible [ ] . this challenge also exists when using procalcitonin (pct) to define the etiology and severity of cap. pct was the latest biomarker to enter into routine clinical practice [ ] . these limitations explain why several attempts to find more effective biomarkers of cap bacterial etiology and disease severity have been made in recent years. recently, it has been suggested that soluble triggering receptor expressed on myeloid cells- (strem- ), midregional proatrial natriuretic peptide (mr-proanp) and midregional proadrenomedullin (mr-proadm) could improve the determination of cap etiology and severity [ ] [ ] [ ] . for all these biomarkers, data collected in adults seem to indicate that their concentrations in body fluids are increased in cases of bacterial infections, particularly in the most severe cases. however, the available data are limited and sometimes conflicting. moreover, to date no evaluation was performed in children. this study aimed to evaluate the diagnostic accuracy of these new biomarkers to distinguish bacterial from viral cap and to identify severe cap cases in children. the results were compared with those derived from wbc counts, neutrophil percentages, and serum crp and pct levels. this research was a prospective, multicenter study carried out in the most important children's hospitals of italy (fondazione irccs ca' granda, ospedale maggiore policlinico, milan; di cristina hospital, palermo; ospedale giovanni xxiii, bari; padova hospital, padua; ospedale sant'orsola, bologna; treviso hospital, treviso; regina margherita hospital, turin; santobono hospital, naples; irccs bambino gesù hospital, rome; irccs giannina gaslini hospital, genoa, italy; and policlinico g.b. rossi, verona). the protocol was approved by the ethics committee of each center. written informed consent was obtained from either the parent(s) or legal guardian(s) of each study participant, and children aged > years provided their written assent. otherwise healthy children months- years old consecutively hospitalized for clinical signs suggestive of cap, such as tachypnea and abnormal breath sounds, and a radiological confirmation of cap were recruited. exclusion criteria included the presence of an underlying chronic disease or an antibiotic treatment of any type in the hours before the admission. in each center, all chest radiographs were evaluated by an expert radiologist who classified the findings as alveolar cap, non-alveolar cap or no cap in accordance with the world health organization (who) criteria for the standardized interpretation of pediatric chest radiographs for a diagnosis of pneumonia [ ] . chest radiography characterized by presence of consolidation (defined as a dense or fluffy opacity that occupies a portion or whole of a lobe or of the entire lung, that may or may not contain air-bronchograms above) or pleural effusion in the lateral pleural space was considered indicative of alveolar cap. non-alveolar cap was diagnosed in case of linear and patchy densities (interstitial infiltrate) in a lacy pattern involving both lungs, featuring peribronchial thickening and multiple areas of atelectasis. the same diagnosis was made when minor patchy infiltrates not of sufficient magnitude to constitute primary consolidation and small areas of atelectasis that could not be distinguished from consolidation were evidenced. the cap severity of disease was established in all the participating hospitals using the criteria indicated for children by the british thoracic society (bts) [ ] . in particular, features of severe disease in an infant were considered as follows: oxygen saturation < %; cyanosis; respiratory rate > breaths/min; significant tachycardia for the fever level; prolonged central capillary refill time ! s; difficulty in breathing; intermittent apnea; grunting; and not feeding. features of severe disease in an older child included the following: oxygen saturation < %; cyanosis; respiratory rate > breaths/min; significant tachycardia for the fever level; prolonged central capillary refill time ! s; difficulty in breathing; grunting; and signs of dehydration. both the evaluation of the chest radiograph and the classification of severity of each cap episode were blinded to all the studied biological criteria, including wbc count, and crp and pct serum levels. after enrollment, within minutes from hospitalization the demographic, clinical history and clinical disease characteristics of each child were recorded. moreover, a blood sample was drawn at admission to the hospital and divided in two parts: one sample was sent to the central laboratory of the hospital for the determination of routine tests including the wbc count, the percentage of neutrophils, and crp level; the second sample was used for the determination of pct, strem- , mr-proanp, and mr-proadm levels as well as for pneumococcal and mycoplasma pneumoniae detection. finally, a nasopharyngeal swab was obtained from all the enrolled children using a pernasal nylon flocked swab and was stored in a tube of universal transport medium (kit cat. no. c, copan italia, brescia, italy) for respiratory virus, streptococcus pneumoniae, and mycoplasma pneumoniae detection. the serum of the blood samples that had to be used for new biomarkers' serum level determination and nasopharyngeal samples were conserved in freezer at - ˚c in each center and later sent to the laboratory of the pediatric high intensity care unit of the university of milan for centralized processing. biomarker determination. wbc counts, neutrophil percentages and serum crp levels were determined by the central laboratory of the hospital using routine methods. strem- concentrations were measured using an elisa according to the manufacturer's instructions (iq products, groningen, the netherlands) with a detection level of < pg/ml. an automated immunofluorescent assay was used for the determination of the levels of mr-proadm, mr-proanp and pct according to the manufacturer's instructions (brÁaÁhÁmÁs, germany). the functional assay sensitivity was previously assessed as being less than . nmol/l for mr-proadm, pmol/l for mr-proanp, and . ng/ml for pct. the detection limit that was calculated using the imprecision profile was previously assessed as being . ng/ml with a probability of % for pct, . nmol/l for mr-proadm, and . pmol/l for mr-proanp. strem- , mr-proadm, mr-proanp and pct were chosen due to the sensitivity and specificity showed in adults with cap for differentiating viral and bacterial cap or severe and nonsevere cap [ ] [ ] [ ] . clinical and radiographic information, new biomarkers' serum level determinations and results on nasopharyngeal samples were not available for the central laboratory of the hospital where routine methods were performed. two different persons in the laboratory of the pediatric high intensity care unit of the university of milan performed the determination of the new biomarkers and the viral and bacterial analyses on nasopharyngeal samples without exchanging information and in absence of any clinical and radiographic information. respiratory virus detection. viral rna or dna was extracted from the respiratory secretions within hours of collection using a nuclisens easymag automated extraction system (biomérieux, craponne, france) and was then tested using the luminex x tag respiratory virus panel fast assay (luminex molecular diagnostics inc., toronto, canada) to detect influenza a virus (subtype h or h ), influenza b virus, respiratory syncytial virus (rsv)-a and -b, parainfluenzavirus- , - , - and - , adenovirus, human metapneumovirus (hmpv), coronaviruses e, nl , oc and hku , enterovirus/rhinovirus (rv) and human bocavirus in accordance with the manufacturer's instructions. the enterovirus/rv-positive samples were retested using a real-time polymerase chain reaction (pcr) assay using the iag-path-id one step rt-pcr kit (applied biosystems, foster city, ca) and the primers and probe sequences reported by lu et al. to identify rv cases [ ] . streptococcus pneumoniae and mycoplasma pneumoniae detection. to identify pneumococcal cases, nucleic acid extracts from blood and swab samples were tested for the autolysin-a (lyta) and wzg (cpsa) genes of s. pneumoniae using real-time pcr as previously described [ ] . each sample was tested in triplicate and was considered positive if at least of the tests were positive. to maximize sensitivity, no internal amplification control was used in the reaction, but there was an external control. m. pneumoniae was looked for in blood and nasopharyngeal swabs with validated, nested pcr, as described previously [ ] . identification of probable bacterial and viral infection. chest radiographs with alveolar or non-alveolar findings were initially classified as of possible bacterial or of possible viral origin, respectively, according to the who indication [ ] . then, radiological findings were coupled with results of the real-time pcr tests on blood samples and nasopharyngeal swabs. evidence of s. pneumoniae or m. pneumoniae in these samples further supported bacterial etiology. notably, s. pneumoniae can be detected in the nasopharyngeal secretions of children with viral cap [ ] , but its presence in absence of viral detection in children with alveolar cap is suggestive of probable pneumococcal cap [ ] [ ] [ ] . moreover, even if it has been recently reported that m. pneumoniae is frequently carried in otherwise healthy children [ ] , it seems reasonable to think than when this pathogen is detected in children with cap in absence of s. pneumoniae or respiratory viruses, it is the real cause of the lower respiratory infection independent of the radiological characteristics [ ] . finally, the presence of one or more respiratory viruses in the nasopharynx is commonly considered the etiologic agent of cap because carriage of viruses in healthy subjects is uncommon [ ] . in practical terms, cap was considered to have a probable bacterial (pb) origin in the presence of ) the detection of s. pneumoniae and m. pneumoniae in the blood with a chest radiograph indicative of any type of cap; ) a nasopharyngeal swab positive for s. pneumoniae associated with chest radiograph suggesting alveolar cap; and ) a nasopharyngeal swab positive for m. pneumoniae associated with chest radiograph suggesting any type of cap. probable viral (pv) cap was diagnosed in the presence of a nasopharyngeal swab that was positive for one or more respiratory viruses associated with a chest radiograph leading to the diagnosis of non-alveolar cap. cases that could not be included in these groups were considered undetermined. clinical information and blood test results were not available to the person that made this final classification of bacterial versus viral cap: a total sample size of patients (assuming that about % of them have bacterial infection) achieves % power, with alpha = . , to detect a change in sensitivity from . to . (and % power to detect a change in specificity from . to . ), using a two-sided binomial tests. sample size was computed using pass software v. (ncss, lcc, kaysville, utah, usa). all pb cases and all pv cases were evaluated together. continuous variables are presented as the mean ± standard deviation (sd), and categorical variables are presented as numbers and percentages. comparisons between groups (i.e., pb vs pv and severe vs non-severe cap) were performed using the χ or fisher's exact test, as appropriate (for categorical variables), or a two-sided student's t-test after confirming that the data were normally distributed (based on the shapiro-wilk statistic) or a two-sided wilcoxon's rank-sum test otherwise (for continuous variables). diagnostic performances of the biomarkers were evaluated with receiver operating characteristic (roc) curves and the area under roc curve (auc). the best cut-off values for different biomarkers were obtained based on the highest sensitivity and specificity through the roctab function in stata. in case of indeterminate results for crp and new biomarkers, the lowest limit of detection of the various methods was considered. missing data were reported in the tables and the missing information was not included in the statistical analyses. all analyses were conducted using sas version . (cary, nc, usa) and stata version . (statacorp lp, college station, tex) statistical packages. a total of children (males, . %; mean age . ± . years) with radiologically confirmed cap were enrolled. their demographic, clinical and laboratory characteristics are reported in table . results on respiratory viruses, s. pneumoniae, and m. pneumoniae were available for all the patients. cap was ascribed to bacteria in ( . %) children and to one or more viruses in ( . %) children. in cases ( . %), the etiology of the disease was undetermined. bacteremia was detected in cases ( . %): s. pneumoniae in cases and m. pneumoniae one case. globally, s. pneumoniae was considered the probable etiologic agent in ( . %) pb cases, and m. pneumoniae was considered the probable etiologic agent in ( %) cases. among pv cap, rsv and rv were the most common and were detected as single pathogens in ( . %) and ( . %) children, respectively. in the remaining cases ( , . %), co-infections between these viruses and other viral agents were found. moreover, ( . %) children had severe disease. among them, ( . %), ( . %), and ( . %) had a pb, a pv or an undetermined infection, respectively. at admission, the percentage of neutrophils was significantly higher in children with pb than in those with pv cap ( . % ± . vs . ± . ; p< . ). similar results were observed for both crp and pct (crp, . ± . mg/l in pb and . ± . mg/l in pv cases, p< . ; pct, . ± . ng/ml in pb and . ± . in pv cap, p< . ). moreover, the levels of mr- proadm found in pb cap cases were significantly higher than those in undetermined cap cases ( . ± . vs . vs ± . , p< . ). for the evaluation of the diagnostic performance of the studied biomarkers, only children with defined pb or pv cap were considered. diagnostic performance of studied biomarkers at enrollment to predict bacterial and viral infections is reported in table . all of them had low auc values. however, crp and pct had the best performances for both pb (auc of . , % ci: . - . , and . , % ci: . - . , respectively) and pv (auc of . , % ci: . - . , and . , % ci: . - . , respectively) cap identification. cut-off values with the highest sensitivity and specificity combination for the identification of pb and pv infections using crp were ! . mg/l and . mg/l, respectively. when pct was considered, the cut-off values with the highest combined sensitivity and specificity were ! . ng/ ml for pb cap and . ng/ml for pv cap. strem- , mr-proanp, and mr-proadm had predictive values for both pb and pv infections that were lower than that evidenced for crp and pct but were not higher than that from the wbc count and neutrophil percentage, as evidenced by the auc value that was lower than . . table shows the biomarker levels at enrollment according to the severity of the disease. all the studied parameters, with the exception of mr-proadm, were significantly higher in severe cap compared with non-severe cap (p< . for mr-proanp, wbc count, neutrophil percentage and pct; p< . for strem- and crp). even for the identification of severe cases, the predictive value of all the studied biomarkers was poor ( table ). the best results were obtained when pct (auc = . , % ci: . - . ) and mr-proanp (auc = . , % ci: . - . ) were evaluated. however, in both table . diagnostic performance of soluble triggering receptor expressed on myeloid cells- (strem), midregional proatrial natriuretic peptide (proanp) and midregional proadenomedullin (proadm) biomarkers, as compared to white blood cell (wbc) count, neutrophils percentage, c reactive protein (crp) and procalcitonin (pct) at enrolment to predict bacterial and viral infections, according to biomarker cut-off with highest sensitivity and specificity. cases, the biomarker cut-off with the highest combined sensitivity and specificity (! . ng/ ml for pct and ! . pmol/l for proanp) had relatively good sensitivity (higher than %) but limited specificity (of approximately %). other biomarkers were even less effective (all auc < . ). this study is the first to evaluate the utility of serum strem- , mr-proanp, and mr-proadm concentrations in predicting the etiology and severity of pediatric cap in comparison to routine biomarkers. in this study, to overcome the clinical, radiological and laboratory problems that limit the definition of etiology and severity of cap in children, the identification of bacterial and viral cap was based on the criteria usually accepted by the international literature [ ] [ ] [ ] . a combined evaluation of radiological findings and detection in the blood and in nasopharyngeal samples of the most important respiratory viral and bacterial agents of cap in children, was performed. moreover, to establish severity, the criteria suggested by bts were used. despite a certain number of cap cases, probably those due to mixed infection, remained . ± . * crp, c-reactive protein; pct, procalcitonin; sd, standard deviation; strem, soluble triggering receptor expressed on myeloid cells- ; mr-proanp, midregional proatrial natriuretic peptide; mr-proadm, midregional proadenomedullin; sd, standard deviation; wbc, white blood cell count. & one subject could not be categorized as severe or non-severe disease due to missing data. § p< . for comparison between severe and non-severe disease groups. * p< . for comparison between severe and non-severe disease groups. doi: . /journal.pone. .t table . diagnostic performance of soluble triggering receptor expressed on myeloid cells- (strem), midregional proatrial natriuretic peptide (proanp) and midregional proadenomedullin (proadm) biomarkers, as compared to white blood cell (wbc) count, neutrophils percentage, c reactive protein (crp) and procalcitonin (pct) at enrolment to predict severity of disease, according to biomarker cutoff with highest sensitivity and specificity. undetermined, this method has probably lead to the identification of those caps which are more likely due only to bacteria or only to viruses. interestingly, as reported in several recent studies and probably thanks to the new molecular diagnostic methods that permit us to enlarge in comparison with the past possibilities for viral identification [ ] , the prevalence of pb and pv among children with severe cap was similar. a global evaluation of the results of this study seemed to indicate that in children with cap, strem- , mr-proanp, and mr-proadm blood levels are unable to differentiate bacterial from viral diseases or to identify severe cases. at admission, the mean values of all these biomarkers were similar in pb and pv cases. when attempts to evaluate the sensitivity and specificity of each of these biomarkers in defining the etiology and severity of the studied cap cases were made, either the sensitivity or the specificity was found to be very low, leading to a modest predictive value. this result was confirmed by the values of the auc, which were always below . for a single biomarker for both the definition of the etiology and the assessment of severity, a value that suggests poor accuracy of the studied tests. moreover, for the definition of the etiology of pediatric cap, the predictive ability of these biomarkers seemed to be lower than that of crp and pct, whereas for the identification of severe cases the best results were obtained with evaluations of pct and mr-proanp. the diagnostic relevance of strem- in bacterial diseases, including cap, has been studied in experimental animal studies and in adult humans with conflicting results. some studies have reported that in cases of sepsis or cap, strem- is a superior indicator of bacterial disease compared with crp and pct [ , ] . moreover, it was demonstrated that strem- levels were significantly higher in neonates with sepsis than in healthy controls [ ] . finally, in children with bronchiectasis, strem- sputum levels correlated with markers of neutrophilic inflammation but not necessarily with crp concentrations, suggesting that strem- may be more sensitive in detecting pulmonary neutrophilic inflammation than crp [ ] . however, other studies have reported results similar to those found by our study. in adults with ventilator-associated pneumonia, strem was a poor predictor of vap among critically ill subjects undergoing direct bronchoscopy [ , ] . different patient and sample characteristics used to measure strem- concentrations might explain the different results. in most of the cases showing a role for strem- in the diagnosis of bacterial infection, the data were collected in patients with a chronic underlying disease who were hospitalized in intensive care unit, whereas in this study, only otherwise healthy children with an acute cap episode were enrolled. moreover, the different criteria used to classify the etiology and severity of cap could explain the differences among the results presented in the literature. changes in mr-proanp have been associated with acute and chronic heart failure [ ] , although the prognostic value of this biomarker in cap seems to be maintained independent of chronic heart failure [ ] . moreover, in diseases associated with bacteremia, this biomarker is increased [ ] . because cap with bacteremia is generally the most severe, it was concluded that this biomarker could simultaneously detect bacterial cap and identify the most severe cases. alan et al. reported that the addition of blood biomarkers, including mr-proanp, to clinical scores significantly improved the prognostic capabilities of the pneumonia severity index [ ] . kruger et al. reported that mr-proanp was a good predictor of mortality risk in patients with cap [ ] . however, the poor ability by mr-proanp to predict bacteremia in patients with cap was evidenced by guinard-barbier et al. [ ] . additionally, in this case, differences in the characteristics of the studied patients might explain the results. none of the children in our study had chronic heart failure, and the number of bacteremia cases was very small. it is possible that the blood levels of this biomarker significantly increased and had a true prognostic value only in very severe bacteremic cases of cap. moreover, the criteria used in this study to measure severity were different from those used in the studies in which adults were enrolled. in those studies, severity was measured considering the final outcome of the disease, whereas in this study, consistent with pediatric guidelines, severity was considered only at admission. similar conclusions can be drawn for the mr-proadm evaluation. additionally, this marker has been tested mainly as a marker of severity, although there are data indicating that it can be of value in the diagnosis and prognosis of sepsis and bacterial cap [ ] . once again, it seems highly likely that modifications of this biomarker occur only in very severe bacterial diseases that are relatively uncommon iamong children with cap. the problems that pediatricians have in differentiating bacterial from viral cap and in assessing the severity of the disease are highlighted by the poor predictive value evidenced in this study for wbc count, neutrophil percentage, and crp and pct levels. crp and pct were slightly better than wbc count and neutrophil percentage. however, the importance of crp and pct in the definition of the etiology and the severity of pediatric cap has been largely studied and discussed with conflicting results. crp as a type of acute-phase reaction protein is closely related with inflammatory reaction and tissue injuries and can be influenced by factors other than bacterial components. for many years, it has been shown that only extremely high crp serum levels are associated with bacterial disease and a negative prognosis, whereas in many cases, such values do not permit an estimate of the real etiology of the disease [ ] [ ] [ ] . cohen et al. showed that pct and not crp was the only independent predictor of apyrexia in children hospitalized for cap [ ] . however, recently, it has been reported that crp can predict outcomes of pediatric cap cases because crp levels are significantly associated with both fever duration and hospital length of stay [ ] . for every mg/dl increase in crp, the length of stay increased by hour. moreover, it was shown that extremely elevated crp levels are associated with unfavorable outcomes, including death, in pediatric patients, highlighting the importance of very high levels, uncommonly assessed in daily practice [ ] . similarly, the results reported for pct are inconsistent. nascimento-carvalho et al. showed that in children, pct had a negative predictive value for differentiating bacteremic infections from viral infections, atypical bacterial infections, and nonbacteremic typical bacterial infections [ ] . more recently, galetto-lacour et al. reported a positive role of pct in differentiating bacterial from viral cp, particularly when the disease was due to s. pneumoniae [ ] . additionally, we previously used a pct cut-off value to identify pv cap and to guide antibiotic therapy [ ] . conflicting results were reported in other studies. korpi et al. reported that pcr had a sensitivity in the identification of bacterial cap of only % [ ] , whereas later, these authors found that high values of pct ! ng/ml were associated with a high predictivity of bacterial cap [ ] . however, it seems evident that only very high serum concentrations of pct are predictive of true bacterial cap. regarding pct and disease severity, a study by don et al. found that higher mean values were present in children who needed hospitalization; additionally, in this case, a non-marginal number of cases could not be classified because of similar results among children with mild and severe disease [ ] . limitations of our study include the missing data for laboratory biomarkers in some patients, potential classification bias in the etiologic diagnosis, and the fact that patients with undetermined infection were excluded from the analysis. however, our evaluation has been done in a large study population with an appropriate calculation of sample size even excluding patients with undetermined infection. in addition, viral and bacterial results in nasopharyngeal aspirates and blood were available for all the study patients. moreover, a sophisticated statistical analyses has been performed, although further research on the role of the studied biomarkers in cap and other infectious diseases is recommended. in conclusion, most of the problems related to the evaluation of the pb or pv origin of a pediatric cap case together with the prevision of its outcome remain unsolved. no advantages are given by the use of strem- , mr-proanp, and mr-proadm, whereas pct maintains its role. more studies 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serum procalcitonin in evaluating severity of community-acquired pneumonia in childhood key: cord- - ftu b q authors: martinez-sanz, j.; muriel, a.; ron, r.; herrera, s.; perez-molina, j. a.; moreno, s.; serrano-villar, s. title: effects of tocilizumab on mortality in hospitalized patients with covid- : a multicenter cohort study date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: ftu b q background while there are no treatments with proven efficacy for patients with severe coronavirus disease (covid ), tocilizumab has been proposed as a candidate therapy, especially among patients with higher systemic inflammation. methods we conducted a cohort study of patients hospitalized with covid in spain. the primary outcome was time to death and the secondary outcome time to intensive care unit admission (icu) or death. we used inverse probability weighting to fit marginal structural models adjusted for time varying covariates to determine the causal relationship between tocilizumab use and the outcomes. results a total of , and , person/days were analyzed. in the adjusted marginal structural models, a significant interaction between tocilizumab use and high c reactive protein (crp) levels was detected. tocilizumab was associated with decreased risk of death (ahr . , % ci . to . , p= . ) and icu admission or death (ahr . , % ci . to . , p= . ) among patients with baseline crp > mg/l, but not among those with crp [≤] mg/l. exploratory subgroup analyses yielded point estimates that were consistent with these findings. conclusions in this large observational study, tocilizumab was associated with a lower risk of death or icu or death in patients with higher crp levels. while the results of ongoing clinical trials of tocilizumab in patients with covid will be important to establish its safety and efficacy, our findings have implications for the design of future clinical trials and support the use of tocilizumab among subjects with higher crp levels. there are still no treatments with proven efficacy to prevent mortality in patients with severe coronavirus disease (covid- ) pneumonia. however, various medications such as hydroxychloroquine, azithromycin, and lopinavir/ritonavir have been used off-label worldwide to minimize the impact of the current sars-cov- pandemic. tocilizumab is an fda-approved humanized monoclonal antibody against the soluble interleukin- (il- ) receptor. it is widely used in the treatment of autoimmune disorders such as rheumatoid arthritis or cytokine release syndrome. , tocilizumab has been suggested as an effective treatment for severe covid- pneumonia due to the increased interleukin (il- ) blood levels in patients with covid- and its correlation with a more severe lung damage. tocilizumab is not currently approved for use by the fda in covid- patients. no efficacy results from observational studies or clinical trials in this disease have been published, and the available data comes from small studies with surrogate endpoints that are underpowered to detect significant clinical effects or lack a control group. [ ] [ ] [ ] [ ] [ ] despite this absence of information, tocilizumab has been widely used due to its potential effect in the treatment of sars-cov- -induced cytokine release syndrome in which il- plays an important role. , , il- determination is rarely available in clinical settings. however, c-reactive protein (crp)-an inflammatory biomarker upstream in the il- pathway-, is commonly used to monitor the activity of inflammatory diseases. in attempt to recruit the population with covid with a higher probability to respond, some ongoing clinical trials of tocilizumab have considered heightened high crp levels as an inclusion criterion (clinicaltrials.gov: nct and nct ). given the urgent need to respond to the covid- pandemic, observational studies are important to evaluate clinical outcomes associated with the medications empirically used to treat covid- . however, critical analytical issues, including the risk of immortal time bias and indication bias from time-varying confounding , challenge the validity of observational data in this setting. here, we investigate the association between tocilizumab use and mortality in a large cohort of hospitalized covid- patients in spain. we hypothesized that tocilizumab use would be associated with a lower risk of death and influenced by baseline systemic inflammation levels. we used marginal structural modeling to account for baseline and time-varying confounders. we analyzed data from , subjects included in the hm hospitales cohort-a multicenter cohort of patients admitted to any of the hospitals in the hm group in madrid and diagnosed with covid- from january st to april rd , . hm hospitales made their anonymous dataset freely accessible to the international medical and scientific community. the dataset includes all available clinical information on patients diagnosed with covid- , confirmed by polymerase chain reaction in nasopharyngeal swabs or another valid respiratory sample. the dataset collects the different interactions in the covid- treatment process including detailed information on diagnoses, treatments, admissions, intensive care unit (icu) admissions, diagnostic imaging tests, laboratory results, discharge or death, and diagnostic and procedural records coded according to the international statistical classification of disease and related health problems (icd- ) classification. we excluded patients younger than years and those who died or were transferred to another facility within hours after admission to the emergency department. this study was approved by the ethics committee at university hospital ramón y cajal (ceic.hrc@salud.madrid.org, approval number / ). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint the primary end point was the time from study baseline to death. the secondary outcome was a composite event including admission to the icu or death (hereafter icu/death). study baseline was defined as the first day of hospitalization. we tested the associations among the preadmission variables with treatment variable by chi-square tests for categorical variables and wilcoxon rank sum tests for continuous variables. we calculated the incidence rates of death and icu/death and compared the time of death or the composite endpoint according to tocilizumab using kaplan-meier methods and log-rank tests. we fitted marginal structural models to estimate discrete time hazards of death according to tocilizumab use via an inverse probability treatment weight (iptw) estimation to account for the non-randomized treatment administration of tocilizumab, baseline confounding, and time-varying confounders. , we assumed that once a patient received tocilizumab, they remained on it until the end of follow-up. this assumption helped obtain a conservative estimate of the treatment hazard ratio analogous to intention-to-treat analysis in an unblinded randomized controlled trial. we structured the data set to allow for exposure, outcomes, right-censoring, and time-dependent covariates to change daily after admission. propensity score logistic models predicted exposure at baseline and censoring over time as a result of recognized confounders of severe covid- , including age, gender, comorbidities (hypertension, diabetes, ischemic heart disease, kidney disease, congestive heart failure, lung disease), oxygen blood saturation and need for oxygen therapy at baseline, and time-varying parameters of clinical severity (blood pressure, heart rate, total lymphocyte and neutrophil count, lactate dehydrogenase, alanine aminotransferase, urea, d-dimers, and crp). there were , subjects in the dataset with the information needed to fit marginal structural models. the characteristics of the individuals not included due to missing data in the information required for the statistical modelling strategy are shown in table s in the supplement. the main differences between groups in the analyzed population were comparable to those found in the population with missing . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint information. iptw were stabilized and truncated below the first percentile and above the th percentile. the models included a main term for the exposure and a flexible functional form of time, that is, restricted cubic splines with knots set at the first, th , th , th , and th percentiles of the subjects' day of follow-up, and the interaction term between tocilizumab and elevated crp levels (> mg/l, cutoff selected based on the th percentile value, mg/l). the interaction term between tocilizumab and crp was significant, and thus we report the adjusted (weighted) hazard ratios (hrs) derived from marginal structural models for the primary and secondary outcomes segregated by crp levels. we planned exploratory sensitivity analyses restricted to subjects who received specific concomitant treatments against sars-cov- (corticosteroids, hydroxychloroquine, azithromycin, lopinavir/ritonavir). due to the recognized prognostic value of lymphocyte counts and d-dimer levels, we also performed sensitivity analysis to explore the possible confounding effect of d-dimer > ng/ml (upper limit of the normal range in the reference laboratory) or absolute lymphocyte count < /ul (lower limit of the normal range in our reference laboratory). statistical analyses were performed using stata v. we analyzed , subjects accounting for , observations and , person-days of follow-up who were diagnosed with covid- in hm hospitals between january st and april rd , and have the information needed for iptw estimation. we excluded patients because they died, were discharged, or were transferred to a different hospital within hours after admission to the emergency department. a total of subjects ( . %) died, ( . %) were admitted to the icu, and had a composite outcome of death or icu admission ( . %). the median time to censoring date was (iqr - ) days. of the , patients, ( %) received a median total dose of mg (iqr - mg) of tocilizumab. the first dose was administered at a median time of (iqr - ) days . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint from inpatient admission. the distribution of the patient's characteristics according to tocilizumab use is shown in table . compared to the control group, there was a higher frequency of men and previous lung disease in the tocilizumab group while controls were significantly older and had a higher prevalence of diabetes. as expected, there were small differences between both groups in some of the baseline vital signs and laboratory parameters that were indicative of greater disease severity in the tocilizumab group than in the control group. the , subjects accounted for , observations, and the crude incidence rate of death was we used kaplan-meier estimates as a first approach to visualize the cumulative probabilities of death and icu/death. we did not observe differences in the estimates of death or icu/death in the pooled analysis ( figure a-b) . however, we found a significantly lower cumulative probabilities of both outcomes among patients with baseline crp levels above > mg/l (figure c-d) but not among those with crp ≤ mg/l (figure e-f) . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . (figure ) . weighted hazard ratios derived from marginal structural models adjusted for sex, age, comorbidities (hypertension, diabetes, ischemic heart disease, chronic kidney disease, congestive heart failure, lung disease), need for oxygen therapy at baseline, oxygen blood saturation, and time-varying parameters of severity (blood pressure, heart rate, total lymphocyte and neutrophil count, ldh, alt, urea, d-dimer, and crp). abbreviations: alt, alanine aminotransferase; ci, confidence interval; icu, intensive care unit; ldh, lactate dehydrogenase. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint figure and table s show the adjusted hazard ratios for exploratory sensitivity analyses restricted to patients with baseline lymphocyte count < cell/µl and baseline d-dimer > ng/ml segregated by crp levels. the results are consistent with the principal analysis. individuals with baseline crp levels higher than mg/dl maintained a lower risk of death and icu/death, but no significant effects of tocilizumab were found among those with low crp levels. weighted hazard ratios derived from marginal structural models adjusted for sex, age, comorbidities (hypertension, diabetes, ischemic heart disease, chronic kidney disease, congestive heart failure, lung disease), need for oxygen therapy at baseline, oxygen blood saturation, and time-varying parameters of severity (blood pressure, heart rate, total lymphocyte and neutrophil count, ldh, alt, urea, d-dimer, and crp). abbreviations: alt, alanine aminotransferase; ci, confidence interval; icu, intensive care unit; ldh, lactate dehydrogenase. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint we also explored the effects of concomitant therapies against sars-cov- in sensitivity analyses restricted to subjects who received corticosteroids (n= ), hydroxychloroquine (n= , ), azithromycin (n= ), or lopinavir/ritonavir (n= ) ( table s ). the effect sizes among subjects with baseline crp > mg/l were very similar to those observed in the principal analyses for both the primary and secondary outcomes (all p-values < . except azithromycin and lopinavir/ritonavir, with p= . in the primary and p= . in the secondary outcome, respectively). this is the first study to evaluate the effects of tocilizumab on the mortality of hospitalized patients with covid- . while the overall risk of death or icu admission did not differ among patients who received tocilizumab to those who did not and had crp levels ≤ mg/l, we found a % reduction in the risk of is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint the ct scan after days. in a single-arm study of patients with a proinflammatory and pro-thrombotic state due to severe covid- , treatment with tocilizumab was associated with a decrease in crp, d-dimer, and ferritin levels. thus, tocilizumab and other repurposed medications have been widely used offlabel to treat covid- in an attempt to mitigate the dramatic clinical consequences of sars-cov- pandemic, despite the lack of information on the effects of tocilizumab on robust clinical outcomes. the first confirmed case of covid- in spain occurred on january of , and , cases had been identified by may th , . due to the impact of the disease at a time when randomized trials were lacking, many protocols were developed, and the use of - doses of tocilizumab adjusted by weight was allowed by the spanish national guidelines as a possible treatment for covid- . shortly after the release of this document, the number of doses was restricted to a single dose adjusted by weight ( mg or mg) to avoid a tocilizumab shortage. in this multicenter cohort, we could compare subjects who received tocilizumab with who did not. these subjects accounted for deaths, icu admissions, and combined events of icu admission or mortality. we selected an analytical approach capable of dealing with the potential confounders inherent to observational studies in which subjects receiving tocilizumab were expected to have more risk factors for clinical progression and greater disease severity at baseline. in our cohort, controls were significantly older and had a higher prevalence of hypertension, which are the risk factors that have been more robustly associated with severe covid- and death. , , , however, subjects who received tocilizumab tended to have a greater prevalence of other potential risk factors for disease severity such as lung disease, as well as differences in baseline vital signs and laboratory parameters indicative of greater disease severity. all of these factors were included as covariates, and the estimates were consistent across the two endpoints analyzed. we found a strong and consistent protective effect of tocilizumab among patients with crp levels above mg/l (ahr . , % ci . - . ). the selection of the modeling strategy was a critical decision. longitudinal studies in which exposures, confounders, and outcomes are measured repeatedly over time . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint can facilitate causal inferences about the effects of exposure on outcome. however, there are key analytical issues in this setting, including the risk of immortal time bias (i.e., the requirement for patients to survive long enough to receive the intervention of interest, which can lead to a potentially incorrect estimation of a positive treatment effect), and indication bias from time-varying confounding (e.g., the use of tocilizumab following elevations of crp). standard regression models for the analysis of cohort studies with time-updated measurements may result in biased estimates of treatment effects if time-dependent confounders affected by prior treatment are present. , marginal structural models are a powerful method for confounding control in longitudinal study designs that collect time-varying information on exposure, outcome, and other covariates, such as the present one. , our study has a number of limitations. as with any observational study, there is still a risk of unmeasured confounding. tocilizumab targets the il- receptor, and thus using baseline il- levels instead of crp in the interaction term with tocilizumab use could have helped to better discriminate the population benefiting most from tocilizumab treatment. although il- measurements are rarely available in clinical settings, crp is widely accessible and is an inflammatory biomarker upstream of the il- pathway. hence, we doubt that the use of crp instead of il- limited the scope of the results. ongoing trials of tocilizumab in covid- have also considered heightened crp instead of il- to identify patients with heightened inflammation and, therefore, potential greater benefit with this treatment (clinicaltrials.gov: nct and nct ). in addition, the results should be interpreted cautiously and must not be taken as confirmatory of tocilizumab efficacy because of the relatively wide confidence intervals in the principal analysis. the sensitivity analyses suggested that patients with high crp and high d-dimer levels or lymphopenia may also be target populations for tocilizumab use. however, despite the fact that the size effects observed here were consistent with those obtained in the principal analyses, the sub-analyses must only be interpreted as exploratory and hypothesis-generating. the main strengths of the study include the large sample size and multicenter contribution that is representative of a real-life setting. this can allow . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint generalizability of the results. the availability of daily information on covariates defining treatments and laboratory parameters allowed us to control confounding issues using marginal structural models. finally, the high number of outcomes powered the statistical analysis, and the results are novel and biologically plausible. in summary, we analyzed a large number of consecutive patients hospitalized with covid- and found that tocilizumab was associated with a lower risk of mortality or icu admission/mortality among patients with crp > mg/l, but not among those with lower crp levels. although the results of ongoing clinical trials of tocilizumab in patients with covid- are mandatory to establish its safety and efficacy, our findings have implications for the design of future clinical trials and support the use of tocilizumab among subjects with higher levels of inflammatory markers. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . https://doi.org/ . / . . . doi: medrxiv preprint absolute lymphocyte count (cells/µl), median (iqr) treating covid- -off-label drug use, compassionate use, and randomized clinical trials during pandemics tocilizumab in rheumatoid arthritis: a meta-analysis of efficacy and selected clinical conundrums therapeutic efficacy of humanized recombinant anti-interleukin- receptor antibody in children with systemiconset juvenile idiopathic arthritis clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study the cytokine release syndrome (crs) of severe covid- and interleukin- receptor tocilizumab may be the key to reduce the mortality pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe covid- effective treatment of severe covid- patients with tocilizumab use of tocilizumab for covid- -induced cytokine release syndrome: a cautionary case report tocilizumab treatment in covid- : a single center experience tocilizumab for the treatment of severe covid- pneumonia with hyperinflammatory syndrome and acute respiratory failure: a single center study of patients in supportive treatment with tocilizumab for covid- : a systematic review general office of the national health committee of china, china traditional chinese medicine administration office from c-reactive protein to interleukin- to interleukin- : moving upstream to identify novel targets for atheroprotection controlling for time-dependent confounding using marginal structural models who | who family of international classifications (who-fic) marginal structural models to estimate the causal effect of zidovudine on the survival of hiv-positive men development and validation of a clinical risk score to predict the occurrence of critical illness in hospitalized patients with covid- baseline characteristics and outcomes of patients infected with sars-cov- admitted to icus of the lombardy region sars-cov- cell entry depends on ace and tmprss and is blocked by a clinically proven protease inhibitor a crucial role of angiotensin converting enzyme (ace ) in sars coronavirus-induced lung injury the cytokine release syndrome (crs) of severe covid- and interleukin- receptor tocilizumab may be the key to reduce the mortality autopsy findings and venous thromboembolism in patients with covid- : a prospective cohort study absolute neutrophil count (cells/µl) alt (u/l), median (iqr) urea (mg/dl), median (iqr) c-reactive protein (mg/l), median (iqr) /ml), median (iqr) interleukin (pg/ml), median (iqr) outcome non-icu length of stay (days), median (iqr) all variables were available in the , subjects, with exception of il- , which was measured only in individuals we acknowledge all study participants who made this research possible. we thank hm hospitales group for releasing the dataset used to perform this research to the scientific community. outside the submitted work, s. s.-v. reports personal fees from viiv healthcare, janssen cilag, gilead sciences, and msd as well as non-financial support from viiv healthcare and gilead sciences and research grants from msd and gilead sciences. j.m.-s. reports non-financial support from viiv healthcare, non-financial support from jannsen cilag, non-financial support from gilead sciences. ja.p. reports grants, personal fees and nonfinancial support from viiv healthcare, and grants from msd, outside the submitted work.s.m. reports grants, personal fees and non-financial support from viiv healthcare, personal fees and non-financial support from janssen, grants, personal fees and non-financial support from msd, grants, personal fees and non-financial support from gilead, outside the submitted work. there are no potential conflicts of interest. key: cord- -ld vmct authors: clark, kristina e n; collas, oliver; lachmann, helen; singh, animesh; buckley, jim; bhagani, sanjay title: safety of intravenous anakinra in covid- with evidence of hyperinflammation, a case series date: - - journal: rheumatol adv pract doi: . /rap/rkaa sha: doc_id: cord_uid: ld vmct objectives: anakinra is a selective il- inhibitor, which has been used in the context of secondary haemophagocytic lymphohistiocytosis. although usually given in the subcutaneous form, previous anecdotal reports have emphasized its utility when given intravenously. our aim is to report our experience on the beneficial effects of intravenous anakinra in patients with sars-cov- and evidence of hyperinflammation. methods: we report patients with severe covid- infection requiring intensive care admission and ventilatory support. results: all four patients showed evidence of deterioration with hyperferritinaemia, and increasing oxygen requirements, with supra-added bacterial infections. upon commencement of intravenous anakinra, there was subsequent improvement in the patients clinically with reducing ventilatory support and inotropic support, and biochemically, with rapid improvement in inflammatory markers. conclusion: intravenous anakinra is safe to use in patients with covid- and evidence of supra-added bacterial infection. although its utility has not been confirmed in a randomized trial, current research in the covid- pandemic aims to establish the utility of immunosuppression, including il- blockade on the outcomes of patients with moderate to severe disease. our case series support its use in patients with severe-life threatening covid- and evidence of hyperinflammation. anakinra is a recombinant il- receptor antagonist originally marketed for use in rheumatoid arthritis. it has increasingly found off-label use in patients with haemophagocytic lymphohistiocytosis (hlh). efficacy data predominantly comes from case series ( , ) , where it achieves disease remission, normalization of laboratory abnormalities, and resolution of pyrexia from cytokine storm ( , ) , even in the context of sepsis. traditionally given subcutaneously, the intravenous form is safe at doses up to mg/kg ( ) . despite the limited evidence, consensus guidelines support its use in the treatment algorithm of cytokine storm ( ) . covid- typically presents with fever, dry cough and dyspnea, although the array of symptoms is wide. mean time-lag from symptom onset to dyspnea is - days, and to acute respiratory distress syndrome (ards) is - days ( , ) . ards affects - % of patients ( ) , and these patients have increased risk of cytokine storm and progressive multi-organ damage. severe covid- is more common in older patients, and those with certain comorbidities including obesity, diabetes and cardiovascular disease ( ) . severe covid- is characterised by prominent alveolar damage, with focal reactive hyperplasia of pneumocytes, patchy inflammatory cellular infiltration as well as intravascular thrombosis. key pathological cells include cd + and cd + t cells and macrophages. the cytokine profile is similar to hlh, with increased interleukin (il)- , il- β, il- , granulocyte macrophage -colony stimulating factor (gm-csf), interferon-γ (ifn-γ) macrophage inflammatory protein -α, monocyte chemoattractant protein- (mcp- ), and tumour necrosis factor-α ( , , ). sars-cov evades a number of immune system recognition points which usually initiate viralmediated immunity. the activation of innate immune cells by infected macrophages results in the expression of pro-inflammatory il- , il- and tnf-α production through the nf-κb pathway. the concentrations of these cytokines continue to increase via a process of auto-amplification, and recruit adaptive immune cells ( ) . aberrant cd + t cell activation releases ifn-γ and gm-csf. the gm-csf results in increased cd + cd + inflammatory monocyte subsets, a subset rarely seen at significant levels in health ( ) . this subset of monocytes express increased levels of il- which are likely to be responsible for the acceleration and progression of a systemic ihinflammatory response. il- and related pro-inflammatory pathways intertwined with aberrant t-cell responses play a crucial role in disease severity ( ) . elevated ferritin and il- concentrations correlate with mortality ( ) . we define hyperinflammation by this systemic inflammatory response, which has strong similarities to that seen in cytokine release syndrome. one current treatment strategy is controlling hyperinflammation with targeted immunosuppression. we describe a cohort of patients with severe sars-cov- infection admitted to the intensive care unit during the pandemic, with elevated ferritins between , - , g/l. all four patients were diagnosed with covid- and required ventilatory support. these patients all showed evidence of hyperinflammation with raised inflammatory markers, and crp, and were given intravenous anakinra, with safe and successful use, suggesting the potential benefit from il- blockade in this subgroup of patients with confirmed covid- . -year-old gentleman with a background of end stage renal failure (esrf) secondary to birth asphyxia, and a dbd (donation after brainstem death) renal transplant (baseline creatinine mol/l), maintained on sirolimus and tacrolimus. this was the patients' second transplant, the first being complicated by graft rejection, maha and requiring graft nephrectomy in . the current transplant had taken place over a year prior to the current presentation, of which he had had one episode of bl nephropathy treated with steroids. he had been stable following this, with no significant infections. he presented with a -day history of feeling unwell with fevers, and a -day history of a cough, sore throat and difficulty breathing. initial saturations were % on room air, which improved to % on % oxygen via a venturi face mask. his blood pressure (bp) was / mmhg, heart rate /min, temperature o c, respiratory rate (rr) /min. chest x-ray (cxr) showed bilateral patchy consolidation and nasopharyngeal swab (nps) confirmed sars-cov- . blood tests revealed ferritin of g/l, creatinine µmol/l, crp mg/l. oxygen was titrated to keep his saturations above %, and he was initiated on co-amoxiclav. after two days, with increasing oxygen requirements and progressive cxr consolidation, he was transferred to the icu where he was commenced on cpap (continuous positive airway pressure). the sirolimus was stopped but he remained on tacrolimus. ferritin at the time was g/l, crp mg/l, and procalcitonin . mcg/l (normal range < . mcg/l). microscopy from blood cultures and urine cultures were all negative, and cmv and ebv viraemias remained very low level. given the increasing oxygen requirement, and persistent inflammatory state, intravenous anakinra mg was initiated (table ) . a marked improvement in ferritin was seen within two days, crp steadily decreased ( figure ), creatinine improved, and his respiratory effort stabilised. after days of cpap, he was weaned off, and stepped down to the ward. intravenous anakinra was stopped on day , where the ferritin was g/l. he was discharged on day with a creatinine of µmol/l, and crp mg/l and remained on tacrolimus. -year-old gentleman was admitted days after having a dbd renal transplant for esrf secondary to iga nephropathy. the transplant itself was uneventful. his other past medical history comprised of transfusion dependent beta-thalassaemia intermedia (baseline ferritin was μg/l), and splenectomy. he was discharged on tacrolimus, mycophenolate mofetil and prednisolone. he was readmitted days later with a -day history of dry cough, dyspnoea, and self-recorded pyrexia of °c. examination revealed coarse crepitations predominantly on the right, saturations of % of room air, rr /min, bp / mmhg. blood tests showed a ferritin μg/l, crp mg/l, and procalcitonin of . mcg/l. cxr showed consolidation in the right mid and lower zones, and nps confirmed sars-cov- . ceftriaxone was initiated. on day , his oxygen requirement increased with worsening bilateral mid zone air space shadowing. he was commenced on cpap days after admission and underwent endotracheal intubation on day . given the clinical deterioration, and rising crp ( mg/l) he was commenced on anakinra mg intravenously once a day (table ) . following initiation of anakinra, inotropes were weaned within hours, and significant improvement in his blood parameters was noted (ferritin g/l, crp mg/l). his icu admission was complicated by an enterococcus faecium bacteraemia on day of admission, for which he completed days of teicoplanin. anakinra was reduced and stopped after days. following a successful tracheostomy wean, he was discharged on day . a year old woman with a background of non-hodgkin's lymphoma (nhl) was re-admitted weeks after being discharged with covid- . she has known follicular lymphoma stage a diagnosed in may . she was treated with rituximab, last receiving a dose three months prior to her first admission. at the time of her first admission, she presented with a few weeks history of fever, myalgia and a sore throat. she had been given co-amoxiclav and azithromycin in the community, one week prior to admission. her shortness of breath on exertion was deteriorating, and she was found to have saturations of %. nps confirmed sars-cov- , and her cxr was consistent with the diagnosis. she was managed on the ward with oxygen and intravenous antibiotics, and was discharged weeks later, having had a ctpa confirming no pulmonary emboli, and a pet scan which showed no advancement of her nhl. she was readmitted days later, with profound hypoxia, requiring intubation on arrival in hospital. a ctpa at the time showed extensive bilateral pes with evidence of right heart strain. there were severe covid related changes with widespread ground glass opacification throughout both lung fields. on admission, ferritin was g/l, crp mg/l, and procalcitonin was . mcg/l. she was anaemic (hb g/l), but not cytopaenic, with platelets of x /l, and a neurophilia of . x /l. nps and edta blood samples were positive for sars-cov- . she was admitted to the icu, initiated on intravenous tazocin and underwent thrombolysis for her pes. the following day, ferritin rose to g/l, crp was mg/l, and procalcitonin increased to . mcg/l. anakinra was initiated (table ) . she was initially started on mg four times a day, but due to pressures on the nursing staff this was changed to mg twice a day. within hours of intravenous anakinra, the ferritin improved to mcg/l (figure ), and three days later continued to fall to . a biofire film was positive for streptococcus pneumonia. her icu stay was complicated by worsening consolidation on her cxrs, necessitating a prolonged course of meropenem. she commenced ambisome on day of admission, which was continued after a positive galactomannan test on her sputum and strongly positive βd glucan ( . pg/ml), weeks into her admission. it took days from admission for the sars-cov- viraemia to disappear on both edta blood and nps. she remains on icu, and is currently weaning off the ventilator, with a tracheostomy-in-situ, and on minimal inotropic support. a -year-old lady presented with a -week history of non-productive cough and fever, with one week of diarrhoea. she has esrf secondary to lupus nephritis, requiring haemodialysis. her past medical history includes antiphospholipid syndrome, with thromboses; and ischaemic heart disease. her medication included warfarin, and prednisolone. initial blood tests showed an elevated crp ( mg/l), and ferritin ( µg/l), with bilateral patchy consolidation on cxr. she was admitted on l/min oxygen via nasal cannula. ceftriaxone and gentamicin were initiated, and sars-cov- was confirmed via nps. on day , her oxygen requirements increased with worsening patchy consolidation bilaterally on cxr. she underwent endotracheal intubation on icu, and her antibiotics were changed to temocillin, teicoplanin and gentamicin. on day , blood tests showed worsening thrombocytopenia and transaminitis with rising ferritin: plt x /l, ferritin mcg/l, with a peak in her procalcitonin of mcg/l. an assumed diagnosis of hlh was made, and she commenced anakinra mg intravenously (table ) . she required increasing inotropic support and her thrombocytopaenia deteriorated with associated increasing ferritin over the following days. on day , blood tests revealed ferritin , mcg/l. a ct chest revealed small bilateral lower lobe pulmonary emboli, and extensive consolidation throughout both lungs. the clinical deterioration suggested worsening hlh, so anakinra was increased sequentially to mg twice a day, and antibiotics switched to meropenem and caspofungin. days later, there was notable improvement in ferritin, crp and the transaminases started to normalise. the patient remains intubated and ventilated, with reducing inotropic support. we present four cases of immunosuppressed patients, receiving beneficial effects from the use of intravenous anakinra to treat severe covid- with hyperinflammation and concomitant bacterial infections. careful consideration of the immunosuppressive treatment needs to factor in the ability to clear the virus without allowing for hyperinflammation. anakinra has previously been used in the context of virally induced inflammatory conditions such as multicentric castleman's disease; a reactive lymphoproliferative disorder typically described in hiv positive patients, with close association with hhv- (human herpes virus) ( ). cavalli et al ( ) described the use of anakinra in patients with ards due to covid- , who also had hyperinflammation. they used intravenous anakinra at mg/kg twice a day (high dose group) for days. a subgroup of patients received mg subcutaneously twice a day (low dose group) for days. standard care included mg hydroxychlorquine, along with lopinavir and ritonavir. at days, survival was % in the high-dose group and % in the standard treatment group (p= . ). their lower threshold for diagnosis of hyperinflammation ((crp > mg/l or ferritin ng/ml), and differing standard practice, reflects a cohort of patients not necessarily classified as severe in the uk. a ferritin < ng/ml have a high negative predictive value for hlh ( ), whereas > mg/l is diagnostic of hlh in children ( ) . the use of oral hydroxychloroquine may skew the mortality data, with a potential for increased cardiac complications ( ) . an observational study on the use of hydroxychloroquine in covid- did not report any difference in mortality ( ) , and is not included in uk treatment algorithms. furthermore, concomitant bacterial infections were excluded. anakinra has received increasing use in the context of cytokine storm syndromes/hlh ( ) . although licensed subcutaneously, concerns over unreliable absorption in the critically ill patient, and the requirement of multiple injections, along with the support of its safety at higher doses in the context of sepsis, have all favoured intravenous administration. the support for our use of higher dose intravenous anakinra is further gained from the recent lack of benefit for the subcutaneous form in the context of covid- ( ) . the administration of anakinra intravenously leads to a maximum plasma concentration - times higher when compared to subcutaneous administration. it also has a shorter terminal half-life in the intravenous format as well ( . hrs compared to . hrs subcutaneously) ( , ) , with the caveat that the subcutaneous half-life increases with greater adipose tissue. the intravenous form therefore enables a higher and faster maximal plasma concentration of anakinra; a trait that is desirable during cytokine storm syndromes. there is not sufficient evidence currently to suggest that the majority of patients with severe covid- develop hlh, as the other diagnostic parameters not including ferritin (hypertriglyceridaemia, low fibrinogen, cytopaenias) do not correlate with severe disease ( ) . none of our cases developed organomegaly, and only case showed evidence of thromcoytopaenia, however the other blood count lineages did not fall. therefore we believe we are treating hyperinflammation, and not hlh in our cases. timing of treatment with anakinra is one of the challenges in managing patients with covid- , and any clinical trial design. whereas antiviral therapy is likely to be beneficial in the early phase of the disease, cytokine modulation and immunosuppressive therapy are most likely to have an impact at later stages ( ) . a number of trials are attempting to answer this question. a recent large adaptiveplatform trial (recovery trial) showed a significant mortality-benefit of low-dose dexamethasone, with the biggest risk-reduction in mortality observed in patients requiring invasive mechanical ventilation ( ). this affirms the concept of the need for immune modulation in critically unwell patients requiring ventilatory and organ support. further trials in the uk include remap-cap (https://www.remapcap.org/); an adaptive-platform trial to assess the use of antibiotics, antivirals and immunomodulators in covid- . it offers the opportunity to explore targeted immune modulation therapy which will include interferon-beta- a, il- receptor antagonists (anakinra), tocilizumab and sarilumab (both anti-il- ), all against placebo. covacta (https://clinicaltrials.gov/ct /show/nct ) randomized severe sars-cov- pneumonitis to tocilizumab (a monoclonal antibody targeting the il receptor). can-covid (https://clinicaltrials.gov/ct /show/nct ) randomises canikunimab (a monoclonal antibody https://mc.manuscriptcentral.com/rheumap which specifically targets the il- β cytokine ) to severe covid- , not requiring mechanical ventilation. the results of these trials will be extremely informative to direct treatment strategy for covid - infections in the future. whether single treatment, combination therapy, or early intervention are optimal remains to be elucidated. our case 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pharmacokinetics of anakinra in subjects with different levels of renal function is the hscore useful in covid- ? key: cord- -s ijzyaq authors: mueller, alisa a.; tamura, tomoyoshi; crowley, conor p.; degrado, jeremy r.; haider, hibah; jezmir, julia l.; keras, gregory; penn, erin h.; massaro, anthony f.; kim, edy y. title: inflammatory biomarker trends predict respiratory decline in covid- patients date: - - journal: cell rep med doi: . /j.xcrm. . sha: doc_id: cord_uid: s ijzyaq in this single-center retrospective cohort analysis of hospitalized covid- patients, we investigate whether inflammatory biomarker levels predict respiratory decline in patients who initially present with stable disease. examination of c-reactive protein (crp) trends reveals that a rapid rise in crp levels precedes respiratory deterioration and intubation, while crp levels plateau in patients that remain stable. increasing crp during the first hours of hospitalization is a better predictor (with higher sensitivity) of respiratory decline than initial crp levels or rox indices (a physiological score). crp, the pro-inflammatory cytokine il- and physiological measures of hypoxemic respiratory failure are correlated, which suggests a mechanistic link. our work shows that rising crp predicts subsequent respiratory deterioration in covid- and may suggest mechanistic insights and a potential role for targeted immunomodulation in a subset of patients early during hospitalization. identification of patients that will deteriorate and progress to critical illness could guide risk stratification, the need for close clinical monitoring and early immunomodulatory intervention. to address this question, we performed a retrospective cohort study of the first patients admitted to the brigham and women's hospital (bwh) for covid- infection. we hypothesized that inflammatory biomarker profiles would stratify patients into three cohorts: ( ) stable and non-intubated throughout their hospital admission ("mild"); ( ) initially stable and nonintubated but then had respiratory deterioration requiring intubation or high-flow nasal cannula later in their hospital course ("progressive"); and ( ) patients who were unstable and required intubation within hours of admission ("severe"). among patients who were stable and did not require intubation at admission, elevated crp values at admission were associated with progressive respiratory failure later during their hospital course. crp level at admission correlated with physiological measures of disease severity (sofa score, pao /fio ) and with the inflammatory cytokine il- . however, the significant overlap in admission crp values between "mild" and "progressive" patient sub-cohorts would limit the practical utility of initial crp values for clinical care decisions. remarkably, we found that a rise in crp values over the first - hours of hospital admission distinguished patients that would develop progressive respiratory failure from patients that would remain stable throughout their hospital course. first, we show that the crp trend is a clinically predictive tool and can be superior to a physiological index such as the rox index. second, since crp is down-stream to several immune pathways including il- , our results suggest that these pathways are dynamic early in hospital admission and precede respiratory deterioration. our work suggests that close, serial monitoring of early crp values may aid clinical prognostication and consideration of immunomodulatory therapy in covid- patients. j o u r n a l p r e -p r o o f we reviewed the first consecutive cases admitted to bwh who tested positive for severe acute respiratory syndrome coronavirus (sars-cov- ) in the course of their hospitalization ( figure s ). patients ( %) were excluded for the following reasons: sars-cov- testing was later deemed as false positive (n = ); medical issues unrelated to covid- drove hospital admission with sars-cov- positivity as a later incidental finding (n = ); the patient was an inpatient for more than hours before transfer to bwh (n = ). thereafter, patients remained for evaluation. prior studies typically stratify covid- patients into either "noncritical" or "critical" categories and do not distinguish patients that were critically ill at admission versus those patients that initially had non-critical illness and then deteriorated. given the clinical importance of predicting which non-critically patients would remain stable and which non-critically patients would later deteriorate, we divided our cohort into three categories. ( ) "mild" patients were stable patients who remained on room air or supplemental oxygen (via lowflow nasal cannula or face mask) throughout their hospital course and never required intubation or high-flow nasal cannula (hfnc). ( ) "progressive" patients were initially stable on room air, low-flow nasal cannula or face mask but then deteriorated and required intubation and mechanical ventilation or hfnc. ( ) "severe" patients required intubation or hfnc within hours of admission. these hospitalized covid- patients were evaluated and classified as mild ( ; %), progressive ( ; %) or severe ( ; %). ( figure s , table ). patients with progressive and severe disease were older than patients with mild disease ( ± [severe] vs. ± [progressive] vs. ± [mild] years; p = . ) (table ) . notably, other demographic j o u r n a l p r e -p r o o f characteristics, co-morbidities, or social history did not show significant differences between mild, progressive, and severe cases (table ) . patients in all groups presented to the hospital approximately week after symptom-onset (table ) . those with mild cases spent [iqr: [ ] [ ] [ ] [ ] [ ] [ ] days in the hospital, while progressive and severe patients were discharged or deceased within and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] (table ). all cases were followed until the hospital discharge. mortality rate among patients was ( %) overall, with a significant difference (p < . ) in mild (mortality rate %), progressive ( %), and severe ( %) ( table ). while our primary analyses were focused on the comparison of patients in the three aforementioned categories, we also evaluated patients with a second model based on treatment location that is commonly used in other studies. in this model, patients are deemed as "floor" vs. "icu," whereby patients designated as "floor" cases receive care solely on the general medical floors in the non-icu setting while icu patients are those that required care in the icu at some point during their hospitalization ( figure s , figure s c ). notably, il- was markedly elevated in patients that required icu level care at any point during their hospitalization, compared to non-icu patients ( . [ . - . ] vs. . [ . - . ] u/l, p = . ). the binary categories of "floor" versus "icu" masks one key aspect of the natural history of covid- illness during hospital admission-inpatients that are initially stable on the "floor" who later decline and require icu-level care. the factors that distinguish patients that remain stable from patients that are initially stable but then deteriorate are poorly characterized. we classified covid- inpatients into three cohorts according to the stability and severity of their respiratory failure: ) "mild" (remained on room air or supplemental oxygen); ) "progressive" (initially on room air or supplemental oxygen then later required intubation or high-flow nasal cannula); or ) "severe" (required intubation within hours of admission) ( figure s and table ). initial levels of crp, d-dimer, procalcitonin, and il- were elevated in patients with progressive disease compared with mild disease ( . [ . - there are a number of tools used to assess clinical condition. perhaps the most commonly used is the sequential organ failure assessment (sofa) score, which is a measure of organ dysfunction with higher scores representing worsening organ damage. respiratory function is assessed as a subscore of this system and is based on the ratio of the arterial oxygen partial pressure to fractional inspired oxygen (pao /fio or p/f ratio). lower p/f ratios indicate worsening hypoxemia. patients with progressive disease presented with a higher sofa score than those with mild disease, although there was significant overlap ( [ - . ] vs. [ . , p = . ) ( figure a ). additionally, as expected given our classification criteria, admission respiratory sofa score ( figure b ) and p/f ratios (table ) were not significantly different between progressive patients and mild patients. at admission, crp and d-dimer were clinically relevant as they were correlated with measures of organ and respiratory function. both crp levels and d-dimer levels showed a strong positive association with sofa score (ρ = . , p < . ; ρ = . , p < . , respectively) ( figures c and s a ). moreover, these levels were inversely correlated to p/f ratio on admission (ρ = - . , p < . ; ρ = - . , p = . , respectively), demonstrating an association of these markers with the severity of acute hypoxemic respiratory failure ( figures d and s b ). among patients that were intubated, crp values at the time of intubation showed some correlation with the p/f ratio at the time of intubation, though it was not statistically significant ( figure s c ). the association of crp to respiratory deterioration and physiological measures of disease severity was particularly intriguing, as crp levels can have mechanistic implications. crp levels are tracked in a wide range of inflammatory diseases and are linked to il- signaling, which has been a therapeutic target in covid- . indeed, il- levels did show a striking j o u r n a l p r e -p r o o f correlation to crp ( figure s d ) and p/f ratio ( figure s e ). however, the number of patients with il- levels were limited, as this institution's clinical guidelines did not endorse routine clinical measurement of il- because results took over hours to return. in many institutions, crp levels result within several hours and can capture rapidly evolving clinical courses that cytokine assays, which take more than - days, cannot. these results supported the further investigation of crp as a biomarker with mechanistic implications and potential practical clinical utility. (figures b and c and tables s and s ). in all patients, crp levels peaked early within approximately days of symptom onset ( figure c ). the longitudinal crp trend of progressive patients closely resembled that of severe patients, with a sharp, early rise in crp ( figure b ). in contrast, mild patients (who remained non-critically ill) had a lower plateau and then a steady decline in crp ( figure b ). further quantification revealed that the change in crp over the time course less than hours of admission was significantly different between mild and progressive patients (p = . ), whereas it was similar between progressive and severe patients (p = . ) ( figure d ). this indicates that progressive patients when compared to mild patients had a more rapid rise in crp levels drawn at - hours and - hours after admission, ( . ± vs. . ± mg/l, p = . ; . ± vs. . ± mg/l, p < . , respectively) ( figure d ). the odds ratio of requiring advanced respiratory support was j o u r n a l p r e -p r o o f . [ %ci: . - . ] (p = . ) when crp value of greater than mg/l (upper limit of the assay at our institution) was achieved within hours of admission. we tested the prognostic utility of crp levels in determining the need for advanced respiratory support in covid- patients, using receiver operating characteristic (roc) curve analyses incorporating patients with mild vs. progressive disease. in particular, we first compared with predictive value of admission crp levels (day crp) and change in crp from day to day ( (table s ) . we demonstrated the predictive value of both crp levels and rox index to predict respiratory deterioration during hospitalization. further, we showed that the change in crp had superior predictive value to either initial crp value alone or the rox index. crp, d-dimer, and procalcitonin levels at admission were increased in the progressive cohort, compared to mild (i.e., stable). at the same time, we found that crp did have a remarkably close association with the degree of respiratory failure as the correlation of crp to p/f ratio was highly significant. while significantly different, these tests would have limited prognostic utility for frontline clinicians, as there was a high degree of overlap between mild and progressive cohorts that precluded a simple threshold value. to address this clinical challenge, we noted that maximum crp distinguished stably non-critical (mild cohort) patients from those with progression of respiratory failure. this finding suggested that crp values are dynamic in covid- patients that develop later respiratory failure. similar results were reported indicating the utility of maximal crp for the need of mechanical ventilation. however, the maximal crp is not useful as a clinical decision-making tool because the determination whether the crp value is at the maximum is only made retrospectively. we did find that a rapid rise in crp preceded and associated with respiratory deterioration among patients that were stable at admission. by tracking crp values longitudinally during hospitalization, we found that crp j o u r n a l p r e -p r o o f levels rose more precipitously in the first days after hospital admission in the progressive cohort compared to the mild cohort, with an appreciable elevation detectable as early as to hours after admission. thus, the rate of change of crp, rather than the absolute value of admission values, were more closely associated with clinical deterioration. initial absolute values of crp were similar between mild and progressive patients, but the dynamic trends of crp were similar between progressive and severe patients. another study also found limited prognostic utility for admission crp values and required a variable risk score to predict clinical deterioration. our study suggests that examination of dynamic trends, rather that absolute value at admission, can lead to strong associations with prognosis despite only using a single laboratory value. we confirmed that change in crp had clinical utility in predicting intubation as shown in our roc analyses where utilizing change in crp resulted in a higher auc than the rox index, a clinically validated index used to predict intubation. similar to our results, a high crp cutoff for a single-value crp was reported. this high crp cutoff selects for an extremely ill patient population and leads to high specificity and low sensitivity, which make it unhelpful as clinical predictors. in contrast, while the auc value for ∆crp was not dramatically higher than that of rox or admission crp, the high sensitivity for respiratory decompensation makes it a much more valuable screening test. our study suggests that trending crp, a highly accessible tool for frontline clinicians compared to complicated scoring systems, has predictive value for respiratory failure among initially non-critically ill patients on the general medical floor. while our study has implications for clinical prognostication, our result also may suggest underlying pathological mechanisms and possible strategies for therapeutic intervention. as in sars-cov and mers-cov infection, , several proinflammatory cytokines (e.g., il- , il- , j o u r n a l p r e -p r o o f il- , and ifn-gamma) are increased in covid- . , [ ] [ ] [ ] [ ] we demonstrate a correlation between the crp and d-dimer inflammatory biomarkers with disease severity and a particularly close association of crp with hypoxemic respiratory failure (p/f ratio). our study highlights the potential role of il- , which is upstream of increased crp. in our cohort analysis, il- levels showed a positive correlation with crp in patients who had il- levels drawn, and patients treated with tocilizumab, an il- receptor monoclonal antibody, had rapid and sustained decrease in crp levels (n= , figure s ). our study suggests that increased crp rise, and by virtue presumed elevation of il- , in the first - hours may be of critical importance to disease progression; no other study is focused only on this hyper-acute period. furthermore, in many studies, covid- patients are simply categorized as non-critically ill ("floor") or critically ill ("icu"), as in a longitudinal study of lymphocyte subsets and cytokines or single-cell rnasequencing of bronchoalveolar lavage. our results may suggest that "critically ill" covid- patients should be sub-divided into two sub-cohorts as patients that developed a requirement for advanced oxygen support later in their hospital course ("progressive") had a distinct inflammatory biomarker profile than patients who required immediate intubation on hospital admission ("severe"). multiple rcts are examining tocilizumab in covid- infection, - and preliminary results from recent phase iii studies have been mixed. the covacta trial evaluating tocilizumab (f. hoffmann-la roche ltd, press release: https://www.roche.com/investors/updates/inv-update- - - .htm) and another trial centered on sarilumab (sanofi-aventis u.s. llc, press release: https://www.sanofi.com/en/media-room/press-releases/ / - - - - - ), did not meet primary endpoints. however, the empacta trial (f. hoffmann-la roche ltd, press release: https://www.roche.com/media/releases/med-cor- - - .htm) did show that tocilizumab reduced likelihood of progression to mechanical ventilation. our work may suggest j o u r n a l p r e -p r o o f that there is value in delineating the particular "progressive" patients whose uptrend in crp may suggest that they could be particularly poised to benefit from this type of il- directed therapy. recent studies have suggested that acute respiratory distress syndrome (ards) related to covid- is not more inflammatory than ards unrelated to covid- , with similar levels for plasma il- in covid- and non-covid- ards. , however, it is clear from this study and others that severe covid- is more inflammatory than milder covid- . this study highlights that the dynamic nature of the inflammation in covid- is key and directly associated to physiological parameters. the key limitations of this work are its single-center and retrospective design. future prospective studies could study a wider range of cytokines and chemokines along with the interaction of crp rise and immunomodulatory treatment. in conclusion, we suggest that closely tracking the levels of crp in the hyper-acute phase of admission for covid- patients is a valuable tool to stratify the risk that a patient will have progressive hypoxemic respiratory failure requiring intubation. this metric is feasible for frontline clinicians in the emergency department observation units or medical floor inpatient wards. second, longitudinal crp profile may distinguish unique phenotypes of patients with critical illness from covid- . finally, these findings suggest that clinical trials of il- receptor monoclonal antibodies should pay particular attention to intervention in the first hours of the hospital course. limitations of this study include its single-centered retrospective nature and small sample size, and future efforts focused on the prospective analyses will strengthen our understanding of the prognostic utility of crp. the size of the study was a consequence of balancing the need for more immediate analysis for frontline physicians. it should be noted that in our analyses, the no new reagents or materials were generated as part of this study. patient data reviewed in this study is not publicly available due to restrictions on patient privacy and data sharing. there was no new code developed as part of this study. this investigation was approved by the partners healthcare institutional review board (protocol p ). opt-out consent was designated for the study. demographic information including age and gender are provided in tables and s . this was a single-center retrospective cohort study. we included patients who were admitted to anticipated that a patient may require intubation, that patient was transferred to the icu, and any patient requiring pressure support was required to be in the icu unless it was part of a nightly cpap or bipap regimen that they had used at home. in general, during the time of this study, the institution recommended against high-flow nasal cannula use in covid- patients due to concern regarding potential transmission with aerosolization. instead, patients who were unstable on regular nasal cannula were transitioned to venturi mask or intubated. descriptive statistics were reported as mean ± sd or median with iqr, and frequencies with covid- in critically ill patients in the seattle region -case series clinical and immunological features of severe and moderate coronavirus disease the role of biomarkers in diagnosis of covid- -a systematic review at the heart of covid- the need to manage the risk of thromboembolism in covid- patients factors associated with hospital admission and critical illness among people with coronavirus disease viral and host factors related to the clinical outcome of covid- clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study the sofa (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. on behalf of the working group on sepsis-related problems of the european society of intensive care medicine rox index predicts intubation in patients with covid- pneumonia and moderate to severe hypoxemic respiratory failure receiving high flow nasal therapy clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan, china elevated levels of il- and crp predict the need for mechanical ventilation in covid- development and validation of a clinical risk score to predict the occurrence of critical illness in hospitalized patients with covid- covid- -associated hyperinflammation and escalation of patient care: a retrospective longitudinal cohort study characterization of cytokine/chemokine profiles of severe acute respiratory syndrome clinical progression and cytokine profiles of middle east respiratory syndrome coronavirus infection clinical features of patients infected with novel coronavirus in wuhan longitudinal characteristics of lymphocyte responses and cytokine profiles in the peripheral blood of sars-cov- infected patients covid- : consider cytokine storm syndromes and immunosuppression immune cell profiling of covid- patients in the recovery stage by single-cell sequencing single-cell landscape of bronchoalveolar immune cells in patients with covid- off-label use of tocilizumab in patients with sars-cov- infection tocilizumab treatment in covid- : a single center experience pilot prospective open, single-arm multicentre study on offlabel use of tocilizumab in patients with severe covid- tocilizumab for the treatment of severe covid- pneumonia with hyperinflammatory syndrome and acute respiratory failure: a single center study of patients in effective treatment of severe covid- patients with tocilizumab prevalence of phenotypes of acute respiratory distress syndrome in critically ill patients with covid- : a prospective observational study is a "cytokine storm" relevant to covid- ? nonlinear imputation of pao /fio from spo /fio among mechanically ventilated patients in the icu: a prospective, observational study predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: the utility of the rox index key: cord- -hg cxcs authors: keddie, s.; ziff, o.; chou, m.k.l.; taylor, r.l.; heslegrave, a.; garr, e.; lakdawala, n.; church, a.; ludwig, d.; manson, j.; scully, m.; nastouli, e.; chapman, m.d.; hart, m.; lunn, m.p. title: laboratory biomarkers associated with covid- severity and management date: - - journal: clin immunol doi: . /j.clim. . sha: doc_id: cord_uid: hg cxcs the heterogeneous disease course of covid- is unpredictable, ranging from mild self-limiting symptoms to cytokine storms, acute respiratory distress syndrome (ards), multi-organ failure and death. identification of high-risk cases will enable appropriate intervention and escalation. this study investigates the routine laboratory tests and cytokines implicated in covid- for their potential application as biomarkers of disease severity, respiratory failure and need of higher-level care. from analysis of samples, crp, il- , il- and ldh were most strongly correlated with the who ordinal scale of illness severity, the fraction of inspired oxygen delivery, radiological evidence of ards and level of respiratory support (p ≤ . ). il- levels of ≥ . pg/ml provide a sensitivity of . and specificity of . for a requirement of ventilation, and a crp of ≥ mg/l of . and . . reliable stratification of high-risk cases has significant implications on patient triage, resource management and potentially the initiation of novel therapies in severe patients. international efforts to 'flatten the curve' of coronavirus disease- (covid- ) through social isolation restrictions have allowed most health systems to cope with huge demands on healthcare facilities, in particular providing time to acquire ventilators and intensive care beds. as governments loosen lockdown processes and with the unknown influences of seasonal variation and acquired immunity, front line services need to prepare for a second wave of infection. lessons learnt regarding covid- disease biology, transmission, risk factors, complications and treatments will be used to adapt and improve clinical services and improve outcomes. the heterogeneous disease course of covid- is unpredictable with most patients experiencing mild self-limiting symptoms. however up to % require hospitalisation, and up to % of these require intensive care support for acute respiratory distress syndrome (ards), hyperinflammation and multiorgan failure. [ ] [ ] [ ] a cytokine storm in patients with severe disease was identified in the early reports of wuhan patients and is intrinsic to disease pathology. in this cohort, elevated plasma interleukin (il)- , il- , il- , granulocyte colony stimulating factor (gcsf), interferon γ-induced protein (ip , monocyte chemoattractant protein- (mcp ), macrophage inflammatory protein -alpha (mip a) and tumor necrosis factor -alpha (tnf-α) levels in icu patients were identified. some subsequent studies have implicated il- as a valuable predictor of adverse clinical outcome and a potential therapeutic target. , one or more clinical and wet biomarkers may enable early identification of high-risk cases, assisting disease stratification and effective use of limited specialist resources. this study comprehensively explored clinical disease features and routine laboratory tests against specialist cytokine biomarkers associated with covid- disease and its complications, to address their association with disease severity, respiratory intervention and outcome. one hundred consecutive hospital in-patients with covid- infection, whose sera were sent for cytokine testing, were investigated as part of standard care and routine practice at university college london hospital nhs trust. all cases were confirmed as covid- by polymerase chain reaction (pcr) analysis ( %) or deemed highly likely based on internationally recognised diagnostic criteria including recent exposure, clinical, radiological and laboratory features. laboratory biomarkers including cytokines were collated with baseline demographics, risk factors, disease features, treatments and outcomes. level of clinical care (ward based, high-dependency or intensive treatment), oxygen requirements and vital signs were associated with the biomarkers at the time of sample collection, at peak illness and on most recent assessment. serial samples were analysed to establish whether biomarkers correlated with, or could predict disease course. severity of covid- illness was determined utilising the world health organisation (who) covid- ordinal severity scale which broadly measures level of respiratory compromise and requirement of intervention, with a score of defined by no limitation of activities, to requiring ventilation and additional organ support. other features of organ system compromise such as neurological involvement, renal failure and requirement for dialysis were analysed for association with laboratory biomarkers. bloods for cytokine analysis were centrifuged within hours of collection, separated and sera frozen at - c for up to hours before being analysed. immunoassays were performed according to manufacturer's instructions and reads were fully automated. routine laboratory data from automated analysers including c-reactive protein (crp), d-dimer, lactate dehydrogenase (ldh), lymphocyte count, ferritin, fibrinogen and platelets were collated with the clinical and cytokine data. chi-square was used for the comparison of categorical variables. biomarker levels comparing dichotomous variables were evaluated using welch's unpaired t-test. comparison of multiple group outcomes was performed using one-way anova. biomarker and continuous clinical variables were correlated using pearson correlation coefficient. the predictive values of biomarkers were calculated by identifying youden's index on receiver operator characteristic curves. p-value ≤ . was considered statistically significant. all statistical analyses were made using r statistical package . . . samples from patients were collected from the th april to the th may from patients hospitalised at university college london hospital (uclh) sites, from the main hospital and from the national hospital for neurology and neurosurgery (including neuro-intensive care). eighty-six patients were covid- pcr positive and deemed highly likely based on diagnostic criteria. seventy-four cases were male, with a median age of years ( - ). one hundred and forty samples were collected from ward environments versus on intensive care. the who covid severity score ranged from (hospitalised, no oxygen therapy) to (severe j o u r n a l p r e -p r o o f disease, ventilation and additional organ support) with a median of (severe disease, intubated and ventilated). background characteristics associated with more severe infection and intervention included older age (p≤ . ), diabetes (p≤ . ) and hypertension (p≤ . ). clinical features and grouped biomarkers are displayed in table il- β was the only biomarker which significantly differentiated by gender, with higher levels in males (p≤ . ) who have a higher mortality. biomarkers of covid- severity did not differ by number of comorbidities or smoking status. all the biomarkers in figure were analysed for their correlations with who covid- severity scores and arranged into a heat map (see figure ). biomarkers that significantly correlated with the who severity score included crp (r= . , p= . e - ), il- (r . , p = . e - ), ldh (r . , p < . e - ) and il- (r . , p = . e - ). il- and crp were most significantly indicative of the level of respiratory support (figure a and b) with il- being marginally better at differentiating respiratory requirement from none. il- and crp were both closely associated with increased fraction of inspired oxygen delivery (fio ) requirements (r= . and . respectively) and radiological evidence of acute respiratory distress syndrome (ards) (il- ≤ . , crp ≤ . ). a cut-off of . pg/ml for il- in this assay gives a sensitivity . and specificity . for requirement of intubation. similarly, a mg/l cut-off for crp has a sensitivity of . and specificity of . . tnf-α also correlated with who severity (p≤ . ) and level of respiratory support (p≤ . ) but to a lesser degree than il- and crp. renal failure leading to a requirement for renal dialysis was determined by higher levels of tnf-α (mean . vs . pg/ml, p< . ), crp ( vs mg/l, p< . ), il- ( . vs . pg/ml, j o u r n a l p r e -p r o o f journal pre-proof p< . ) and il- ( . vs . pg/ml, p< . ). il- β did not correlate with disease severity measures, presence of ards or level of respiratory support. neurological presentations with covid- were also common, with cases presenting with delirium ( ), ischemic stroke ( ), intracerebral haemorrhage ( ) to the proinflammatory cytokine milieu, inherent to severe disease and reflect a functioning immune system. the binding of covid- to the toll like receptor (tlr) causes release of pro-il- β which is cleaved by caspase- , followed by inflammasome activation and production of active il- β which is a mediator of lung inflammation, fever and fibrosis. il- β has been shown to be raised in covid- infection compared to healthy controls by some. this study however does not provide any indication that il- β levels reflect severity of disease. , despite this, initial trials of the il- β antagonist anakinra appear to reduce the need for mechanical ventilation and mortality in severe cases. however no studies have studied the influence of the drug on pre-and post-treatment levels of il- β, or stratified entry to anakinra on il- β levels. our study would indicate that non-il- β biomarkers might be of more practical utility. the association of tnf-α, crp and il- with dialysis requirement without any association with il- possibly supports a role for sepsis driving renal failure. in post-mortem studies microthrombi are seen in both the kidney and alveolar blood vessels, but the primary insult on those two tissues may be different. neurological cases had lower levels of covid- disease severity markers, which may be accounted for in part by selection bias, where patients were hospitalised due to neurological disease with concurrent, less severe covid- infection compared to those admitted primarily due to covid- respiratory failure. the primary targets for sars-cov- cov- are respiratory epithelial cells and alveolar macrophages. following infection of respiratory cells, rapid production and release of cytokines and chemokines occur. macrophages are in turn activated, as are other key components of the innate immune system, such as dendritic cells, which leads to a more extensive immune response initiating the cytokine storm. it is therefore conceivable from our findings that only severe pulmonary infection and infiltration results in cytokine activation and proliferation, and neurological features are either a consequence or coincidence j o u r n a l p r e -p r o o f of covid- infection in this cohort. however more research is required to understand the neurological manifestations of covid- and the associated cytokine response to more definitively explain such findings. c-reactive protein is unsurprisingly very strongly correlated with levels of il- , as il- drives the production of crp primarily in the liver. crp may potentially suffice in isolation to predict high risk cases requiring more aggressive intervention, negating the requirement of more specialist cytokine tests. similarly, ldh, released from multiple tissues on cell death and activated through t-cell proliferation may be a practical and easily measured surrogate biomarker although its utility here is lower than the crp. levels of ferritin were raised across the cohort likely reflecting heightened acute phase response to infection as opposed to suprahigh levels indicative of shlh. absolute lymphocyte count and subsets have been shown to inversely correlate with severity in covid- , , , although not demonstrated in this study. lymphocyte counts may be a less reliable marker due to the variety of factors which cause lymphocytosis such as sepsis from concomitant infections and the stress response. although select routine laboratory markers correlate with disease severity, cytokine analysis provides additional predictive support for prognosis and likely interventions in the covid- cytokine storm as well as reassurance that when low, little escalation of intervention may be required. note that a limitation of the study is that cases were deemed not appropriate for intensive care, therefore escalation of respiratory support would be precluded regardless of clinical severity. we conducted a sensitivity analysis and inclusion/exclusion of these cases had no effect on biomarker correlations with severity. biomarker analysis of crp, ldh and the cytokines il- , il- and tnfα, alongside thorough clinical assessment of covid- patients, enables more accurate stratification of high from low risk cases and the need for intensive care support. such stratification enhances management not heatmap shows biochemical signatures for each patient, arranged by who covid- severity score. visualisation was performed using the pheatmap r package. biomarkers values are log transformed, centred and scaled. no patients had who severity scores , or as these are non-hospitalised patients. a score of is hospitalised patients requiring no oxygen therapy; a score of requires oxygen therapy; requires non-invasive ventilation (niv); of requires intubation and mechanical ventilation; and requires ventilation and additional organ support including vasopressors, renal replacement therapy and ecmo. a score of is death. higher levels of crp, il- , il- ldh and tnf-α are associated with higher who covid- severity scores. the role of cytokines including interleukin- in covid- induced pneumonia and macrophage activation syndrome-like disease report on covid- in critical care rapid risk assessment -coronavirus disease covid- in the eu/eea and the uk -eighth update clinical features of patients infected with novel coronavirus in wuhan level of il- predicts respiratory failure in hospitalized symptomatic covid- patients. medrxiv interleukin- in covid- : a systematic review and meta-analysis. medrxiv european center for disease prevention and control. case definition for coronavirus disease (covid- ), as of world health organisation. blueprint novel coronavirus covid- therapeutic trial synopsis opensafely: factors associated with covid- death in million patients prognostic value of interleukin- , c-reactive protein, and procalcitonin in patients with covid- detectable serum sars-cov- viral load (rnaaemia) is closely j o u r n a l p r e -p r o o f journal pre-proof correlated with drastically elevated interleukin (il- ) level in critically ill covid- patients high il- /ifn-γ ratio could be associated with severe disease in covid- patients treatment of severely ill covid- patients with anti-interleukin drugs (cov-aid): a structured summary of a study protocol for a randomised controlled trial a prospective, randomised, double blind placebo-controlled trial to evaluate the efficacy and safety of tocilizumab in patients with severe covid- pneumonia (toc-covid): a structured summary of a study protocol for a randomised controlled trial relationships among lymphocyte subsets, cytokines, and the pulmonary inflammation index in coronavirus (covid- ) infected patients analysis of clinical features of patients with anakinra for severe forms of covid- : a cohort study may the central nervous system be fogged by the cytokine storm in covid- ?: an appraisal lymphocyte subset counts in covid- patients: a meta-analysis the clinical course and its correlated immune status in covid key: cord- -r usk authors: nan title: research communications of the th ecvim‐ca congress date: - - journal: j vet intern med doi: . /jvim. sha: doc_id: cord_uid: r usk nan saccharomyces boulardii (sb)is a non-pathogenic yeast used in the prevention and treatment of gastrointestinal disorders in human beings and horses. the aim of this study was to evaluate the effect of sb in healthy dogs and dogs with chronic enteropathies (ce). sb was formulated in x cfu capsules. its concentration and viability within the capsules was controlled by yeast culture in subsequent steps until expiration date. four healthy dogs (hd) and dogs with ce ( inflammatory bowel disease -ibd, protein losing enteropathy -ple) were included. in hd sb was administered for days ( x cfu/kg bid); daily clinical evaluation was performed to assess possible adverse effects and quantitative stool cultures for yeasts were performed before, during and after the administration. in dogs with ce a randomized double blind placebo-control study was performed, administering sb ( x cfu/kg bid) or placebo (pl). sb or pl administration was added to standard therapeutic protocols (diet, antibiotics and immunosuppressive drugs), to evaluate its efficacy for the treatment of ibd and ple. complete blood work, abdominal ultrasonography, gastro-duodenal and colon endoscopy and histopathological evaluation of intestinal samples were performed at diagnosis and after days of treatment. validated score system for the clinical signs (ceccai), ultrasonography, endoscopy and histopathology were applied. significance was set for p < . . results in hd showed the absence of sb in the faeces before treatment, its presence after one day, its steady state ( x cfu/g) after days and its complete elimination days after withdrawal of treatment. no adverse effects were reported. in ce dogs the clinical score improved significantly in dogs receiving sb compared to dogs receiving pl (p = . ). in ple dogs the albumin concentration increased significantly (p = . ) in the group receiving sb with respect to pl. the daily frequency of defecation in the sb group was significantly lower with respect to pl after (p = . ) and (p = . ) days of treatment. no statistical differences were found between dogs receiving sb and pl after treatment, based on the endoscopic evaluation of duodenum and colon. no statistical differences were found between the two groups on the duodenal ultrasonographic and histological evaluation after treatment. in conclusion, sb can be safely used in dogs with ce, in addition to standard treatment, to achieve a better control of clinical signs and a significant increase in albumin concentration compared to the standard therapy alone. no conflicts of interest reported. canine inflammatory bowel disease (ibd) is an immune-mediated enteropathy likely triggered by environmental and immunoregulatory factors in genetically susceptible dogs. previous studies suggest a pivotal role for gut bacteria in disease pathogenesis since luminal microbial composition is markedly altered (ie, dysbiosis) at diagnosis. probiotic bacteria appear to be therapeutically effective in some forms of human ibd. controlled studies evaluating the efficacy of probiotic therapy for canine ibd have not been previously reported. the aim of the present study was to characterize the mucosa-associated microbiota and determine the clinical, microbiological, and mucosal homeostatic effects of orally administered vsl# probiotics in dogs with ibd. twenty dogs diagnosed with moderate-to-severe ibd (cibdai score > ) were randomized to receive standard therapy (ie, elimination diet and glucocorticoids) with or without probiotic vsl# . the mucosal microbiota from endoscopic intestinal biopsies of ibd dogs and controls was evaluated by fluorescence in situ hybridization (fish) targeting the s rrna genes of total bacteria, group-specific organisms, and individual bacterial species shown to be relevant in human ibd. epithelial tight junction protein (tjp) expression was studied using immunohistochemistry. clinical signs and changes in mucosal microbiota and tjp expression were assessed before and after probiotic vsl# therapy. ibd dogs showed a reduction in gi signs following weeks of probiotic therapy compared with baseline cibdai scores (p < . ). adherent and sporadic invasive bacteria (eub) were observed in the small intestines and colon of healthy dogs. the diseased canine duodenum was nearly bacteria-free. ibd dogs given probiotic vsl # had altered spatial redistribution of most bacterial groups in the mucus and adherent compartments of the colon. subset analysis showed that lactobacilli were significantly (p < . ) increased in the lumen and mucus post-vsl # , while the number of mucus laden bifidobacteria approached significance (p = . ). expression of tjp showed that occludin was significantly lower in control intestines as compared to duodenal and colonic mucosa obtained from ibd dogs that received probiotic (p = . and p = . , respectively). in contrast, claudin- expression in the colon was significantly higher (p < . ) in control dogs versus vsl # treated ibd dogs. our data demonstrate that probiotic vsl# alters some of the mucosa-associated microbiota in dogs with ibd. these probiotic changes in bacterial composition are associated with up-regulated tjp expression indicative of enhanced epithelial barrier integrity, similar to vsl# -induced disease protection seen in human ibd. the probiotics used in the trial were supplied free of charge by the manufacturer. canine inflammatory bowel disease (ibd) is thought to be partially caused by an aberrant immune response towards the intestinal microbiome. in humans and mice, administration of probiotics can alleviate ibd severity and/or prevent relapse by induction of a more "tolerant"microenvironment. the aim of this study was to investigate the effect of probiotic enterococcus faecium ncimb e (ef) on intestinal microbiome composition. dogs were recruited to receive ef at x e cfu in a double-blinded, placebo-controlled manner in addition to an exclusion diet (hydrolysed protein). seven dogs were included in the probiotics group and dogs in the placebo group. all dogs improved clinically after treatment, however, there was no obvious effect on clinical severity in those that received probiotics. fresh naturally voided faecal samples were collected from all dogs before and after treatment, snap-frozen in liquid nitrogen and stored at - °c until further analysis. genomic dna was extracted from each faecal sample using the mobio power soil dna isolation kit (mobio laboratories), as recommended by the manufacturer. next generation sequencing was performed on the ion-torrent[trademark] (life technologies) platform based upon the v -v region (e. coli position - ) of the s rrna gene with the following primers: forward f: gag-tttgatcntggctcag and reverse r: gtnttacn gcggckgctg. raw sequence data were screened, trimmed, filtered, and chimera depleted with default settings using the qiime pipeline version . and uchime software, in which microbiome composition between treatment groups before and after treatment was compared. microbiota composition was not significantly different between probiotic and placebo treatment groups, and did not change significantly before and after treatment. however, there was large individual variability in the microbiome composition. species richness of faecal samples increased after treatment in both groups, but was only statistically significant in the probiotic treatment group. in conclusion, probiotic treatment in dogs with ibd leads to a significantly increased richness of the faecal bacterial microbiome. a possible additional effect of the change of diet cannot be excluded. further studies should investigate microbiomic changes in healthy dogs fed the same diet to assess if similar changes in the fecal microbiome occur due to dietary changes alone. this study is based on a phd supported by probiotics ltd., somerset, uk (the manufacturer of the probiotic product enterococcus faecium mentioned in this study). the aim of this study was to assess the prevalence and risk factors for faecal carriage of extended-spectrum beta-lactamases (esbl) and plasmidic ampc beta-lactamases (pampc) e. coliproducers in healthy dogs. a -month cross-sectional study was conducted at a private hospital in lisbon, portugal and rectal swabs were obtained from healthy dogs. the dogs included in the study were healthy with no history of antimicrobial consumption in the previous month. esbl and pampc genes were detected by pcr and were sequenced. potential risk factors for esbl-and pampc-producing e. coli faecal carriage were obtained through a questionnaire to the owner regarding reason for veterinary visit, hospitalisation and antimicrobial treatment within the last year, habitat (shelter, dog breeders and private owner), cohabitation with other animals, street access, kennel/hotel access, age and gender. data were analysed by sas software (version . ; sas institute inc., cary, n.c.) and logistic regression models were used. rectal swabs obtained from healthy dogs yielded positive samples for e. coli. about % of the isolates carried esbl genes (bla ctx-m- n = , bla ctx-m- n = , bla ctx-m- n = , bla ctx-m- -like n = ) and % carried pampc genes (bla cmy- n = , bla cmy- -like n = , bla dha- n = ). thirteen dogs carried an e. coli isolate with both an esbl and a pampc gene. dogs previously treated with antimicrobials within the last year were at higher risk of carrying at least one ß-lactamase (p = . ; or = . ; ci %: . - . ) or both ß-lactamases (p = . ; or = . ; ci %: . - . ) than non-treated dogs. dogs in shelters/breeders tended to show a higher incidence of esbl-producing e. coli (p = . ; or = . ; ci %: . - . ) or at least one ß-lactamase producing e. coli (p = . ; or = . ; ci %: . - . ) than dogs from private owners. males tended to be less likely to carry at least one ß-lactamase (esbl or pampc) (p = . ; or = . ; ci %: . - . ) or a pampc enzyme (p = . ; or = . ; ci %: . - . ) than females. this study suggests that dogs may act as reservoirs for resistant bacteria, namely for cephalosporin-resistant e. coli. three potential risk factors associated with the carriage of esbl-and/or pampc-producing e. coli by dogs were identified, which is important for the implementation of effective control measures and judicious antimicrobial therapy. conflicts of interest: dr pomba currently receives research funding from the government and national programmes (fundac ßão para a ciência e a tecnologia). in the past, she has occasionally received research support or honoraria for lectures from pharmaceutical companies including zoetis and atral cipan. she is vice-chair of the antimicrobial working party there are few reports in the literature reporting long-term relapse rate, owner compliance and clinical severity of dogs with chronic enteropathies. the goal of this study was to compare clinical activity index (ccecai), number of relapses and compliance rates - years after diagnosis. food-responsive disease (frd) was defined as dogs that responded to elimination diet alone within weeks after initiating therapy, whereas antibiotic-responsive disease (ard) dogs had an unsuccessful dietary trial before and responded to metronidazole within weeks after initiation of therapy, and steroidresponsive disease (srd)dogs had an unsuccessful dietary and antimicrobial trial before, and required immunosuppressive therapy to control their clinical signs. ccecai was extracted from the medical record database at - years after diagnosis. relapse rate was obtained by requesting the medical records of the referring veterinarians and defined as number of return visits to the referring practice after diagnosis. compliance data was obtained by telephone questionnaire to the owners. the frd group consisted of / dogs ( %), whereas the ard and srd groups consisted of ( %) and dogs ( %), respectively. there was a significant difference in ccecai at follow-up between frd and ard, and frd and srd (median ccecai . (range - ) for frd, (range - ) for ard, and . (range - ) for srd, p = . ). for the frd dogs, % of owners stated that they deviated from the prescription diet on a daily basis, % once a week, and % once a month, with a median ccecai at the time of deviation from the diet of . (range - ). relapse rate was highest for the ard group, when compared to frd and srd ( for ard, . for frd, and . for srd, p = . ). in the frd group, / dogs had been kept on the prescribed diets, and dogs had been changed to supermarket brands. all of the ard dogs had been given immunosuppressive treatment in addition to antibiotics at the time of follow-up, while / srd dogs were still on immunosuppressive treatments, with one dog being in remission with dietary treatment alone. in conclusion, this pilot study indicates that compliance rate for frd dogs is the lowest, with owners willing to tolerate the highest severity of clinical signs related to deviation from the prescription diet. ard dogs had the highest relapse rate in this cohort, indicating poor response to treatment in the long-term. conflicts of interest: dr allenspach has received research funding from bbsrc, american kennel club, comparative gastroenterology society, probiotics ltd uk, laboklin gmbh germany, and bioiberica sp. she has also undertaken paid consultancy work for bioiberica spain and hoffmann-laroche, switzerland. despite the high prevalence of canine pancreatitis in postmortem studies and the introduction of new diagnostic tests, it is believed that the disease, particularly in its chronic form, remains under recognised due to the non-specific nature of presenting signs. histology is considered to be the gold standard for diagnosis of canine pancreatitis, however, most clinicians are reluctant to take pancreatic biopsies due to significant risks to the patient. numerous serum markers have been reported to be elevated in canine pancreatitis, although most lack sensitivity or specificity. consequently, confirmed diagnosis requires results from a range of tests including imaging, serum biochemistry and physical examination. we and others have previously shown in other diseases that performance of individual low specificity markers can be dramatically improved by combining data from multiple markers with clinical information using analytical algorithms. we therefore applied this approach to the detection of pancreatitis in dogs. the activity of two non-specific biomarkers, amylase and lipase, was determined in serum samples from dogs suspected of having pancreatitis by their veterinarian. of these samples were positive by virtue of their pancreatic lipase (cpli) results (cpli > ug/l). the amylase and lipase data was then used to develop a series of algorithms using mathematical data mining and classification techniques. additional algorithms were developed using extra parameters including age, sex, vomiting, diarrhoea and abdominal pain in addition to the two enzyme levels. the performance of the algorithms was assessed using separate blinded serum samples taken from dogs which were scored clinically for acute pancreatitis according to the system described by mccord et al (j vet intern med ; : - ) . these cases presented for evaluation with vomiting, diarrhoea, inappetance and abdominal pain and were included if a clinical history, results of routine haematology, biochemistry, cpli assay and abdominal ultrasound were available. the results of the multifactorial analysis and cpli assay results were compared to the clinical scores. using amylase and lipase data alone, the algorithm gave a sensitivity of . % and specificity of . %, compared to cpli results for the same samples of . % and . % respectively when both methods were referred to clinical scoring. when the presence of additional clinic data was also included into the algorithm, the sensitivity increased to . % with specificity of %. the data suggests that test performance for canine pancreatitis can be dramatically improved when multiple diagnostic parameters are combined using disease specific algorithms. the author receives a salary as editor of the bsava journal companion, and has undertaken unrelated paid consultancies for bayer and merial. the author also receives a salary from avacta animal health, and duties involved working directly on this project. canine chronic enteropathy (cce) can cause significant long-term morbidity. in some cases this is due to intestinal inflammation, resulting from idiopathic inflammatory bowel disease (ibd). currently, the diagnosis of idiopathic ibd and assessment of disease severity relies on results of subjective clinical indices, laboratory data, diagnostic imaging and intestinal histopathology, whilst ruling out known causes of inflammation. in humans with ibd, a number of faecal biomarkers including lactoferrin, aid with diagnosis and determining disease activity. it may therefore be valuable to develop similar non-invasive objective methods to aid diagnosis and clinical assessment of disease severity in dogs with intestinal inflammation due to idiopathic ibd. this pilot study aimed to measure faecal lactoferrin concentration (flc) in dogs with cce and histologically confirmed intestinal inflammation (hcii) and to compare this with control dogs. in addition, the flc in dogs with hcii would be compared with the canine inflammatory bowel disease activity index (cibdai) and wsava standard histopathological criteria for intestinal inflammation to determine whether there was correlation between these methods when assessing disease severity. faecal samples were obtained from dogs with hcii (n = ) having undergone investigation for cce (serum biochemistry, complete blood count, full faecal and urinalysis, serum cobalamin, quantitative cpli, abdominal ultrasound and intestinal biopsies). the control population were dogs presented for reasons unrelated to cce (n = ). analysis was carried out using a faecal lactoferrin elisa previously validated in dogs (techlab, usa). the flc in dogs with hcii (median . lg/g -range . to . ) was significantly higher than control dogs (median . lg/g -range . - . ) (p < . ). a cut-off flc of . lg/g correctly identified / ( %) of dogs with hcii. using this cut-off, there was no overlap between non-cce dogs flc and the hcii group; giving a sensitivity of % and specificity of %. neither the presence of neutrophils nor the extent of inflammation on histopathology showed significant correlation with flc. the cibdai showed moderate correlation with flc in dogs with hcii (r = . , p = . ). the results of this pilot study suggest that flc is able to discriminate between dogs with cce due to hcii and dogs without cce. it is possible that incorporating flc into a panel of faecal biomarkers will enable non-invasive assessment of hcii and could serve as an adjunct to current measures of disease severity in dogs with idiopathic ibd. ryan bettencourt and james boone are employees of techlab, usa. they provided the elisa kits free of charge for this work. there was no other incentive provided and the results have been openly discussed between all parties. there has been no censorship placed on the results by tech-lab and they have been supportive of the work and submission of this abstract. there are no other conflicts to disclose. fecal s a and fecal calprotectin concentrations have been described as biomarkers in dogs with chronic enteropathies [ ]. however, to date there has been no direct comparison of these two markers in dogs with chronic diarrhea. the aim of this study was to evaluate the performance of these two markers in this situation. thirty one dogs presented for a history of chronic diarrhea were prospectively enrolled. the initial diagnostic workup for all patients included a serum biochemistry profile, fecal parasitology, abdominal ultrasound examination, and gastrointestinal endoscopy with collection of endoscopic biopsies. the severity of clinical signs was evaluated using the ccecai scoring index and patients were grouped by having a ccecai of < or ≥ . fecal calprotectin and s a were quantified as previously described [ ] . correlations were evaluated with the spearman rank correlation test. for both markers a receiver operating characteristics (roc) curve was used to select cut-off value that allowed the best discrimination between dogs with a ccecai< and dogs with a ccecai ≥ . sensitivity and specificity were calculated. correlation analyses revealed a significant positive correlation between s a and calprotectin (r = . ; p < . ). the optimal cut-off value for fecal calprotectin concentration was . lg/g, which was associated with a sensitivity of . % and a specificity of . % (auc= . ; p = . ). the optimal cutoff value for fecal s a concentration was . ng/g, which was associated with a sensitivity of . % and a specificity of % (auc= . ; p = . ). the sensitivity for fecal s a was higher than that for fecal calprotectin (p = . ). no significant difference was observed for the specificity of these two markers (p = . ). out of the dogs ( %) had concordant results for s a and calprotectin tests. among these dogs, presented with a ccecai < and of these dogs had both markers below their cut-off values. among the dogs with a ccecai≥ , dogs had both markers above their cutoff values. % of dogs ( / ) presented histologic signs of inflammation. sensitivities for fecal calprotectin and s a concentrations for histopathological intestinal inflammation were % and %, respectively, and specificities were % and %, respectively. at least in this group of patients fecal s a concentration was more sensitive (but less specific) to detect dogs with a cce-cai ≥ or histopathologic intestinal inflammation than fecal calprotectin concentration. weight loss and malabsorption of fat, protein, cobalamin and tocopherol in the face of normal exocrine pancreatic function have been reported in up to - % of cats older than years of age fed a variety of nutritionally balanced dry and wet foods (patil ap and cupp cj. proc. nestle-purina compan anim nutr summit, focus on gastroenterology, [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) . the objectives of this study were to determine if serum cobalamin concentrations increased after oral administration of a cobalamin supplement to affected cats, and the duration of any positive response following cessation of supplementation. the study evaluated cats older than years of age with fat malabsorption demonstrated by either increased fecal fat (> %) or subnormal fat digestibility (< %), but without exocrine pancreatic insufficiency (epi) as assessed by assay of serum trypsin-like immunoreactivity (ftli). a commercially available solution of cobalamin containing mg mixed with ml of a liquid flavor enhancer was added to the food of each cat in a single dose each day for months, after which supplementation ceased. serum cobalamin (assayed by competitive binding assay performed through the gi laboratory at texas a&m university and evaluated using reference ranges derived by that laboratory) was determined immediately prior to initiation of supplementation, then weekly for weeks, then monthly for months. at the start of the study serum cobalamin was subnormal (< ng/l) in of the cats (range < to ng/l) and within the reference range ( to ng/l) in the remaining cats ( to ng/l). serum cobalamin was above the reference range in every cat ( to ng/l) after one week of supplementation and remained above the reference range in every sample collected during the supplementation period, with the exception of two cats with values within the reference range when supplementation was stopped. serum cobalamin , and months after cessation of supplementation ranged from < to , < to , and < to ng/l, respectively. at the end of the study serum cobalamin was subnormal in of the cats. it is concluded oral cobalamin supplementation can effectively increase serum cobalamin concentrations in geriatric cats with idiopathic chronic enteropathy, but that following cessation of supplementation concentrations decrease rapidly and can become subnormal again within as few as weeks. the primary author collaborated with nestle-purinaon the work reported in this abstract, and a co-authoris an employee of nestle-purina. the primary author has previously received funding from iams, mars, hills and nestle-purina. the author also acts as a paid consultant for the gi-lab, texas a&m university. left atrial measurements are crucial in assessing severity of cardiac disease in dogs with myxomatous mitral valve disease (mmvd). however, linear and area dimensions might not provide a comprehensive assessment of patient status, and cannot differentiate between severe subclinical (b ) and clinical disease (chf). estimates of left atrial function could provide additional information to help categorize these patients. we examined dogs with mmvd ( normal, b , b and c) presented for cardiac evaluations by d echocardiography. left atrial linear and area dimensions in right parasternal short and long axis views were obtained at time points -early diastole (la max ), just prior to mitral valve opening, at the onset of atrial systole (la p ) and just prior to mitral valve closure (la min ). we calculated indices of la function: total la emptying fraction (la tef ), active la emptying fraction (la act ), passive la emptying fraction (la pas ) and la reservoir function (la res ) for all sets of measurements. we examined the differences in selected la function indices between different disease stages with a kruskal wallis test with post-hoc multiple comparisons. we also examined the diagnostic accuracy of selected indices of la function in differentiating dogs in stage b and stage c (chf) using roc analysis. three functional indices consistently differed across the various stages of mmvd -la tef , la act and la res . these differences were most apparent in the rpla view for linear measurements and rpsa view for area measurements. dogs with chf had worse function than all other groups, which differed variably depending on the functional index being examined. laarea act showed the best ability to discriminate between b and chf dogs, with a % specificity, % sensitivity and an auc of . , but this was no better than use of la:ao measurements. our data suggest that la function differs between dogs with differing severities of mmvd, but does not provide a clear distinction between dogs with subclinical disease and chf. no conflicts of interest reported. materials and methods: de was used to evaluate consecutive, non-sedated dogs that weighed more than kg. the study population for the morphologic study included normal dogs, and dogs with acvim stages b or b -c mmvd. de image data were digitally recorded and then analyzed offline, using commercially available software. results: de image acquisition was feasible in / ( . %) consecutive dogs. patient anxiety ( ), arrhythmias ( ) and panting ( ) explained failure to obtain a de dataset. fortyone of ( . %) datasets were of analyzable quality. body weight and heart rate were significantly lower in dogs for which it was possible to perform de. dogs with analyzable de datasets were significantly older and weighed less than dogs in which de could not be analyzed. the mitral valve of normal dogs is saddle shaped (annulus height to commissural width ratio (ahcwr): . ae . [mean ae sd]) and has an elliptical annulus (sphericity index (si): . ae . ). the following measurements were significantly related to body surface area (bsa): antero-posterior diameter (apd) (r = . , p < . ), anterolateral-posteromedial diameter (alpmd) (r = . , p < . ), annulus area (aa) (r = . , p < . ), anterior leaflet length (all) (r = . , p < . ), anterior leaflet area (ala) (r = . , p < . ). these variables were indexed (i) to bsa for subsequent statistical analyses. dogs with mmvd had a significantly greater si, non-planar angle, apdi, alpmdi, alai and alli, while having a significantly lower posterior leaflet area (pla), posterior leaflet length (pll), annulus height (ah), tenting height (th), tenting volume (tv), tenting area (ta), and ahcwr compared to normal dogs. ah, tv and ta were significantly greater in normal dogs, compared to dogs with mmvd. si, apdi, al-pmdi, aai, alai and alli were significantly greater in dogs with stages b -c mmvd, compared to normal dogs and those in stage b . pll and pla were significantly lower in b -c dogs, compared to normal dogs. th was significantly different between the three groups; greatest in normal dogs and lowest in dogs in stages b -c, suggesting that flattening of the mv occurs with disease progression. conclusions: de assessment of the canine mv is feasible. morphologic changes associated with mmvd progression are presented. effective regurgitant orifice area (eroa), calculated from a dimensional measurement of the width of vena contracta (vc) as the narrowest portion of the proximal regurgitant jet, might be used to estimate severity of mitral regurgitation (mr). however, this simplified assumption only holds when the eroa is circular, which might not be true in dogs with myxomatous mitral valve disease (mmvd). the aim of the study was to compare measured eroa using color doppler real-time dimensional echocardiography (rt d) with calculated eroa estimated by dimensional echocardiography ( d) in chamber ( ch) and chamber ( ch) views of the left ventricle (lv) in dogs with mmvd. ninety-three privately owned dogs of breeds diagnosed with naturally acquired mmvd were examined using d and rt d. according to the acvim classification of congestive heart failure (chf), dogs were classified with chf ( in class c and in class c ) and dogs without chf ( dogs in class b and dogs in class b ). age ranged from to years (median years), and body weight ranged from . to kg (median kg). fifty-nine males ( %) and females ( %) were included, and heart rate ranged from to beats/minute (median b/min). eroa was calculated from d measurements of vc diameter, in the ch view only (assuming a circular regurgitant orifice), and from measurements of vc diameter in both ch and ch views (assuming an eliptical regurgitant orifice) of lv. bland-altman plots were used to compare eroa measured by rt d with calculated eroa obtained from d ch and ch/ ch lv views. none of the d estimations of eroa showed good agreement with the measured rt d eroa when corrected for bsa, and the difference between methods increased with increasing eroa. the difference between rt d and d methods normalized to the mean eroa value did not increase with increasing eroa, but showed a systematic underestimation of eroa by % ( ch) and % ( ch/ ch), respectively, compared to rt d. the beat-to-beat variation of eroa assessed by rt d (n = ) had a coefficient of variation ranging from . % to % (median %). in conclusion, substituting assessment of eroa with a measurement of vc in or dimensions might underestimate the mr severity in dogs with mmvd. in some dogs, the beat-tobeat variation of the eroa was large, thereby necessitating the need for several consecutive measurements. no conflicts of interest reported. micrornas (mirna) are short ( - nucleotides), singlestranded, non-coding rnas that specifically anneal with complementary sequences in multiple mrna targets, and they silence mrnas and suppress downstream protein translation. a mirna can act as a fine-tuner of gene expression or an on/off switch. these features highlight the potential of mir-nas as therapeutic targets. the role of mirnas in myocardial fibrosis and hypertrophic cardiomyopathy has been widely studied in human patients. however, there is no data available for canine and human myxomatous mitral valve disease (mmvd). the aim of this study was to investigate mirna transcriptomics in canine mmvd by using global transcriptional profiling, mirna target prediction software (diana tool, targetscan . ) and network analysis software (biolayout express d ). four myxomatous mitral valves (ckcs) and controls valves were profiled using the affymetrix canine gene . st array. in total out of mirnas were found to be statistically significantly differentially expressed (down-regulated) based on the false discovery rate, p-value, and fold-change. expression of three mirna (cfa-mir- b, cfa-mir- c, cfa-mir- ) were also validated by quantitative polymerase chain reaction (q-pcr, taqman), and the results were in agreement with the microarray findings. for network analysis and visualization, markov clustering algorithms were conducted in bio-layout express d , and major clusters of mirnas were exported and uploaded to the diana-mirpath (kegg pathway) web-server. the pathways identified in the main cluster were attributed to the biological functions of focal adhesion, cytoskeleton (actin) regulation, tgf-b signalling, glycosaminoglycan biosynthesis, osteoclast differentiation, notch signalling and vegf signalling. the most significantly down-regulated mirna in mmvd was cfa-mir- , which is an endothelial specific mirna shown to regulate endothelial migration and vessel patterning. the top predicted target of cfa-mir- is glucuronic acid epimerase (glce) which is the main enzyme controlling heparan sulphate biosynthesis. other interesting findings were down-regulation of cfa-mir- and members of the cfa-mir- family. cfa-mir- targets multiple extracellular matrix transcripts, such as collagens, elastin, integrin, laminin, mmp (matrix metalloproteinase) and adamts (a disintegrin and metalloproteinase with thrombospondin motifs), whereas cfa-mir- targets hyaluronic acid synthase (has ). since the major pathology of mmvd is aberrant turnover of extracellular matrix proteins, this may be linked to mir-na regulation. dysregulation of valve mirnas might be potential therapeutic targets in the treatment of canine mmvd. no conflicts of interest reported. mitral regurgitation (mr) progresses slowly, but dogs living long enough often develop congestive heart failure (chf). however, tools to predict onset of chf are sparse. echocardiographic examinations in dogs were performed in a longitudinal, multicenter study with a surveillance time of up to . years. client-owned dogswere enrolled at the university hospitals in finland, sweden and denmark (subset to the svep study). left ventricular end diastolic (lvidd) and systolic (lvids) diameters, fractional shortening (fs), left atrial (la) and aortic root (ao) diameters were estimated. values were normalized for body size (nlvidd, nlvids, and nla, respectively) and, for comparison, ratios to aortic root were calculated (lvidd/ao, lvids/ao and la/ao, respectively). a cox's proportional hazard analysis with a counting process approach was used. spline smoothed graphical models were constructed to evaluate linearity of hazards. curves were then used to find cut-off values for interval hazard ratios (hrs). the hr for nlvidd, nlvids and nla (per . unit, % confidence intervals), were . ( . - . , p = . ), . ( . - . , p = . ), and . ( . - . , p = . ), respectively. the hrs for lvidd/ao, lvids/ao and la/ao ( . unit increase) were . ( . - . , p = . ), . ( . - . , p = . ), and . ( . - . , p = . ), respectively. the hr for fs was . ( . - . , p = . ). the relative hazard plot presented a steep increase for fs values above %. hrs for intervals < %, < %, and ≥ % were . ( . - . , p = . ), . ( . - . , p = . ), and . ( . - . , p = . ), respectively. the hr for nlvidd increased linearly. hrs for intervals . < . , . < . , . < . and ≥ . were . ( . - . , p = . ), . ( . - . , p = . ), . ( . - . , p = . ), and . ( . - . , p = . ), respectively. in contrast, the hazard for nlvids remained stable until . , whereafter it increased. the hrs for nlvids ( < . , . < . , . < . and ≥ . ) were . ( . - . , p = . ), . ( . - . , p = . ), ( . - , p = . ), and . ( . - , p = . ), respectively. hrs for values normalized to ao diameter behaved in a parallel way. we conclude that fs, left ventricular and atrial size may be used to predict chf. however, because the value of a hr is dependent on the unit used and, more essentially, does not account for nonlinear change in hazard, interpretation of hazards is challenging. in contrast, interval hazards are only dependent on the reference interval used. therefore they are easier to implement in every day clinical work. no conflicts of interest reported. systemic arterial hypertension is not frequently recognized in dogs with mitral valve degeneration (mvd), although borderline hypertension is difficult to assess, mainly because of different measurement techniques, inter-operator variability and, most importantly, examination-related stress. the object of this study was to evaluate systolic arterial blood pressure (sbp) at initial presentation and at regular intervals in dogs with various clinical stages of mvd. fifty six dogs with mvd that had not received any heart medication prior to admission, were included in the study. based on the isachc staging system, were assigned to class i (group a), to class ii (group b) and to class iii. small-breed dogs and miniature poodles, in particular, were overrepresented. comorbidities that could affect sbp were ruled out prior to enrollment. sbp was measured using a commercially available veterinary oscillometric device, by applying the proper cuff on the cephalic artery. dogs were left to acclimate for - minutes and measurements were always taken by the same investigator, before any other examination was performed, with the dog sitting on the owner's lap. a total of readings were taken, outlier values were discarded and the mean of the remaining measurements was documented. after initial consultation, treatment was customized according to the clinical stage. sbp was then measured every months, up to months after initial admission. at presentation, all class i dogs had sbp > mm hg, with only / having spb ≥ mm hg, whereas all class ii dogs had sbp < mm hg. of class iii dogs, had sbp > mm hg, and had sbp ≥ mm hg. a linear mixed effects model was used to assess the temporal variability of the measured parameters between groups. groups were matched for gender, age and body weight. blood pressure measurements, for the duration of the study, were higher in group a dogs, compared to groups b and c (p < , ). at the same time, group c had significantly higher sbp values than group b dogs (p < , ). asymptomatic mvd dogs seem to have higher sbp measurements, compared to those with clinical evidence of heart failure. whether this difference is stress-related, a maladaptive mechanism of sympathetic and raas activation to mvd or idiopathic remains to be elucidated. no conflicts of interest reported. sarcoplasmic reticulum (sr) ca + -atpase and its regulatory proteins are pivotal determinants of myocardial active relaxation via calcium uptake against the sr-cytoplasmic gradient. the lowered density of the sr ca + -atpase has been well demonstrated in many species during chronic hemodynamic overload. the genes linked to sr calcium uptake were reported not only being expressed in peripheral blood but serving as potential cardiac biomarkers in dogs with chronic mitral regurgitation, such as sr ca + adenosine triphosphatase isoform a (ser-ca a), phospholamban (pln), and hs- associated protein x- (hax- ). the aim of this study is to determine whether the target genes expressed in the blood will be translatable to the myocardial setting as cardiac biomarkers. the mrna expression levels of the target genes (serca a, pln, hax- ) from biopsied left ventricle (lv) and peripheral white blood cells (pwbc) in surgical mitral valve repair cases were estimated with quantitative real-time pcr using comparative ct method with gapdh. the gene expression levels in lv and pwbc were compared and their clinical relationships were evaluated. the diagnostic power of the genetic expressions in pwbc was analyzed by comparing to those of normal dogs. the levels of all target genes expressed in lv and pwbc were highly correlated each other in linear regression analysis (p < . ; serca a, r = . , r = . ; pln, r = . , r = . ; hax- , r = . , r = . ), although lv and pwbc showed different expression levels in a paired comparison (p < . ). according to the severity of the heart failure (isachc), the expression levels of all genes were gradually and significantly reduced in both lv and pwbc (p < . ). especially, the serca a and pln expressed in pwbc could clearly discriminate all isachc groups from the control (p < . ). multivariate regression adjusted by age and body weight revealed that serca a and pln in lv were negatively associated with lv internal systolic dimension (p = . , adjusted r = . and p = . , adjusted r = . , respectively). pln was also negatively related with lv internal diastolic dimension (p = . , adjusted r = . ). additionally, receiver-operating characteristic analysis using pwbc showed high area under the curve (auc) values for all target genes on overall isachc groups (p < . ; serca a, auc= . ; pln, auc= . ; hax- , auc= . ). in conclusion, the transcriptional changes of the calcium uptake related genes in pwbc may be able to reflect myocardial hemodynamic stress as well as to be utilized as promising cardiac biomarkers. no conflicts of interest reported. the aim of this study was to estimate heart-rate normalized pulmonary transit times (nptt) in cardiomyopathic cats with or without congestive heart failure (chf), to assess potential associations of echocardiographic variables and nptt, and to evaluate nptt as a test for presence of chf. privately owned cats were included. nptt was measured using echocardiography and the ultrasound contrast media sonovue â in groups of cats: healthy cats (group ), cats with cardiomyopathy (cm) but without chf (group ), and cats with cm and chf (group ). receiver operating characteristic curves (roc) were created for nptt, left atrial diameter (lad) and the left atrial to aortic root ratio (la:ao) to assess and compare their usefulness as tests for presence of chf. interrelations between pulmonary blood volume (pbv), nptt, stroke volume (sv) and echocardiographic variables were investigated by means of uni-and multivariate analysis. nptt values in group , group and group were . (interquartile range (iqr) . - . ), . (iqr . - . ), and . (iqr . - . ), respectively. values were significantly different between all groups. pulmonary blood volumes in group , group , and group were . ml (iqr . ml- . ml), . ml (iqr . ml- . ml) and . ml (iqr . ml- . ml). sv, pbv and shortening fraction < % were significant predictors of nptt. nptt and la:ao ratio, not sv were the main predictors of pbv. analyzing roc for nptt as a clinical test for chf yielded an auc of . which was similar for la:ao ratio. nptt may be useful test for the presence of chf in cats with cm and as a measure of cardiac performance. nptt and la: ao ratios predict chf with equal accuracy. increased pbv is significantly associated with higher nptt and la:ao ratios. both decreased sv and increased pbv explain the increased nptt in cardiomyopathic cats. the author received a travel scholarship from zoetis to attend this congress. acute arterial thromboembolism (aate) occurs commonly in cats, and less frequently in dogs, mostly resulting in limb paresis or paralysis. diagnosis is based typically on physical examination and advanced imaging. diminished affected-limb peripheral blood flow induces changes in several analytes concentrations in affected limb venous samples, compared to their peripheral venous concentration. we hypothesized that in aate, local, affected-limb venous glucose concentration decreases below reference interval, while systemic glucose concentration remains unaffected. the study included groups for each species: paralytic aate cases, non-ambulatory controls with limb paralysis of orthopedic or neurologic disorders, and ambulatory controls diagnosed with various diseases. systemic and peripheral, affected-limb blood glucose concentrations were measured. group absolute (dglu) and relative (% dglu) differences were compared. no procedure-associated complications or pain were noted. peripheral blood glucose concentrations were decreased (p ≤ . ) only in cats and dogs with aate. dglu and %dglu were higher in the aate groups in both cats and dogs compared to their respective control groups (p < . , p < . , respectively), with no differences between the control groups. receiver operator characteristics analysis of dglu and %dglu as predictors of aate in cats had areas under the curve of . and . , respectively, and . and . , in dogs, respectively. dglu cutoffs of mg/dl and mg/dl, in cats and dogs, respectively, corresponded to sensitivity and specificity of % and % in cats, respectively, and % in dogs. dglu and %dglu are extremely accurate, readily-available, simple diagnostic markers of aate in cats and dogs. no conflicts of interest reported. glycaemia determination is usually included in routine biochemisty panels. no works are devoted to the evaluation of pheripheral glycaemia in animals suffering from arterial thrombosis. the aim of this study was to document the pheripheral glycaemia variations in hypoperfused limbs of patients affected by mriconfirmed arterial thrombosis. eleven dogs referred for monoparesis or paraparesis were recruited. inclusion criteria were a clinical examination supportive of limb hypoperfusion and availability of blood cell count, biochemical profile and urine analyses. before mri examination, peripheral glycaemia was tested. two blood samples were obtained, one from the affected limbs and one from a healty limb.plasmatic glycaemia was measured using an automated glucose analyser. all the patients underwent a total body mri (mri intera . t, philips medical systems) that provided the final diagnosis. the arterial thrombosis location was documented and the entity was scored. all the eleven patients were diagnosed with a peripheral thrombosis involving an arterial vessel and in some cases the relative branches. the thrombus was located: in the abdominal aorta ( / ), in the subclavian artery ( / ), in the axillary artery ( / ), in the iliac arteries ( / ). of the total amount of abdominal aortic thrombosis, / involved also the internal iliac arteries, / the external ones and / both internal and external. the extent of the thrombosis was classified as grade (g ), when the greatest portion of the thrombus did not reach half of the vessel lumen ( / patients); grade (g ), when the greatest portion of the thrombus was between / and / of the vessel lumen ( / ); grade (g ), when the thrombus exceded / of the lumen ( / ). a substantial decrease in pheripheral glycaemia values was found in sampling arising from the thrombosisaffected limbs. comparing thrombosis-affected limbs values with healthy limbs measurements from the same patient, the reduction was found from . % to . %. accounting only the g scored patients, the percentage of reduction was found up to the . % suggesting a proportional decrease related to the grade of occlusion. results from this study suggest that peripheral glycaemia values are affected by limb hypoperfusion disorders. if an arterial thrombosis is suspected, samples from the affected limbs and the healthy ones could be used to compare glycaemia values and to support the early stage therapy in anticipation of diagnostic imaging. further studies are needed to confirm the proportional relation of the decrease with thrombus entity. no conflicts of interest reported. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease mainly affecting west highland white terriers (whwt). pulmonary hypertension (ph) may develop secondary to hypoxic vasoconstriction and/or pulmonary parenchymal infiltration. in the absence of measurable tricuspid regurgitation (tr), this co-morbid condition may be difficult to diagnose non-invasively. the degree of cardio-pulmonary impairment in cipf dogs can be evaluated through blood gas analysis (bga) and minute walking test ( mwt). a new echocardiographic index, the right pulmonary vein to pulmonary artery ratio (pv/pa) has been described for the detection of pulmonary venous hypertension. the aim of this study was to investigate pv/pa in cipf in order to determine its utility in the detection of ph and in the assessment of cardio-pulmonary disease severity. this prospective clinical cohort study included whwt with cipf (group a), healthy whwt (group b) and healthy dogs from other breeds (group c). diameters of right pv and pa were measured, in bi-dimensional (bd) and m-modes (mm), in a parasternal right long axis view, at the end of the t wave. other echocardiographic parameters for evaluation of ph were also measured: speed of tr, acceleration time to ejection time ratio of the pulmonary flow (at:et) and pulmonary artery to aorta ratio (pa/ao). bga was performed in dogs ( , and in groups a, b and c) and mwt in dogs ( , and ). values are given as meanaesd. in bd and mm mode, the pv/pa ratio was lower in group a (mm: . ae . , bd: . ae . ) compared to group b (mm: . ae . , bd: . ae . , p ≤ . ) and group c (mm: . ae . , bd: . ae . , p ≤ . ). the changes in pv/pa were both due to an increase of pa (p ≤ . ) and a decrease of pv (p ≤ . ). tr was found in % of dogs with cipf; mean pressure gradient was . ae . mmhg. at:et was lower in group a ( . ae . ) compared to group c ( . ae . , p = . ) and tended to be lower compared to group b ( . ae . , p = . ). pa/ao was not statistically different between groups. pv/pa was correlated with arterial po values (b mode: r = . , p = . ) and results of the mwt (b mode: r = . , p = . ). pv/pa was also correlated with at:et and the speed of tr, but not with pa/ao. in conclusion, in whwt affected by cipf, pv/pa is a useful indicator of ph and could serve in the assessment of disease severity. no conflicts of interest reported. ventricular septal defect (vsd) is the fourth most common congenital cardiac defect in dogs and the most common in cats. the aim of this study was to evaluate the long-term outcome in vsd patients. case records of animals were reviewed, of these re-evaluated echocardiographically and followed up by phone interview only. out of dogs pug was the most common breed ( %) followed by border terrier ( %). out of cats domestic short hair was most common ( %) followed by main coon ( %). isolated vsds were present in dogs and cats. complex defects (cds) were present in cases, most frequent anomalies being sub-aortic stenosis ( dogs, cat), pulmonic stenosis ( dogs, cats), tetralogy of fallot ( dogs, cats), cushion defects ( cats) and double-chambered right ventricle (dcrv) ( dogs, cats; in / dogs not present initially supporting the cause-and-effect theory). eisenmenger was observed in dog and cats. aortic insufficiency, not considered a cd, was noted in dogs. in dogs and cats ( % of isolated vsds and cat with a dcrv) the defect closed spontaneously. nine dogs and cats ( %) died of non-cardiac causes with an age at death of to (mean . ) months; dogs and cats died due to cardiac causes with an age at death of . to (mean . ) months. cardiac deaths were sudden ( dogs with cds) or euthanasia for left sided congestive heart (chf) failure associated with cds ( dogs, cat); right sided chf associated with cds ( cats); biventricular failure ( cat with cd); weakness (eisenmenger, dog and cat; fallot dog; cd cat). two cats developed chf due to unrelated hcm. only one dog with an isolated vsd was euthanized for chf. these results indicate that spontaneous vsd closure occurs more often than previously thought, most patients with isolated restrictive vsds live a normal life span without surgical intervention, but non-restrictive vsds or complex defects can be associated with significant morbidity and mortality. echocardiography early in life is crucial to identify the anomaly and cds, as well as useful to prognosticate long-term outcome and to identify patients where a surgical intervention should be considered if available. follow-up echocardiography is indicated to corroborate the prognosis, to detect complications due to the vsd and to detect unassociated acquired cardiac diseases. no conflicts of interest reported. centronuclear myopathy (cnm) is the most prevalent congenital inherited disorder affecting skeletal muscles in labrador retrievers. this disabling condition segregates worldwide and a recessive loss-of-function founder mutation was identified in the protein tyrosine phosphatase-like, member a gene (ptpla/ hacd ). the objectives of this study were ) to describe ptpla expression pattern in hearts from homozygous wild type (wt), heterozygous (het) and homozygous mutated (cnm) dogs, ) to assess and compare the left myocardial function in aging wt, het and cnm dogs. for this purpose, seven wt, four het and eleven cnm dogs were included in the study. ptpla mrna levels were assessed by rt-pcr and rt-qpcr. all dogs were examined using conventional echocardiography, d color tissue doppler imaging (tdi) and tdi-derived strain imaging. we found that the expression of the two wild type ptpla splice isoforms increased post-natally in wt dogs. their levels were halved in het dogs and drastically reduced in cnm dogs. in both het and cnm dogs, a slight left ventricular hypertrophy was detected using conventional echocardiography. tdi and strain imaging revealed that the left ventricular myocardial function was significantly altered in both het and cnm dogs compared to wt dogs. moreover, these functional defects were associated with significantly higher values of systemic arterial blood pressure, although maintained within normal ranges. in conclusion, subclinical myocardial alterations were detected in both het and cnm aging dogs from our french pedigree, suggesting a role for ptpla in long-term cardiovascular homeostasis. these findings prompt globalized confirmation in additional ptpla"'deficient dogs, which may thus be considered as a new large-size model for human left ventricular sub-clinical myocardial dysfunction. no conflicts of interest reported. mitral regurgitation (mr) secondary to degenerative mitral valve disease (dmvd) is the most common heart disease in dogs. in dogs with mr, mitral valve prolapse caused by degeneration of the mitral valve leaflet, chordae tendinae extension and/or rupture and mitral annulus dilation are observed. however, limited data are available on morphological changes in dogs with mr. currently, there are no studies confirming the anomaly of the mitral complex via direct observation in living dogs with mitral regurgitation. at our institution over the last ten years, approximately dogs have undergone mitral valve repair. during surgery, the anomaly of mitral complex can be observed macroscopically (directly visualized). to our knowledge, this is the first study evaluating the anomaly of the mitral valve leaflet and chordae tendineae in dogs undergoing mitral valve repair. animals: dogs that underwent mitral valve repair with cpb at nihon university between february and june were included in this study. methods: confirmation of chordae tendineae rupture was visually confirmed during surgery. the sites of chordae tendineae rupture were also recorded at that time. septal chordae and mural chordae were divided three division depend on the site (s , s , s and m , m , m respectively). results: ninety eight dogs were included in this study. the mean age and body weight were . ae . years and . ae . kg, respectively. of the dogs, ruptured chordae was observed in dogs ( . %). septal leaflet chordae was ruptured in dogs ( . %) and mural leaflet chordae was ruptured in dogs ( . %). chordae of both leaflets were ruptured in dogs ( . %). no chordal rupture was observed in dogs ( . %). in the dogs with ruptured septal chordae, the chordae between s and s was most often ruptured (n = , %). in this study, rupture of the septal chordae tendineae was most commonly observed. this is the first pilot study to visually evaluate the anomaly of the mitral valve leaflet and chordae tendineae in dogs undergoing mitral valve repair. future studies comparing pathological changes and molecular biological analysis to gross findings of mitral chordae tendineae in dogs undergoing mitral valve repair may be useful in advancing the understanding of the disease. no conflicts of interest reported. echocardiographic aortic valve (ao) measurements are routinely obtained during cardiac evaluation of patients. cardiologists commonly use diastolic ao measurements to obtain ratiometric weight-independent estimates of dimensions of other cardiac structures, most commonly the left atrium (la). however, no consensus exists about the point in diastole at which ao measurements should be obtained -immediately after closure of the aortic valve, when la size is largest (ao max , but often with least distinct margins), during the p-wave of the ecg (ao p ) and at the onset of ventricular electrical systole, when la size is smallest (ao min ). we examined the linear and area dimensions of the ao (aod and aoa) to determine if clinically significant differences exist at distinct diastolic time-points, or if these measurements could be interchangeable. we examined patients ( dogs and cats) presented for cardiac evaluations by d echocardiography. three replicates of each time-point linear and area measurement (ao max , ao p , ao min ) were obtained in each patient and averaged for analysis. only patients with aortic valve disease and those with atrial fibrillation were excluded from analysis. beat-to-beat variability of the ao measurements was determined. standard and normalized limits of agreement (loa) plots were generated for each pairwise comparison. the frequency of each ao measurement being the largest or smallest within-patient measurement was determined, and compared via repeated measures anova. all pairwise agreement plots of both aod and aoa demonstrated heteroscedasticity; normalized aod plots showed % loa to be % of the mean aod measurement, with a bias of approximately . % for aod max -aod min , % for aod max -aod p , and % for aod p -aod min . normalized aoa plots showed %loa to be % of the mean aoa measurement, with a bias of approximately % for aoa max -aoa min , % for aoa max -aoa p , and % for aoa p -aoa min . aod max was the largest measurement in / ( %) patients and aod min was the smallest measurement in / ( %) patients; aoa max was the largest measurement in / ( %) patients and aoa min was the smallest measurement in / ( %) patients. rmanova confirmed that ao max >ao p >ao min (p < . ). median within-patient within-measurement variability was % for aod and % for aoa measurements. our data suggest that ao measurements differ throughout diastole, with ao max >ao p >ao min . the disparity is greater for area than linear estimates. the degree of disagreement between ao max and ao p is small and similar to the within-measurement variability. thus, using either ao max or ao p measurements should result in similar ratiometric estimates of cardiac dimensions. no conflicts of interest reported. feline hypertrophic cardiomyopathy (fhcm) is the most common heart disease in cats. hcm is considered an inherited disease of the sarcomere and fhcm has been linked to mutations in one sarcomere protein i.e. mybpc . however, the pathophysiologic mechanisms behind disease development and progression are largely unknown. in this study we investigate whether mitochondrial morphological changes in the myocardium accompany mitochondrial dysfunction and enhanced oxidative stress formation that we recently found in fhcm. myocardial tissue from the left ventricle (lv) was obtained immediately after euthanasia from cats diagnosed with primary hcm on echocardiography ( maine coon, british shorthair, exotic shorthair, norwegian forest cat) and age-matched control cats ( maine coon, norwegian forest cats). ultrastructural examination was performed by the use of transmission electron microscopy. in hcm cats, marked ultrastructural changes of the cardiomyocytes were observed. the population of subsarcolemmal mitochondria (ssm) was absent in large cellular areas in cats with moderate and severe lv hypertrophy. flattening of the sarcolemma was a common finding, causing disorganization of the t-tubular system. interfibrillar mitochondria (ifm) were disorganized but not depleted. additional changes in cardiomyocytes from cats diagnosed with fhcm included remodeling of sarcomeres, disorganization of myofibrils, convolution of gap junctions, accumulation of intracellular z-disc material, perinuclear lipofuscin granula and extensive extracellular deposits of collagen. in healthy mammalian cardiomyocytes, the t-tubular system upholds cellular structure, prevents mitochondrial reticulum formation and provides calcium, oxygen and substrates, necessary for normal functioning muscle. disorganization of the sarcolemma and t-tubular system may cause the depletion of ssm. possible mechanisms are atrophy or disruption of the mitochondria or altered fusion-fission dynamics. calcium cycling and substrate supply are likely to be compromised by the observed structural changes. we propose this to be related to mitochondrial dysfunction and oxidative stress formation that occurs in fhcm, however a causative relationship remains unknown. in conclusion, morphological changes of mitochondria and extra-sarcomeric structures are common in fhcm, regardless of breed, genotype and phenotypic disease expression. moreover, mitochondrial subpopulation-specific changes occur in fhcm with depletion of ssm. ultrastructural and functional changes of cardiac muscle mitochondria are considered important molecular mechanisms, responsible for the development and progression of fhcm and may be relevant future treatment targets. no conflicts of interest reported. patent ductus arteriosus (pda) is one of the most common congenital cardiac defect in the dog. ductal patency is associated with pulmonary overcirculation, left ventricular volume overload and can rapidly determine congestive heart failure if untreated. several devices to close the pda have been used, with amplatzer canine duct occluder (acdo©) being considered the safer device with lowest complication rates. echocardiography represents the cornerstone of pda diagnosis, but its role has been recently expanded to wider field of application: device sizing and intraoperative monitoring, as well as a tool to quantify cardiac morphology and function. speckletracking echocardiography (ste) has been used to evaluate cardiac function in a wide variety of diseases in human and veterinary patients, however no study has evaluated its usefulness in dogs affected by pda both before and after percutaneous closure of pda. the aim of our study was therefore to assess standard m/bmode derived parameter of cardiac function and ste derived longitudinal, radial and circumferential strain and strain rate before and after pda closure. twenty-five dogs of different breeds, age and weight were prospectively recruited and a complete echocardiographic evaluation was performed before and hours after pda closure. end diastolic and systolic diameters indexed for body surface area (edvi/esvi) both derived by m-mode and b-mode views, allometric scaling derived allod and allos, sphericity index (si) and pulmonary to systemic flow ratio (qp/qs) were assessed both pre and postoperatively. ste derived parameters assessed were longitudinal, radial and circumferential strain and strain rate. a statistically significant difference was found in all standard parameters of cardiac function before and after pda closure (p < . ), with a general decrease in values hours postoperatively. ste derived parameters of cardiac function showed a trend toward a decrease back to normal values, which was statistically significant (p < . ) for circumferential and radial strain and strain rate, while longitudinal strain and strain rate did not reach statistically significance. based on our results, no cardiac dysfunction was identified by the use of ste derived parameters both before and after pda closure, with an increased contractility as identified by higher than normal ste values before pda closure and a decrease back to normal strain and strain rate values for both circumferential and radial immediately after percutaneous closure. longitudinal strain persists on higher than normal values, refusing the hypothesis of systolic dysfunction after pda closure and suggesting a longer reverse remodeling process after pda closure. dr bussadori receives royalties from esaote (florence, italy) related to an european patent (nr ) he developed for xstrain software. the study was not funded by a research grant. cardiac cachexia which is characterized by progressive weight loss and depletion of lean body mass, is an independent predictor of survival in human patients with congestive heart failure. chronic degenerative mitral valve disease (cdmd) is one of the most common cardiac diseases in dogs. the aims of this study were to evaluate the prevalence and the effects of cardiac cachexia in survival of dogs with cdmd. medical records of client-owned dogs with cdmd were reviewed. the mean age at entry was . ae . years; were females, and were males. data obtained from the records including breed, sex, body weight, age at diagnosis, complete blood counts, biochemical profiles, urinalysis, systemic blood pressure, thoracic radiographs, electrocardiograms, ultrasonography and echocardiographic examinations at initial visit and survival time. diagnosis of cdmd was based on echocardiographic characteristics and categorized by modified new york heart association (nyha) functional classification. cardiac cachexia was defined as presence unintentional weight loss (> % within months after diagnosis) together with anorexia and muscle weakness, anemia (red cell count < . /ll, hemoglobin < g/dl, or both), hypoalbuminemia (plasma albumin < . g/dl), and azotemia (blood urea nitrogen > g/dl, creatinine > . g/dl, or both). dogs with other cardiac disorders and other systemic disorders those would cause anemia and hypoalbuminemia were excluded from this study. prevalence of cardiac cachexia, anemia and azotemia was . %, . % and . %, respectively. these conditions were the most prevalent in nyha class , followed by nyha classes and . the prevalence of hypoalbuminemia was not significantly different among classes. the one-year body weight change was found in the nyha classes (increased . ae . %), (decreased . ae . %) and (decreased . ae . %). the difference between classes and was significant. results of the cox proportional hazard model indicated that survival time was significantly positively associated with nyha functional severity at diagnosis (p < . ), presence of cardiac cachexia, weight loss, anemia, hypoalbuminemia and azotemia (p < . , p = . , p = . , p = . and p = . , respectively). the prevalence of cardiac cachexia was common in advanced cdmd dogs, and the parameters of cardiac cachexia, namely weight loss, anemia, hypoalbuminemia and azotemia were strong prognostic factors associated with survival. no conflicts of interest reported. mitral valve disease (mvd) is the most common cardiovascular disease in dogs. it's characterized by myxomatous degeneration, which causes mitral valve prolapse (mvp), mitral regurgitation (mr) and a left apical systolic murmur (lasm). mvd affects small breed dogs with a very high prevalence in cavalier king charles spaniels (ckcs). the main goal of this study was to determine the prevalence of lasm, mvp and mr in the maltese, the most presented breed among dogs with mvd in taiwan. the correlation between these measurements and the influence of age, gender, reproductive state, and body weight were also investigated. study results were compared to other mvd prevalence studies in europe and north-america. client-owned maltese dogs ( males and females; body weight . - . kg; age - yrs) with no signs of heart failure were recruited. the intensity (grade - ) of lasm was recorded. grade of mvp (mild/severe) and mr severity (mild/moderate/ severe) were evaluated by echocardiography. logistic regression was used to determine the correlation between age and presence of lasm, mvp and mr. a chi-square test was used to evaluate whether sex and reproductive-status were related to prevalences of lasm, mvp and mr. spearman's correlation coefficient was used to assess the relationships between age, body weight, lasm intensity, grade of mvp and severity of mr. the prevalence of lasm, mvp and mr were . %, % and . %, respectively. all have positive correlation with age (p = . ). the age at which % of the dogs had lasm, mvp and mr was . , . , and . years, respectively. the lasm intensity, mvp grade and mr severity were all positively correlated to age (all p = . ) and had no correlation with bw and reproductive status. females had a significantly higher prevalence of lasm than males ( % vs. . %, p = . ). maltese dogs in taiwan have a very high prevalence and an early development of mvd as compared to other small breed dogs, similar to mvd in ckcs in other countries. since we only recruited asymptomatic dogs, this study may underestimate the prevalence of mvd in the whole maltese population. to our knowledge, this is the first report to document the high prevalence of mvd in taiwanese maltese.the maltese may be a new canine model for genetic, pathology, and natural history studies in mvd. boehringer-ingelheim sponsored the author's accommodation costs for this congress. esvc-o- cardiorenal syndrome in dogs with chronic valvular heart disease: a retrospective study. e. martinelli , p. scarpa , c. quintavalla , c. locatelli , p. brambilla . university of parma, parma, italy, university of milan, milan, italy in human medicine, primary disorders of the heart often result in secondary dysfunction or injury to the kidneys. the coexistence of the two problems in the same patient is referred as cardiorenal syndrome (crs). just little information about crs is available in veterinary medicine. the aim of this study was to define the prevalence of chronic kidney disease (ckd) complicating chronic valvular heart disease (cvhd) in dogs and to investigate the relationship between class of cardiac insufficiency (acvim) and class of renal insufficiency (iris). medical records of dogs presented at the cardiology service of the department of veterinary science and public health, university of milan, between january and december were retrospectively evaluated. dogs with a complete physical examination, thoracic radiographs, a cvhd diagnosis based on echocardiographic examination, and a serum biochemical panel, including assessment of serum creatinine (scr) and serum urea (bun), were included in the study. dogs with other heart disease, neoplasm or systemic diseases were not included in the study. one hundred eighteen dogs of both genders ( males and females), to years of age ( . ae . years), to kg of bodyweight ( . ae . kg) fulfilled the inclusion criteria. the % of males and the % of females were neutered. the most represented breeds were mongrel ( %), miniature poodle ( . %), york shire terrier ( . %), shih -tzu ( . %), pinscher ( . %) and dachshund ( . %). dogs were classified as follow: % acvim a, % acvim b , % acvim b , % acvim c and % acvim d. while the % of the dogs were normoazotemic (scr < , mg/dl), % were staged in iris , % in iris and %in iris . statistical analysis was performed using jmp . (sas institute inc.). a p value < , was considered significant. the prevalence of ckd associated with azotemia in dogs affected by cvhd was %. there was a statistically significant direct correlation between acvim and iris class (pearson test p = . ). unexpectedly, the % of dogs receiving drugs for medical management of heart failure (acvim class c and d) were normoazotemic. despite a definite conclusion about the role of cvhd on the induction and/or progression of ckd cannot be drawn from this cross-sectional study, these results suggest that there is a direct correlation between the severity of ckd and cvhd. no conflicts of interest reported. there is growing evidence of breed differences in concentrations of several blood variables in dogs. the aim of the study was to investigate breed differences in plasma concentrations of components of the renin-angiotensin-aldosterone system (raas), endothelin- (et- ) and serum cortisol concentration in healthy dogs. healthy, privately-owned dogs of nine breeds were examined at five centers as part of the european lupa-project. absence of cardiovascular or other clinically relevant organrelated or systemic disease was ensured by thorough clinical investigations. plasma concentrations of et- and aldosterone, renin activity, and serum concentration of cortisol were measured by ria or elisa assays. overall significant breed differences were found (p < . for all variables). bonferroni-corrected pair-wise significant differences between breeds were found in % of comparisons for et- , % for cortisol, % for renin and % for aldosterone. for et- , the highest median concentration was found in newfoundlands with values > times higher than most other breeds, while renin was highest in dachshunds, > times higher than in newfoundlands and boxers, which had the lowest concentrations. aldosterone was especially low in belgian shepherds with median concentration < times than the other breeds. cortisol was highest in finnish lapphunds, almost times higher than boxers with the lowest concentration. in conclusion, considerable inter-breed variation in concentrations of et- , components of raas and cortisol was found in healthy dogs. these differences are likely influenced by genetic factors and should be taken into account when designing clinical trials and tests. breed-specific reference ranges might be necessary. no conflicts of interest reported. most studies that assess weight management in obese dogs only examine the early stages of weight loss, and this may not properly reflect a complete weight management regime. the aim of the current study was to examine the kinetics of a complete weight management cycle in obese client-owned dogs. dogs referred to the royal canin weight management clinic, university of liverpool, for the management of obesity, were eligible for inclusion. all dogs were followed until they had either completed (i.e. reached target weight) or the programme was discontinued. rate of weight loss, percentage weight lost, and energy were assessed at different time points. a total of dogs were included, with a range of breeds, ages and sexes represented. rate of weight loss steadily decreased throughout the weight loss period (d : . ae . %/wk; d : . ae . %/wk; d : . ae . %/wk; d : . ae . %/wk; d . ae . %/wk; d : . ae . %/wk; p < . ). the energy intake required to maintain weight loss also progressively decreased (p < . ). by day , mean aesd weight loss was ae . %, and compliance was good, but most had not com-pleted ( % completed, % ongoing, % discontinued). thereafter, more dogs completed, but the number of discontinuing also increased (d : ae . % weight loss, % completed, % ongoing, % discontinued; d : ae . % weight loss; % completed, % ongoing, % stopped). initial weight loss is good in obese dogs but, thereafter, steadily worsens. thus, studies examining only the first few months of weight loss are not fully representative of the entire weight loss process. conflicts of interest: the following conflicts of interest apply: the diet used in this study is manufactured by royal canin.whilst vb is employed by royal canin. vb and ss are employed by royal canin. ajg's readership is funded by royal canin. obesity and obesity-related metabolic dysfunctions are increasing in humans as well as in dogs. obese dogs become affected by chronic diseases at young age, have a decreased quality of life and a shorter life-span. the aim of the study was to describe the metabolic and hormonal response to a feed-challenge test in lean and overweight dogs. twenty-eight healthy intact male labrador retrievers aged . ae . years with varying body condition score (bcs, scale - ) were included. twelve dogs were classified as lean (bcs - ), ten as slightly overweight (bcs ) and six as overweight (bcs . - ). an overnight fasting period and blood sample collection was followed by a high fat meal. after food intake, blood samples were collected hourly for four hours. a glucagon elisa was validated for use in dogs. the assigned bcs was supported by positive association with serum leptin concentrations. postprandial triglyceride concentration was significantly higher in the overweight group. a tendency to higher cholesterol concentration was seen in the overweight group but cholesterol was not affected by food intake. glucagon concentration rose after food intake and resembled the response seen in humans after a mixed meal. glucose and insulin concentrations followed the same pattern while free fatty acids had declined one hour after the meal. in this study, the metabolic and hormonal response to a high fat meal was similar between lean and slightly overweight dogs, whereas the response of overweight dogs differed. studies on the health significance of postprandial hypertriglyceridemia in dogs are warranted. conflicts of interest: the study was financially supported by the swedish veterinarian federation, the companion animal research foundation, and the foundation of thure f. & karin forsberg. feline weight-loss programs are often hindered by compliance issues and sedentary lifestyle. the purpose of this study was to assess the effectiveness of a new dietetic weight management food (ndwmf)* in achieving weight loss in overweight/obese, client-owned cats. the objectives were ) to evaluate weight loss parameters in cats fed the ndwmf* and ) to describe the owner's perception of the cat's quality of life. overweight/obese, otherwise healthy, client-owned cats (> / body condition score -bcs) were enrolled in the study (n = ). initial veterinary evaluation comprised a physical examination, nutritional assess-ment, determination of ideal body weight (ibw), and development of weight loss feeding plan. daily energy requirement (der) for weight loss was calculated as der = . x ( x ibw kg . ). initial and follow-up evaluations (monthly for months) consisted in determination of body weight (bw), bcs, body fat index (bfi), muscle condition score (mcs), and current feeding practices. quality of life assessment by owners included cat's level of energy, happiness, appetite, begging behavior, flatulence, stool volume, and fecal score. statistical analysis encompassed scatterplots, regression analysis, summary statistics as appropriate for the type of analyses (continuous or categorical variables, distribution), a mixed model anova was used to assess changes over time (statistical significance at p < . ). eighty three percent of the cats (n = ) lost weight with an average weight loss of % (sem, . %) over months and an average weekly weight loss rate of . % (sem, . %). a significant decrease in bcs from week - and in bfi from week - compared to baseline was observed. mcs did not change. average duration of weight loss was days (sem, . days) with days (sem, . days) between visits. fourteen percent of cats achieved ibw ( . , ci: . - . ). seventy nine percent of cats ate more than the recommended der (median fed above der= %), and the majority of these cats still lost weight. owners perceived a significant increase in energy and happiness (>week ) compared to baseline in the cats that lost weight without changes in appetite or begging behavior. no significant changes were seen in scores for flatulence, stool volume, and fecal score. in conclusion, this clinical study showed that feeding the ndwmf* to client-owned, overweight/obese cats resulted in weight loss. owners reported significant improvements in cat's quality of life without negative side effects. * porphyrias are a group of inborn errors of metabolism resulting from accumulation of porphyrins due to deficient activities of specific enzymes in heme biosynthesis. in humans, they are clinically classified as either erythroid with cutaneous involvement or hepatic with acute neurovisceral attacks. here we describe the clinical, biochemical, and molecular genetic studies in porphyric cats from new brunswick, canada. from to , three separately identified adult domestic shorthair cats from the city of saint john in new brunswick were found to have erythrodontia (brown discolored teeth which fluoresced pink) and pigmenturia. a mild compensated hemolytic disorder with numerous small dark blue irregularly shaped erythrocyte inclusions was noted. there was no evidence of acute lifethreatening neurovisceral attacks or cutaneous lesions. necropsy of one cat revealed massive deposition of porphyrins in all bones and teeth. urine and edta blood samples from one cat were metabolically studied, while molecular genetic studies were performed in all cats either from edta blood or a formalinized splenic tissue block. urinary d-aminolevulinic acid, porphobilinogen, uroporphyrin i, and coproporphyrin i concentrations were increased in the cat studied, suggesting an acute intermittent porphyria (aip). the erythrocytic hydroxymethylbilane synthase (hmbs) activity in erythrocytes was approximately half normal suggesting a dominant enzymopathy, while the erythrocyte uroporphyrinogen iiisynthase activity was normal. sequencing the feline hmbs gene revealed a heterozygous intronic base deletion (c. - _- del) which results in an insertion in the mrna and would predict a truncated protein. in conclusion, these three domestic shorthair cats had the same hmbs mutation causing an autosomal dominantly inherited aip. cats with discolored teeth and normal or mild hemolysis may have either acute intermittent porphyria or congenital erythroid porphyria. interestingly, seven disease-causing mutations have now been found by us in the hmbs gene -more than in any other gene in cats. the biochemical and molecular characterization facilitates clinical screening of affected cats to reach a specific diagnosis. supported in part by nih od . urs giger and raj karthik are also part of the laboratory that offers dna testing for this mutation. fibrinogen decreases when coagulation is activated to form fibrin, while fdps and d-dimers represent the products of fibrinolysis. in humans, activation of coagulation and fibrinolysis develops in all type of ascites and it is also associated with signs of systemic fibrinolysis.these results have lead to the suggestion that ascitic fluid is inherently fibrinolytic. preliminary studies showed similar results also in dogs (javma nov. , ecvim proceedings . in addition, in an old experimental study conducted in dogs, inoculation of blood or of a solution containing fibrinogen and thrombin into the pleural cavity resulted in the activation of the coagulation system followed by fibrinolysis. therefore, the objective of the present study was to determine whether the activation of coagulation and fibrinolysis (i.e. low fibrinogen and elevated fdps and ddimer) occurs not only in the ascitic fluid, as alredy been demonstrated, but also in all type of pleural effusions in dogs. thirty-three dogs referred to the san marco veterinary clinic with pleural effusion, but without ascites, were studied. fibrinogen, fdps, and d-dimer concentrations were measured and then compared in both pleural fluid and venous blood via wilcoxon signed ranks test. the dog's pleural effusions were categorized based on pathophysiology of fluid formation into dogs with transudate ( due to increased hydrostatic pressure and due to decreased osmotic pressure), with an exudate (of which due to septic causes), with a haemorrhagic pleural effusion, and with a chylous effusions. the fibrinogen concentration in the pleural effusion (median: mg/dl; range: - ) was significantly lower (p < . ) than the plasma fibrinogen concentration (median: mg/dl; range: - ). in all dogs, the fibrinogen pleural fluid concentration was lower than the plasma concentration. the fdp concentration in the pleural effusion (median: mg/dl; range: . - ) was significantly (p < . ) higher than plasma fdps concentrations (median: . mg/dl; range: . - . ). in case, the fdps pleural fluid concentration was lower than the plasma concentration and in cases the pleural fluid concentration was higher. the d-dimer concentrations were significantly(p < . ) higher in the pleural effusion (median: . lg/ml; range: . - . ) than in the plasma (median: . lg/ml; range: . - . ). in one case, the d-dimer pleural fluid concentration was lower than the plasma concentration and in cases was higher. these findings support the hypothesis that activation of coagulation followed by fibrinolysis occurs in all type of pleural effusions. no conflicts of interest reported. during primary hyperfibrinogenolysis (phf), fdps production is increased but production of d-dimer is not. therefore, elevated fdps and normal d-dimer are considered an indicator of phf. in humans and dogs, activation of coagulation and fibrinolysis develops in all type of ascites and it is associated with systemic phf, suggesting that ascitis is inherently fibrinolytic. preliminary data have shown that activation of coagulation followed by fibrinolysis occurs also in all type of pleural effusions (pe). the objective of this study was to determine if systemic phf occurs also in dogs with pe. thirty-three dogs referred to the san marco veterinary clinic with pe, but without ascites, were studied (group ). from the electronic data-base of the clinic dogs for inclusion in control groups (healthy dogs) and (sick dogs without pe or ascites) were randomly selected and individually matched to group dogs for age, sex, and breed. fibrinogen, fdps, d-dimers, c-reactive protein (crp), fibrinogen/crp ratio, and prevalence of phf (i.e., dogs with elevated plasma fdps and normal d-dimer) were determined. differences between the groups were analyzed using anova (fibrinogen), chi-square (fdps and prevalence of phf) and kruskal-wallis test (crp, fibrinogen/crp ratio, and d-dimer). post-test analysis were performed by tamhane and mann-whitney test. fibrinogen concentration in group was significantly increased compared to group (p < . ), but not compared to group (p = . ). fdps concentration in group was significantly increased compared to groups (p < . ), but not compared to group (p = . ). d-dimers concentration in group was significantly increased compared to group (p < . ), but not compared to group (p = . ). crp was significantly increased in group compared to group and (p < . for both comparison). fibrinogen/crp ratio was significantly decreased in group compared to group and (p < . for both comparison). prevalence of phf was significantly higher in group compared to groups (p = . ), but not compared to group (p = . ). these results support the hypothesis that phf occurs significantly more often in dogs with pe compared to healthy dogs. despite there was a trend of increased phf also in dogs with pe compared to sick dogs, this difference did not reach significance. nevertheless, the decreased in fibrinogen/crp ratio in group compared to group , in the face of a similar d-dimer concentration, would suggest that phf is also more prevalent in dogs with pe compared to sick control dogs. no conflicts of interest reported. the systemic inflammatory response syndrome (sirs) refers to clinical signs of systemic inflammation in response to (non-) infectious insults. current diagnosis of sirs is based on clinical and basic laboratory data and is a sensitive screening to identify patients at risk. c-reactive protein (crp) is a major canine acute phase protein with concentrations related to disease severity and underlying cause. crp rises in response to proinflammatory cytokines, mainly interleukin (il)- and tumor necrosis factor (tnf)-a, which are considered the main triggers of sirs. we therefore evaluated crp, il- and tnf-a kinetics in canine emergency sirs patients hypothesizing that crp is ( ) increased in dogs with a clinical sirs-diagnosis, ( ) correlated with il- and tnf-a concentrations, ( ) influenced by the underlying etiology, and ( ) a prognostic marker. canine emergencies with clinically diagnosed sirs were prospectively included. serum and plasma were immediately stored at - °c after sampling at presentation, after (t ), (t ), (t ) and (t ) hours, and at a control visit (t m) over one month after discharge. serum crp was measured with a caninespecific immunoturbidimetric crp assay. plasma il- and tnfa were measured using a bioassay measuring biologically active cytokine concentrations. disease categories were infection (i), neoplasia (n), trauma (t), gastric-dilation and volvulus (gdv), other gastrointestinal (gi), renal (r) and miscellaneous (m) diseases. statistical analysis was performed with sas. concentrations of inflammatory cytokines were expressed logarithmically, with univariate analysis confirming normal distribution. a correlation procedure, mixed procedure on a linear model and a logistic procedure were performed (p-value < . ). sixty seven dogs (i = , n = , t = , gdv= , gi= , r = , m = ) were included. forty-three patients survived (seven died, seventeen were euthanized). twenty patients had a control visit. crp was elevated in . % of dogs at presentation, and only remained within reference range ( - . mg/l) throughout hospitalization in four dogs ( . %). crp concentrations were significantly higher from t ( . ae . mg/l) to t ( . ae . mg/l) decreasing at t ( . ae . mg/l), and returning within reference range at t m ( . ae . mg/l) in all but one dog ( . mg/l). crp was significantly correlated with logarithmical concentrations of il- and tnf-a, however, these did not change significantly over time. none of the evaluated parameters was associated with disease category, nor outcome. crp appears useful to diagnose sirs in emergency patients, and tends to decrease during hospitalization. however, crp, neither il- nor tnf-a concentrations appear useful to predict the underlying disease and outcome in sirs patients. no conflicts of interest reported. calprotectin (s a /a complex) belongs to the s /calgranulin family, and is primarily released from activated neutrophils and macrophages. serum calprotectin concentrations (cp) were shown to be increased in dogs with inflammatory diseases such as inflammatory bowel disease, pancreatitis, systemic inflammatory response syndrome, and sepsis. canine cp thus appears to be a biomarker of inflammation. considerable day-today variation of fecal canine cp was found in both healthy dogs and dogs with chronic gastrointestinal disease. however, the biological variation of canine cp in serum has not been reported. the aim of this study was to determine the biological variation of serum canine cp and its minimum critical difference (mcd). eleven healthy dogs were used for this study. biological variation of serum canine cp was evaluated over a . -months period. tests for outliers were carried out at levels (within-run analytical variance, intra-, and inter-individual variation). a nested analysis of variance (anova) model was used to calculate analytical (cv a ), intra-individual (cv i ), inter-individual (cv g ), and total variation (cv t ), and to determine the index of individuality (ii), index of heterogeneity (ih), and mcd. a total of serial specimens were collected from dogs, serial samples from dogs, and serial samples from dogs. four within-subject outliers were detected and excluded from further analysis, yielding a total of serum samples and slightly right-skewed data. no outlying observations (cochrane test) or outliers among mean concentrations of subjects (reed's criterion) were detected. cv a was calculated as . %, cv i as . %, and cv g as . %, resulting in a cv t of . %. index of individuality (ii) was determined to be . and ih was . , yielding a one-sided mcd of . mg/l. the analytical goal of cv a ≤ ½ cv i was satisfied. although serum canine cp remained within a relatively narrow concentration range in healthy dogs, moderate individuality was detected. moderate changes in serum canine cp ( . mg/l) between sequential measurements are needed to be considered clinically relevant, and using a population-based reference interval may or may not be appropriate for serum canine cp. using the mcd with the previously determined median canine cp concentration ( . mg/l) for the reference sample group yielded a serum canine cp concentration close to the upper limit of the previously established reference interval ( . mg/l), showing that the reference interval for serum ccp ( . - . mg/l) is within reasonable limits. the assay used in the study was developed at the gi laboratory, texas a&m university. most authors also work at the gi laboratory, texa a&m university. canine leishmaniasis (canl) is a multisystemic disease that is endemic in the mediterranean region. in the past, concentrations of acute phase proteins (apps), and specifically c-reactive protein (crp), haptoglobin (hp), ceruloplasmin (cp), serum amyloid a (saa) and albumin (alb), have been reported to change in dogs with leishmaniasis, and revert to normal after successful treatment, highlighting the intrinsic inflammatory reaction of the host to the parasite. since the spectrum of clinical and laboratory derangements is broad, it is possible that apps are increased specifically because of certain clinicopathological syndromes associated with canl. a total of dogs with canl, diagnosed on the basis of cytological amastigote identification and ifat serology, were retrospectively included in the study. in all of them, crp, saa, hp and alb were measured at interlab-umu, murcia, spain, in aliquots of serum, which were stored in - °c for - years (median: years). results for each of the apps were correlated to laboratory and clinical parameters (n: ), clinical and parasitological scoring (n: ), ehrlichia and leishmania serology (n: ), and clinical staging according to leishvet (n: ), using an array of linear and ordinal regression models, as well as one-way anova, t-test and fisher's lsd test. crp and alb were by far the apps most frequently correlated with clinical and laboratory abnormalities such as nutritional status, lethargy and skin ulcers (p < , ), as well as urinary protein to creatinine ratio (upc), total serum protein, and urine specific gravity (p < , ). there were limited associations between hp, cp, saa and clinicopathological parameters. a minor linear relationship was observed between crp and clinical scoring. crp and alb were also correlated with parasitological scoring in bone marrow, but not lymph node cytology (p < . ). dogs with ehrlichia titers had higher crp, cp and lower alb concentrations. finally, crp concentrations were higher in later compared to earlier stages of the infection, as defined by the leishvet criteria. the inflammatory component to leishmania infection doesn't seem to be exemplified by the reaction of a particular tissue, with the possible exception of glomerulonephritis. the magnitude of increase in crp and decrease in albumin is correlated with clinical staging and bone marrow parasitological scoring. no conflicts of interest reported. the consequences of abnormal platelet function in dogs and cats can be devastating and the use of anti-thrombotic therapy to prevent thrombotic events is increasingly common. the ability to measure platelet function and the efficacy of anti-thrombotic therapy is difficult due to limited availability of equipment and inability to delay platelet function analysis. the aim of this study was to adapt and validate test procedures and protocols previously developed for humans for use in dogs and cats. residual samples of citrate anticoagulated blood were used from dogs and cats presented to a specialist referral centre for various reasons unrelated to clotting abnormalities. initially the blood was stimulated using specific combinations of either arachidonic acid/epinephrine (aa/epi) or adp/u , designed to assess the effects of the anti-thrombotic agents aspirin and clopidogrel respectively. after minutes stimulation, the blood samples were fixed using a patented platelet fixative solution developed for human platelets, which allows the delayed analysis of p-selectin an established marker of platelet activation. all analysis was performed by flow cytometry. in order to do this, specific antibodies were selected for the recognition of both canine and feline platelets. cd was used as a platelet identifier antibody while appropriate cd p (p-selectin) antibodies for each species were chosen. fixed samples were repeatedly analysed at time points between to days following fixation to establish the stability of the fixed samples. thirteen dogs and three cats were analysed. high p-selectin expression was detected following stimulation with aa/epi and adp/u in both dogs and cats following fixation. this was significantly different to unstimulated blood (p < . ). there was no significant difference in detectable pselectin expression following storage of the fixed samples at any time-point up to days. this confirmed the fixative was suitable as a preservative of canine and feline platelets. a limited number of dogs were evaluated whilst receiving antithrombotic medication. there was a significant difference in the activation of platelets in the dogs treated with either aspirin (p < . ) or clopidogrel (p < . ) compared with untreated dogs following stimulation with aa/epi (aspirin group) or adp/ u (clopidogrel group). our results show that fixation and delayed analysis of platelet function in dogs and cats is possible for up to days. this demonstrates an exciting opportunity to analyse platelet function remotely and to determine the efficacy of thromboprophylaxis in animals presenting to clinics that do not have on-site platelet analysers. no conflicts of interest reported. several authors consider thyroid hormone supplementation as a valid initial treatment option for dogs with aggression related problems. indeed, mood and behaviour modulating properties of thyroid hormones may, in part, be mediated through the interaction of thyroid hormones with neurohormones such as serotonin and prolactin. at present, prospective trials evaluating neurohormonal status or behaviour in hypothyroid dogs before and after thyroid supplementation are lacking. therefore, the aims of this study were to assess behaviour and measure serum serotonin and prolactin concentrations in dogs with spontaneous hypothyroidism before and after treatment.twenty three client-owned dogs diagnosed with spontaneous primary hypothyroidism were prospectively included in our study. after diagnosis all dogs were treated with levothyroxine ( micrograms/kg bid). behaviour of dogs was screened at initial presentation, at weeks and months after initiation of therapy. owners had to fill in a hard copy of the standardized canine behavioural assessment and research questionnaire (c-barq) consisting of scored questions evaluating seven behavioural categories. the average score on all questions was calculated for each dog at each of the three time periods and a paired t-test was used for comparison. serum serotonin and prolactin concentrations were evaluated at each time period using a commercially validated elisa kit and heterologous ria, respectively.results of the c-barq after six weeks of thyroid hormone supplementation when compared with the time zero demonstrated a significant increase (p < . ) in excitability, activity and aggression, which most likely became unmasked owing to improved overall activity of dogs. conversely, at six months period when compared with the time zero no significant changes in any of the behavioural symptoms were observed. serum serotonin was measured in / dogs colorimetrically at nm. at time zero, weeks and months serum serotonine was . (range, . - . ), . (range, , - . ) and . (range, . - . ). no significant difference was noted between week and month period comparing to time zero (p = . and p = . ). serum prolactin concentration measured in / dogs at time zero, weeks and months was . ng/ml (range, . - . ), . ng/ml (range, . - . ) and . ng/ml (range, . - . ) and did not differ significantly in either time period when compared with time zero (p = . and p = . ).altogether, results of this study failed to demonstrate a significant role of thyroid supplementation on the majority of evaluated behavioural symptoms as well as neurohormonal status of hypothyroid dogs during months of therapy. no conflicts of interest reported. iatrogenic hypothyroidism is a recognized complication of radioiodine treatment of hyperthyroidism in cats, but no prospective studies of the prevalence, clinical features, routine laboratory findings, or results of thyroid function tests have been reported in a series of hypothyroid cats. in this study, we describe the features of hypothyroidism in cats treated with radioiodine over a -month period (october -march ). during this same period, we treated % hyperthyroid cats with radioiodine, providing a prevalence rate of %. hypothyroidism was diagnosed - days (median, days) after i treatment, with doses ranging from - mbq (median, mbq; median pretreatment t , nmol/l). the hypothyroid cats ranged in age from - years (median, years). all were dsh/dlh; ( %) were female and were males (p = . ). clinical signs in these cats included overweight/obesity in ( %), lethargy/dullness in ( %), poor appetite in ( . %), and polyuria/polydipsia in ( %). abnormalities on physical examination included dermatologic signs (dry coat, seborrhea, matting) in ( %) and bradycardia (< bpm) in . twenty-two cats ( %) had no noticeable clinical features of hypothyroidism. routine laboratory abnormalities included hypercholesterolemia (> mmol/l) in ( %) and new or worsening azotemia (> lmol/l) in ( %) and ( %) cats, respectively. median serum concentrations of total t ( . nmol/l; reference interval [ri], - nmol/l), t ( . nmol/l; ri, . - . nmol/l), and ft ( pmol/l; ri, - pmol/l) were all in the low end of the ri. normal ri values for t and ft were maintained in ( %) and ( %) of the cats, respectively. serum ctsh values were high in all cats (median, . ng/dl; range, . - . ng/dl; ri, . - . ng/ml). thyroid scintigraphy showed less-than-normal amounts of residual tissue, as well as low values for thyroid-to-salivary ratio and %-uptake of pertechnetate, in ( %). of those cats with normal scintiscans, serum ctsh decreased into the ri without treatment when retested - months later. in conclusion, this study confirms that i-induced hypothyroidism is not uncommon, with an apparent female sex predilection. serum t and ft remain normal in most cats, but high serum ctsh values and thyroid scintigraphy aid in diagnosis. unless cats have overt, long-standing hypothyroidism, most cats with subclinical disease are relatively asymptomatic, other than worsening azotemia. subclinical hypothyroidism will be transient in some cats, with normalization of ctsh values within a few months. no conflicts of interest reported. iatrogenic hypothyroidism is a recognized complication of radioiodine treatment for hyperthyroidism in cats. at our clinic where we use a variable -i dosing protocol (based on tumor volume and severity of hyperthyroidism), the prevalence of overt or subclinical hypothyroidism is at least %. during the -month period from october to march , we treated cats with iatrogenic hypothyroidism, which had developed - days (median, days) after treatment with radioiodine (median dose, mbq). these cats ranged in age from - years (median, years); all were dsh/dlh; ( %) were female and were males. new or worsening azotemia (> lmol/l) was documented in ( %) and ( . %) cats, respectively. diagnosis of hypothyroidism was based on the following: ) low to low-normal serum concentrations of t , ft , and t ; ) high serum tsh concentration (> . ng/dl); and ) less-than-normal amounts of residual tissue on thyroid scintigraphy. all cats were given thyroid hormone replacement as a liquid l-t preparation (leventa; merck animal health). cats were monitored at - month intervals by repeating serum t and tsh concentrations - hours after the morning l-t dose. ten of the cats were started on a once-daily l-t regimen ( lg); of these, only ( %) had suppression of high serum tsh values into the reference interval (ri). of the cats that had persistently high tsh values, were switched to twice-daily administration ( - lg, bid), which successfully lowered high tsh concentrations in cats. the remaining cats were started on twice daily l-t ( lg, bid); of these, normalization of tsh occurred in cats. overall, l-t treatment was successful in normalizing tsh concentrations in ( %) cats, with once-daily and with twice-daily dosing. peak serum t concentrations of ≥ nmol/l were needed in most cats to normalize tsh values. higher serum t and lower tsh concentrations were achieved when l-t was administered on an empty stomach rather than given with food. a significant decrease (p < . ) in serum creatinine occurred after treatment with l-t . in conclusion, our results indicate that twice-daily administration of l-t is needed in most cats with iatrogenic hypothyroidism to normalize high serum tsh concentrations. many cats appear to absorb l-t rather poorly, which can be enhanced by giving the drug on an empty stomach. the azotemia that commonly develops in cats with hypothyroidism improved or stabilized with adequate l-t supplementation. no conflicts of interest reported. congenital hypothyroidism (ch) has been reported in many species; the hereditary forms can be divided into thyroid dysmorphogenesis and dyshormonogenesis. while thyroid hypoplasia has been described in dogs and cats, the molecular basis remains unknown. in contrast few breeds of dogs with goiterous ch were found to have deficient thyroid peroxidase (tpo) activity. the purpose of our study was to characterize a family of domestic shorthair cats with goiterous ch and disease-causing tpo gene mutations. clinical features included dwarfism and dullness, known as cretinism and seen with ch in all species, but also constipation and megacolon which are unique to cats with ch. pedigree analysis documented an autosomal recessive mode of inheritance. affected kittens developed a goiter and had low serum thyroxine (t ) and triiodothyronine (t ) when compared to controls, but high thyroid stimulating (tsh) hormone levels indicating thyroid dyshormonogenesis. oral thyroid supplementation corrected the progression of clinical signs and prevented further constipation and reversed the megacolon. the tpo enzyme activity was extremely low in hypothyroid cats when compared to that of normal cats. genomic dna and cdna from affected, carrier, and normal cats were extracted and sequenced based upon primers developed from the feline genome database. a homozygous missense point mutation (c. g>a) in tpo, which results in an amino acid change (p.ala thr), was discovered in affected cats and the mutant allele segregated within the family with goiterous ch. this is the first report of a tpo deficiency in cats. other unrelated domestic shorthair cats with goiterous ch did not have this same tpo mutation. the prevalence of this tpo mutation in the domestic cat population seems low, but ch is likely underreported in cats. supported in part by nih od . some of the authors are members of diagnostic laboratories (penngen). supported in part by the nih od # . glucagon-like peptide- (glp- )is a gastrointestinal hormone released in response to food intake that increases insulin secretion, inhibits glucagon secretion, slows gastric emptying and induces satiation. it is also assumed to stimulate beta-cell proliferation. glp- agonists are successfully used in humans with type diabetes mellitus usually either in combination with insulin or other anti-diabetic drugs. in healthy cats twice daily (exenatide) as well as once weekly (exenatide extended-release (er)) application of glp- agonists induced pronounced insulin secretion. benefits of exenatide er are the regimen of once weekly injection and less side effects. the objective of the study was to assess whether administration of exenatide er in addition to standard treatment leads to improved glycemic control and higher remission rates in cats with newly diagnosed diabetes. the study was designed as a prospective, placebo-controlled clinical trial. cats were randomly assigned to two groups receiving exenatide er (group : bydureon â , mg/kg, q d, sc) or . % saline solution (group : q d, sc). both groups additionally received insulin glargine (lantus â , initial dose: ≤ kg: . iu, q h; > kg . - . iu, q h) and diet (purina dm â ). exenatide er was applied over weeks or, in case of remission, for additional weeks after cessation of insulin application. cats were rechecked , , , and weeks after starting therapy. remission of diabetes was defined as absence of clinical signs of diabetes and normal blood glucose and fructosamine concentrations for at least weeks after discontinuing insulin injections. so far cats have completed the study. mild and transient side effects in group (n = ) were reduced appetite (n = ), nausea (n = ), vomitus (n = ), tiredness (n = ) and hiding in dark spots of the house (n = ). in group remission was achieved in / ( %) cats and good metabolic control in / ( %) nonremission cats. in group remission was achieved in / ( %) cats and good metabolic control in / ( %) non-remission cats. median insulin dose given during the study period was . iu/ kg/day in group and . iu/kg/day in group . the preliminary results suggest that exenatide er can be used safely in diabetic cats. a tendency for higher remission rate, better metabolic control and lower insulin requirement was seen when exenatide er was added to the standard treatment regimen. further cases need to be evaluated to verify the potential beneficial role of exenatide er. no conflicts of interest reported. feline diabetes mellitus shares many similarities with human type diabetes mellitus (t dm), including clinical, physiological and pathological features of the disease. domestic cats spontaneously develop diabetes associated with insulin resistance in their middle age or later, with residual but declining insulin secretion. humans and cats share the same environment and risk factors for diabetes, such as obesity and physical inactivity. moreover, amyloid formation and loss of beta cells are found in the diabetic cat pancreas, as in humans. subsequently, studying the molecular mechanisms in the failing beta cells may contribute to a better understanding of the pathophysiology of t dm in both cats and humans. the aim of the present study was to develop a method to study mrna expression of islet-specific genes in healthy and diabetic cats. previous attempts in isolating feline islets with different collagenase-based protocols have led to damaged islets or islets coated with exocrine acinar cells, which either way compromise the results obtained from gene expression studies. by using the laser microdissection technique, we were able to sample islets that were not contaminated with exocrine tissue, from both healthy and diabetic cats. high rna quality was confirmed with gel electrophoresis. by quantitative real-time pcr (qrt-pcr), mrna levels of the islet-specific genes insulin, pdx- , iapp, chga and ia- were detected in both healthy and diabetic cats. we used actin b, gapdh and rps as internal reference genes for normalizations of our qrt-pcr data. the laser microdissection technique allows studies of islets without contamination of acinar cells, as shown in this study, and is of great advantage since it is difficult to get pure feline islets from collagenase-based isolation. differences in gene expression in healthy and diabetic cats may reveal underlying mechanisms for beta cell dysfunction and decreased beta cell mass in human and feline type diabetes. conflicts of interest: the study was financially supported by the swedish juvenile diabetes foundation, the fredrik and ingrid thuring foundation, the magnus bergvall foundation, the lars hierta memorial foundation, and the foundation for research, agria insurance company. feline acromegaly is an increasingly recognised endocrinopathy among diabetic cats, caused by chronic excessive growth hormone secretion by a functional somatotrophinoma in the pars distalis of the anterior pituitary gland. the majority of human somatotrophinomas are sporadic, however up to % of familial isolated pituitary adenomas are caused by germline mutations of the aryl-hydrocarbon-receptor interacting protein (aip). feline acromegaly has phenotypic and biochemical similarities to human familial acromegaly with aip mutations, such as male predominance, somatotroph macroadenoma and resistance to octreotide therapy. the objective of this study was to identify the feline aip gene, identify single nucleotide polymorphisms (snps) within this gene and compare any snps with reported human aip snps. stored pituitary tissue from an acromegalic cat was used to create feline aip cdna using feline specific aip primers. stored edta blood from acromegalic cats (diagnosis of insulin resistant diabetes mellitus, serum igf- > ng/ml and pituitary mass > mm identified using pituitary computed tomography or necropsy) and control cats (no history of diabetes mellitus and greater than years of age) were selected, dna extracted and genotyped using pcr, agarose gel electrophoresis and sanger sequencing. the feline aip gene was identified, encoding a amino acid protein with % homology to the human aip protein. a blast search revealed this gene contained exons and exon specific primers were created to enable sequencing. a single nonconservative snp was identified in exon (aip:c. g>t), encoding for an amino acid change from aspartic acid to glutamic acid in / acromegalic patients and / control cats. two additional conservative snps were also identified (aip:c. t>c and aip:c. t>c). exon encodes for a region of the aip protein considered essential for aip-aip receptor interaction. although different human aip mutations have been identified to date, a human aip:c g>t mutation has not yet been identified. the aip n-terminal is required for the stability of the aip protein-aip-receptor complex, and essential for the regulation of translocation into the nucleus, where it binds to aryl hydrocarbon receptor nuclear translocator leading to activation of genes thought to act as tumor suppressors. loss of normal aip activity is thought to promote somatotrophinoma development. it is therefore possible that the detected aip:c. g>t mutation predisposed to somatotrophinoma tumorigenesis in the two affected patients, and a study containing a larger number of cases is indicated. no conflicts of interest reported. hypersomatotrophism (hs) is an important cause of feline diabetes mellitus (dm). in humans surgical removal of the somatotrophinoma is generally recommended, though hypophysectomy programs have suffered from significant initial morbidity and mortality given a documented steep learning curve in newly established programs. hypophysectomy as treatment for feline hs has thus far only been described in a handful of cases, all having been treated by one single experienced hypophysectomy team. this study's aim was to evaluate the learning curve of a de novo established hypophysectomy program, through analysis of peri-and post-operative morbidity and mortality, and endocrine outcomes in the first cohort of cats with hs treated. from owners of diabetic cats with confirmed hs (igf- > ng/ml, pituitary mass) presented at the royal veterinary college were offered hypophysectomy. all cats undergoing surgery were operated by one neurosurgeon with previously only cadaveric experience of the procedure, through an adapted transsphenoidal approach referencing bony landmarks to computed tomographic scans reconstructed on neuronavigation software. the somatotrophinoma was extirpated using fine surgical tools. all cats received intense electrolyte and blood pressure monitoring, peri-and post-operative ddavp and intravenous insulin and hydrocortisone infusion, transitioning to subcutaneous glargine, conjunctival ddavp, oral hydrocortisone and levothyroxine. between april -february , cats underwent hypophysectomy (median + range age: . years, . - . ; igf- : ng/ml, -> ; pituitary height . mm, . - . ). all displayed uncontrolled dm due to hs (median fructosamine: umol/l); none displayed overt central neurological deficits. two cats ( %, cats and ; pituitary height (mm): . and . ) required mechanical ventilation post-operatively and both were euthanized. post-mortem magnetic resonance imaging revealed brain herniation and cerebral ischaemia was suspected. one cat suffered cardiac arrest post-operatively at time of jugular catheter placement, though made an uneventful recovery. four other cats developed congestive heart failure within days, which was successfully treated not necessitating ongoing therapy. temporarily diminished tear production was seen in cats. seven of the ten surviving cats went into diabetic remission within a median of . days ( - ); others saw reduction of insulin needs by %. serum igf- normalised rapidly and significantly in all but one cat (median serum igf- ng/ml within days). persistent neurological deficits or palatal wound breakdown were not encountered. starting a hypophysectomy program to treat feline hs was associated with some risk of mortality, though surviving cases benefited from the procedure with a high incidence of diabetic remission. no conflicts of interest reported. pituitary dependent hypercortisolism (pdh) in dogs is frequently associated with high serum phosphate and parathormone concentrations. the pathogenesis of such abnormalities remains unknown and the evaluation of the urinary fractional excretion of phosphate and calcium in pdh dogs might be helpful in enhancing the knowledge regarding this issue. the aim of the present study was to evaluate the serum and urinary concentrations and the urinary fractional excretion of phosphate and calcium in dogs with pdh. medical records from one referral center were retrospectively evaluated between and . the diagnosis of pdh was confirmed using the cortisol to creatinine ratio, the ldds test and/or acth stimulation test, the plasma acth concentration, ultrasonography of the adrenal glands and computer tomography (ct) of the pituitary and the adrenal glands in dogs with consistent clinical signs. only newly diagnosed dogs, before treatment for pdh, were evaluated. two control groups were included: one healthy and one sick control dog (without pdh) for each dog with pdh were included. healthy control dogs (hcd) and sick control dogs (scd) were matched for age (ae months), breed, sex and sexual status. data were analysed using non-parametric tests and expressed as median and ranges. significance was set at p < . . one-hundredsixty-seven dogs with pdh were eligible for inclusion in the study. the median age at diagnosis was years (range: - ) and the median body weight was . kg (range: . - . ). there were female ( spayed) and male ( castrated). serum phosphate concentration ( . mg/dl, . - . ) was significantly (p < . ) higher compared to hcd ( . mg/dl, . - . ) and scd ( . mg/dl, . - . ). serum calcium concentration ( . mg/dl, . - . ) was significantly higher compared to scd ( . mg/dl, . - . ) but not different compared to hcd ( . mg/dl, . - . ). urinary fractional excretion of phosphate ( . %, . - . ) was significantly lower compared to hcd ( . %, . - . ) and scd ( . %, - . ). urinary fractional excretion of calcium ( . %, - . ) was significantly higher compared to hcd ( . %, . - . ) and scd ( . %, - . ). urinary calcium to creatinine ratio ( . , - . ) was significantly higher compared to hcd ( . . - . ) and scd ( . , - . ), while urinary phosphate to creatinine ratio were not significantly different in pdh dogs, hcd and scd. in conclusion pdh dogs have lower phosphaturia and higher calciuria compared to control dogs. this findings suggest that, at least in part, the high serum phosphate concentrations are related to the renal retention of phosphate. no conflicts of interest reported. four cortisol-based methods of monitoring trilostane treatment of canine hyperadrenocorticism were compared to the results of a clinical scoring scheme based on an owner questionnaire. cases of canine hyperadrenocorticism that had received a consistent dose of trilostane for more than one month were recruited from first opinion and referral practice. each dog was used only once. owners were asked to complete a questionnaire that assessed clinical control. the dogs were then categorised as being over-controlled, well-controlled, moderately-controlled and poorly-controlled. cortisol was measured in serum samples taken pre-trilostane (peak), hours post-trilostane (trough) and hour post-acth injection. dogs that had an increase in cortisol after trilostane administration were excluded. a scoring system was developed for each of these measurements. a fourth scoring system was developed using a novel algorithm that combined the peak and trough cortisol (peak-trough). the results of each of the scoring systems categorised the dogs into those that would be expected to be over-controlled, well-controlled, moderately-controlled and poorly-controlled. weighted kappa was calculated to assess the agreement between the categorisation according to each of the methods compared to the categorisation using the owners score. the pearson correlation coefficient was calculated to assess relationships between the various parameters. in total tests were analysed. when compared to the results of the owner's questionnaire , , and dogs were correctly categorised using the peak-trough, peak alone, post-acth and trough alone respectively. amongst the miscategorised results , , and dogs were incorrect by category and , , and dogs by categories using the peak-trough, peak alone, post-acth and trough alone respectively. all methods correctly recognised the over-controlled dog that had been identified by the owner's score. the weighted kappas for post-acth and trough cortisol categories compared to the owner score categories were . and . respectively (defined as slight agreement). in contrast the weighted kappas for the peak and peak-trough categories were . and . respectively (defined as fair agreement). there were no significant correlations between the absolute clinical scores and cortisol concentrations. there were significant correlations between the cortisol measurements. the novel methods of peak-trough and peak cortisol better reflected the level of clinical control of hyperadrenocorticism identified by the owners' questionnaire than either post-acth stimulation or trough cortisol. peak-trough and peak cortisol concentrations should be further investigated as monitoring methods for trilostane. financial support from dechra pharmaceuticals. the prognosis of canine adrenocortical insufficiency is generally regarded to be excellent. however, there is paucity of sur-vival analyses in the literature. the aim of the present study was to evaluate the survival of dogs with the diagnosis adrenocortical insufficiency based on data from a cohort of , swedish client-owned dogs insured in one insurance company (agria pet insurance, stockholm, sweden) during the time period - . dogs were identified by search for insurance claims with the register code for adrenocortical insufficiency. dogs were excluded from analysis if they had a previous history of hypercortisolism, and if they were born before begin of the study period. kaplan-meier survival analysis was performed. dogs were regarded as censored when the registered cause of death was other than adrenocortical insufficiency or hypercortisolism that was registered after the first claim for adrenocortical insufficiency. data from dogs was included. one hundred twenty-four dogs were registered to be dead. in dogs the cause of death was related to the adrenocortical insufficiency. the -year estimated survival-rate was % ( % ci, - %). the -year estimated survival-rate was % ( % ci, - %). the -year estimated survival-rate was % ( % ci, - %). twelve dogs ( . %) were still alive after years. in conclusion, the long-term survival of dogs with adrenocortical insufficiency was reasonably good. however, the diseases-related mortality was higher than expected, and occurred mainly during the first years after diagnosis. conflicts of interest: this study was supported by grants from the swedish research council and the foundation for research, agria insurance company. the concomitant occurrence of two or more endocrine tumors and/or hyperplasias, known as multiple endocrine neoplasia (men) is a well-known entity in humans. multiple gene mutations have been identified. the two major forms are men and men . in men , the main affected organs are parathyroid, pancreas and pituitary gland. men occurs in clinical variants: men a, characterized by medullary thyroid carcinoma (mtc), pheochromocytoma and primary hyperparathyroidism; men b, characterized by mtc, pheochromocytoma and additionally abnormalities; familial medullary thyroid carcinoma. in dogs and cats only a few cases have been reported and it is unknown whether hereditary men-like syndromes exist in these species. the aim of this study was to evaluate the prevalence of multiple endocrine tumors in dogs and cats at our institution, to identify possible breed and sex predispositions and to investigate similarities with the human men syndromes. autopsy reports of dogs and cats from until were reviewed. animals with at least two endocrine tumors/hyperplasias (eth) were included. autopsy reports of dogs and cats were examined. dogs had eth affecting a single organ, had multiple eth; cats had single eth, had multiple eth. in dogs with multiple eth, the most common breeds were west highland white terrier (whwt, / ), poodle, golden retriever, mixed-breed dogs (each / ). / were male ( intact); / were female ( neutered). median age was years (range - ). the most common combination was multiple testicle tumors of various types ( / ). the most common affected organs were the adrenals ( / ). adrenal cortical adenomas/carcinomas/hyperplasias were mainly associated with pheochromocytomas ( / ), testicle tumors ( / ) and insulinomas ( / ). all whwts had adrenal adenomas. both poodles had pheochromocytoma associated with pituitary adenoma or adrenal hyperplasia. dogs showed tumor combinations similar to the human men syndrome: pituitary adenoma and insulinoma; pituitary adenoma and parathyroid hyperplasia. / cats were domestic short/long hair, / were persians. / were male ( castrated); / were female ( neutered). the median age was . years (range - ). the most common affected organs were thyroid glands ( / ), combined mostly with lesions of parathyroid ( / ) and adrenal glands ( / ). none of the cats had combinations similar to the human men syndromes. the prevalence of multiple eth in dogs and cats was . % and . %. men-like syndromes were extremely rare in dogs and non-existing in cats. no sex predisposition was observed. possible breed predispositions need further investigations. no conflicts of interest reported. canine angiostrongylosis is an increasingly reported disease worldwilde, including many european countries, possibly due to climatic factors, presence of foxes (acting as reservoir) or more simply, to the availability of more accurate diagnostic methods. although detection of the first-stage larvae (l ) using the baermann technique on faecal samples (preferably collected over three consecutive days) remains the gold standard, recently developed serological and molecular tests (quantitative polymerase chain reaction, qpcr) are now available. until now, the prevalence of canine angiostrongylosis among healthy and coughing dogs in belgium was unknown. the aims of the present study were ( ) to describe a clinical series of recent autochtonous cases and ( ) to retrospectively assess angiostrongylus vasorum qpcr in bronchoalveolar lavage fluid (balf) samples, collected over the last years from a larger series of dogs, healthy or with other respiratory conditions, in order to investigate the past prevalence of the disease in belgium. seven dogs, living in southern or eastern belgium, were recently diagnosed as having angiostrongylosis (mean age= . y, mean body weight= . kg). they all presented with respiratory signs of variable severity. in dogs, balf was obtained and qpcr was positive in all of them, at moderate or high level (ct from , to , ) while larvae were detected in the faeces of only animals. in the remaining two dogs, no balf was obtained, but coproscopy was positive. all dogs responded to medical treatment, consisting in a -week course of fenbendazole and/or two spot-on application of moxidectin at -month interval. balf samples were collected between and from asymptomatic client-owned dogs and dogs with various respiratory conditions, including dogs with confirmed bordetellosis, dogs with eosinophilic bronchopneumopathy (ebp), dogs with chronic bronchitis and dogs with bacterial bronchopneumonia, and were retrospectively assessed with a a. vasorum qpcr assay. amongst those dogs, only one balf, from a dog with ebp, yielded a positive qpcr result. in this dog, faecal analysis was negative. the present data show that, based on balf qpcr and coproscopy, presence of angiostrongylosis in healthy and coughing dogs was negligible in belgium until the last months. it is now considered as an emerging condition and must be included in the differential diagnosis in coughing dogs. the present results also support that qpcr detection of a. vasorum in balf, when available, is an adequate and reliable detection technique. no conflicts of interest reported. ligneous membranitis is a rare chronic inflammatory disease associated with congenital plasminogen deficiency. it has only been described in six unrelated dogs. the objective of this study is to report the presentation, clinicopathological and post mortem findings in three related scottish terrier puppies with ligneous membranitis. ligneous membranitis is well described in humans, where it is inherited in an autosomal recessive manner. patients commonly present as infants. ocular, oral and genital lesions are most common, but other organs are occasionally involved and congenital obstructive hydrocephalus is reported in some individuals. numerous mutations and polymorphisms in the plasminogen gene have been identified in affected individuals. the affected scottish terriers (two male and one female) presented at months of age with severe proliferative and ulcerative conjunctivitis and gingivitis/stomatitis; biopsy confirmed ligneous membranitis. other clinical signs included increased upper respiratory tract noise, nasal discharge and lymphadenopathy. one male was cryptorchid. clinical pathological findings included neutrophilia, proteinuria and hypoalbuinaemia. serum plasminogen activity was measured in two dogs, and was low in one. the dam and sire of the affected dogs had normal serum plasminogen activity and no history or clinical signs consistent with ligneous membranitis. no significant clinical improvement was evident following treatment with antibiotics, glucocorticoids, topical ciclosporin or heparin. one dog died of cardiopulmonary arrest in the hospital and the two other dogs were euthanized due to progressive clinical signs. post-mortem evaluation of the affected dogs revealed multiple abnormalities including severe proliferative fibrinous lesions affecting the trachea, larynx and epicardium, and multiple fibrous adhesions throughout the thoracic and abdominal cavities. the male dog had internal hydrocephalus and lacked a cerebellar vermis. this is the first report of ligneous membranitis in related dogs and the first report in scottish terriers. sequencing the plasminogen gene in the affected dogs, their parents and unrelated control dogs to identify polymorphisms or mutations that may be associated with ligneous membranitis in dogs is ongoing. the author received a travel scholarship from zoetis to attend this congress. health screening of elderly dogs is often recommended, but scientific information on clinical and laboratory abnormalities in senior and geriatric dogs is scarce. this study was undertaken to describe blood pressure measurement, physical examination (pe) abnormalities and routine laboratory test results in senior and geriatric dogs that were apparently healthy for the owner. because life expectancy in dogs is related to body size, the inclusion of dogs was based on a human/pet analogy chart to determine whether a dog was senior (n = ) or geriatric (n = ). to verify health status, owners were asked to complete an extensive questionnaire. systolic blood pressure (sbp) was measured using the doppler technique according to the acvim guidelines. subsequently a thorough pe was performed, including body and muscle condition scoring, orthopedic examination, neurologic evaluation, indirect fundoscopy and bilateral schirmer tear test. complete blood count, serum biochemistry and urinalysis (including urinary sediment, urinary protein:creatinine ratio (upc) and bacterial culture) were evaluated. in of dogs sbp exceeded mmhg, none of the dogs had fundoscopic lesions secondary to hypertension. body condition score was abnormal in animals, were overweight or obese. physical examination revealed a heart murmur in , submandibular lymphadenopathy in , moderate to severe dental plaque in and one or more (sub)cutaneous masses in dogs. twenty-three dogs were leukopenic, had a decreased phosphorus, an increased serum creatinine and one dog a decreased total thyroxine (with concurrent increased thyroid stimulating hormone). crystalluria was commonly detected ( / ) and mostly due to low numbers (< /high power field) of amorphous crystals ( %). struvite crystals were present in % of the crystalluric dogs. overt and borderline proteinuria were detected in and of dogs, respectively. four dogs had a positive urinary culture. sbp was not significantly different between the senior and geriatric group. there was no significant effect of obesity or gender on sbp. the platelet count (p = . ), total thyroxine concentration (p = . ) and the frequency of orthopedic problems (p = . ) and cutaneous masses (p = . ) were significantly higher in the geriatric compared to the senior dogs. hematocrit (p = . ) and body temperature (p = . ) were significantly lower in the geriatric group. these findings indicate that physical and laboratory abnormalities are common in apparently healthy senior and geriatric dogs. this underlines the necessity for regular health screening in elderly dogs and the urgent need for reliable and maybe age specific reference intervals in veterinary medicine. the cost of examinations reported in this study were covered by hill's pet nutrition belgium. systemic lupus erythematosus, sle, is a chronic autoimmune disorder with varying clinical manifestations and diagnosis is based on both clinical signs and laboratory findings. other systemic rheumatic diseases, referred to as sle-related diseases or immune-mediated rheumatic disease (imrd), are also described. the most common clinical signs in dogs are stiffness and pain from varying joints. one hallmark of sle and sle-related diseases in both dogs and humans is high titres of circulating antinuclear antibodies (ana), which can be demonstrated by the indirect immunofluorescence (iif) ana test. earlier studies have shown that canine iif ana positive samples may be divided into two main subgroups: homogenous (ana h ) and speckled (ana s ) iif ana fluorescence pattern. in humans, further determination of the specificity of ana positive sera is frequently employed to characterize the ana reactivity. some of these ana specificities have been demonstrated in man to strongly associate with different systemic autoimmune diseases and also with different iif ana staining patterns. presence and character of antinuclear antibodies in canine sle-related diseases are not well described. the aim of this work was to further characterize the ana specificity in dogs with sle-related disease/imrd. sera from anapositive dogs, including different breeds, were analyzed with elisa and line blot techniques (elisa and euroline ana profile, euroimmun, germany). the five most prevalent breeds were german shepherd dog, nova scotia duck tolling retriever, cocker spaniel, crossbreed and golden retriever. sera displayed a homogenous and a speckled iif ana fluorescence pattern. several specific ana-reactivities earlier characterized in human patients were identified. the majority of ana h , n = , %, showed reactivity against nucleosomal antigens and ( %) against dsdna when conducted on line blot. these sera also reacted against nucleosomes and dsdna on the elisa. there were some additional positive with the elisa, so in total the elisa identified % with nucleosomal and % with dsdna reactivity. in few cases, other reactivities identified were against histones, pcna, jo- and rnp. in the ana s subgroup, the sm+rnp antigen evoked the most frequent reactivity, n = , % with both line blot and elisa. in few cases, reactivity against dsdna, pcna, jo- , pmscl kd, scl- , ssa and ssb were identified. in several dogs no specific antigen was identified. further studies are in progress in order to in more detail characterize and identify subtypes of already known and unknown antigens with clinical importance in canine autoimmunity. one of the authors, erik lattwein, is employed by euroimmun where the analyses were performed. chronic kidney disease (ckd) has a high prevalence in cats. routine renal markers, serum creatinine (scr) and urea are not sensitive or specific enough to detect early ckd. serum cystatin c (scysc) has advantages over scr for the detection of early kidney dysfunction, both in humans and dogs. a significant higher scysc concentration in ckd cats has been demonstrated. the objective of this study was to determine the effect of age, gender and breed on feline scysc and to establish a reference interval for feline scysc. in total, healthy cats between one and years were included. serum cysc was determined with a validated particleenhanced nephelometric immunoassay (penia). serum cr, urea, urine specific gravity (usg), urinary protein: creatinine ratio (upc) and systolic blood pressure (sbp) were also measured. to test for difference between the groups, the f-test was used. the lower and upper value of the % reference interval were obtained as the . % and . % quantiles of the scysc observations. no significant differences in scysc concentration were observed between young, middle-aged and old cats; between female, female neutered, male and male neutered cats; and between purebred and domestic short-or longhaired cats. the % reference interval for feline scysc was determined as [ . - . mg/l]. there was a significant difference in scr concentration between domestic short-or longhaired cats and purebred cats. the sbp was significantly influenced by gender as well as age, while urea was influenced by both age, gender and breed. this study showed that the biological factors age, gender and breed have little or no impact on feline scysc, in contrast to scr and serum urea, making it an interesting marker. therefore, further studies are warranted to evaluate the diagnostic value of scysc as a renal marker in cats. this study recieved support from the institute for the promotion of innovation by science and technology in flanders (iwt) through a bursary to l. ghys. assessment of renal function is often needed, however existing methods including urine and plasma clearances are invasive, cumbersome and time consuming. in this pilot study the feasibility of a transcutaneous glomerular filtration rate measurement was investigated. the transcutaneous disappearance rate (expressed as half-life) of fluorescein-isothiocyanatelabelled sinistrin (fitc-s) was measured in three healthy research dogs and three healthy research cats. plasma clearance of sinistrin ( data points) was performed in both species as previously described (res vet sci ; : - and j fel med surg ; : - ) and half-life was calculated using a -compartment model with a freely available pharmacokinetic calculator (comput meth prog bio ; : - ) . renal elimination of fitc-s was measured transcutaneously for hours ( - data points) using a miniaturized device as described previously for the same purpose in rats (kidney int : - ). the procedures were performed in awake, freely moving animals using escalating doses of fitc-s ( mg/kg, mg/kg, mg/kg) with a wash-out period of at least h in each animal. to find the best position for the device, multiple devices were placed on each animal. the resulting fitc-s disappearance curves were visually assessed to determine the most suitable location and the appropriate dose to reach an adequate transcutaneous peak signal for kinetic analysis. in both species mg/kg were adequate for kinetic calculation. the most suitable place for the device was the lateral thoracic wall in dogs and the ventral abdominal wall in cats, respectively. transcutaneous fitc-s clearance was then repeated using the optimal dose and location and in parallel with the plasma sinistrin clearance. plasma sinistrin clearances [ml/kg/min] were . , . and . in the three dogs, respectively. corresponding plasma elimination half-lives [min] were , and , and corresponding transcutaneous elimination half-lives [min] were , and , respectively. plasma sinistrin clearances [ml/kg/min] were . , . and . in the three cats, respectively. corresponding plasma elimination half-lives [min] were , and , and corresponding transcutaneous elimination half-lives [min] were , and , respectively. in conclusion, transcutaneous fitc-s clearance is a feasible method for assessment of gfr in awake dogs and cats. it is noninvasive, well tolerated and easy to perform even in a clinical setting with results being readily available. a dose of mg/kg of fitc-s seems adequate for kinetic assessment. further studies are now needed to establish reference values and evaluate transcutaneous renal clearance in various conditions. conflicts of interest: zhp and sg are supported by the ec fp marie-curie programme: nephrotools. the device development was supported by the fp activity: place-it.ng is owner of a patent covering fitc-sinistrin and the technology for its measurement. excretion of urinary biomarkers of renal damage should occur at an early stage of chronic kidney disease (ckd), thus facilitating earlier diagnosis of renal disease. albumin and cystatin c in the renal ultrafiltrate are mostly reabsorbed by the proximal tubular cells, therefore increased urinary excretion of albumin and cystatin c (uac and ucysc) would be expected to correlate with the presence of renal tubular damage and ckd. the aim of this study was to establish biological validity of two particle enhanced turbidimetric assays (petias) for the measurement of albumin and cystatin c (previously validated for use in feline urine) by comparing the uac and ucysc between non-azotaemic cats and cats with azotaemic ckd. blood and urine samples were obtained from cats at three uk first opinion practices as part of a geriatric screening programme. haematology, serum biochemistry (including total thyroxine concentration (tt )) and urinalysis (including urine protein:creati-nine ratio (upc)) were performed. dental disease score (calculus and gingivitis) and body condition score (bcs) were recorded. cats with tt > nmol/l, evidence of pyuria or bacteruria, or significant systemic disease were excluded. uac and ucysc were determined in non-azotaemic cats (n = ) and cats with azotaemic ckd (n = , defined as a serum creatinine concentration > lmol/l and concurrent urine specific gravity < . ). comparisons between the non-azotaemic and azotaemic ckd groups were made using the mann whitney u test. correlations were assessed by spearman's correlation coefficient. data are presented as median [ th , th percentile] and statistical significance was defined as p < . . uac was significantly higher in the azotaemic group than the non-azotaemic group ( . [ . , . ]x - vs. . [ . , . ]x - ; p = . ), whereas upc was not significantly different between the groups (p = . ). unexpectedly, ucysc tended to be lower in azotaemic cats than non-azotaemic cats ( . [ . , . ]x - vs. . [ . , . ]x - ; p = . ). uac was weakly positively correlated with serum urea concentration (r s = . , p = . ), but was not correlated with serum creatinine concentration. ucysc was not significantly correlated with serum concentrations of urea, creatinine or tt . uac was also weakly negatively correlated with dental calculus score (r s = - . ; p = . ) and bcs (r s = - . ; p = . ). uac appears to be a more sensitive test for azotaemic ckd than upc, however the apparent low specificity may limit the utility of uac as a urinary screening test for ckd. increased ucysc (determined by petia) would not appear to be a marker of azotaemic ckd in cats. no conflicts of interest reported. cystinuria is an inherited metabolic disorder that causes defective tubular reabsorption of the aminoacids cystine, ornithine, lysine and arginine (cola). the low solubility of cystine in acidic urine promotes formation of cystine crystals and uroliths in the urinary tract resulting in the clinical signs of stranguria, urinary obstruction and renal failure in affected individuals. cystinuria occurs in > breeds of dog and has been classified into types ia (newfoundland, landseer, labrador), iia (australian cattle dog), ib (miniature pinscher) and iii (androgen-dependent; e.g. mastiff, irish terrier). the kromfohrl€ ander is a medium-sized companion dog, bred initially as a cross between a wire fox terrier and a grand griffon vend een, first recognised internationally in . cystinuria has been suspected in this breed but no cases have been reported in the literature to date. we determined urinary cola concentrations in adult kro-mfohrl€ ander dogs aged - years comprising intact and castrated males, and intact and spayed females. a total of ( %) intact males aged . to . years had cola values > lmol/g creatinine and several developed cystic calculi. furthermore, intact male dogs had increased cola but normal cystine levels. all castrated males had normal cola concentrations. no females had increased cola and cystine concentrations or formed any cystine calculi. we conclude that cystinuria with cystine calculi occurs frequently in adult intact male kromfohrl€ ander dogs but neither is seen in females. this appears to be an androgen dependent type iii cystinuria, as seen in mastiff-type dogs and irish terriers. thus, castration may resolve the increased urinary cola excretion and risk for cystine calculi formation and obstruction. the precise mode of inheritance is still unclear. all adult intact male kromfohrl€ ander dogs should be screened by urinary cola testing. work carried out at the author's previous place of employment (university children's hospital, frankfurt, germany). acs, rk, em, md and ug provide a diagnostic service for cystinuria and other inborn errors of metabolism in companion animals. ureteral urolithiasis is an emerging medical concern in cats. there are few reports on epidemiology, diagnosis or medical management of ureteral calculi in cats, particularly in europe. cats diagnosed with ureteral urolithiasis in the teaching hospital of the veterinary school of alfort from to were included in this study. diagnosis was confirmed with radiographs, ultrasound scan and/or laparotomy. signalment, clinical signs, clinicopathologic and diagnostic imaging findings, medical treatment and outcome were recorded. epidemiological data were compared to a reference population of cats. eighty three cats were included in the study. the occurrence of ureteral urolithiasis was significantly higher in birman to the author knowledge, it is the first time that a higher prevalence of ureteral calculi in birman cats is reported in europe. spontaneous elimination of calculus is associated with a small size (< . mm). if the size of calculi tends to be bigger in cats with no improvement of renal function after medical treatment, prospective studies are still needed to determine the best medical treatment. no conflicts of interest reported. feline immunodeficiency virus (fiv) infection has been associated with kidney disease, mainly characterised by an increased prevalence of proteinuria in fiv-infected cats. however, studies evaluating renal variables in fiv-positive cats are scarce. recently, a higher systolic blood pressure (sbp) was reported in a small number of fiv-infected cats. hypertension is an important cause of proteinuria and a frequent cause of renal disease in human immunodeficiency virus (hiv) positive patients. therefore, our main objective was to describe sbp in clinically ill fivpositive cats. secondly we aimed to evaluate routine renal variables in this population. naturally infected clinically ill fiv-positive cats were prospectively included. the doppler ultrasonic technique was used to measure sbp according to acvim guidelines. serum creatinine (screat) and urea (surea) concentrations, urine specific gravity (usg) and urinary protein:creatinine ratio (upc) were determined. the study included cats, with a mean age of . ae . years and a mean body condition score of . ae . on a nine-point scale. the sbp ranged from to mmhg, with a mean of ae mmhg. only two cats were hypertensive (sbp > mmhg). both had isosthenuric urine, were borderline proteinuric (upc . - . ) and one of them was mildly azotemic. mean screat was . ae . lmol/l (reference interval (ri) . - . lmol/l) and mean surea concentration . ae . mmol/l (ri . - . mmol/l). thirteen cats showed increased screat levels, with decreased usg (< . ) in eight, proteinuria (upc > . ) in seven and increased surea concentrations in ten of them. five out of ten azotemic cats were proteinuric with a decreased usg. mean upc was . ae . , with a wide range from . to . . borderline proteinuria was present in / ( . %) and proteinuria in / ( . %). half of the proteinuric cats had a decreased usg. mean usg was . ae . . one third of all cats had a decreased usg, with isosthenuria in seven of them. these results demonstrate that proteinuria and poorly concentrated urine are common in naturally infected clinically ill fivpositive cats, confirming previous reports in cats and humans. however, longitudinal studies of (borderline) proteinuric patients are needed to elucidate the clinical relevance. the low number of hypertensive patients and low mean sbp in our study indicate that hypertension is uncommon and unlikely to be the cause of renal damage in clinically ill fiv-infected cats. aratana therapeutics nv financially supports a clinical trial on the use of antivirals in fiv cats at our university. screeninng examinations repoorted in this trial were part of the required pre-trial investigations for that study. the presenting author is also funded by a scholarship from aratana therapeutics av. the objective of this study was to identify the prevalence of bacterial species and the susceptibility of isolates to doxycycline, trimethoprim-sulfamethoxazole (tms), ampicillin, amoxicillinclavulanic acid (amc), cephalothin, and enrofloxacin in cats with urinary tract infections (uti) with and without predisposing comorbidities. a retrospective analysis of case records between and was performed and resulted in inclusion cats into the study: cats with a systemic comorbidity, cats with indwelling urinary catheters, cats with other local comorbidities, and cats with no comorbidity. the most commonly isolated bacteria were escherichia coli (e. coli), streptococcus species (spp.), staphylococcus spp., and enterococcus spp.. the proportion of gram-negative isolates was significantly higher in the cats with systemic comorbidities than in cats with indwelling urinary catheters (p < . ) and cats with other local abnormalities (p < . ), whereas gram-positive isolates were significantly more commonly isolated from cats with indwelling urinary catheters and other local comorbidities than in cats with systemic comorbidities (p < . ). the proportions of isolates susceptible to amc, enrofloxacin, and tms and the antimicrobial impact factors (if) were higher than the proportions of isolates susceptible to doxycycline, ampicillin, and cephalothin and the respective if. based on these findings, amc and tms would be the firstchoice antimicrobial agents for empiric treatment of bacterial the increasing rates of resistance exhibited by uropathogens represent a serious problem for the selection of an appropriate antibiotic. the aim of this study was to determine secular trends of companion animal urinary tract infection (uti) that involve extended-spectrum b-lactamase (esbl)-and carbapemenase-producing gram negative bacteria (namely, escherichia coli, klebsiella pneumoniae, proteus mirabilis, acinetobacter baumannii), methicillin-resistant-staphylococci (mrs) and ampicillin and high-level-gentamicin-resistance (hlgr) enterococci. nine hundred and twenty two uropathogenic bacteria were isolated from dogs and cats, between january and march , at the veterinary teaching hospital of the faculty of veterinary medicine and at veterinary private practices in the lisbon area. isolates were identified using standard commercial systems. susceptibility testing was performed using the disk diffusion and broth microdilution methods. clsi breakpoints were applied. extended-spectrum b-lactamases (esbl) production was screened by double-disk synergy test. the esbl, plasmid-mediated ampc, carbapemenases, meca and aac( ')-ieaph( '')-ia genes were detected by pcr and gene enzymes were sequenced. among enterobacteriaceae . % were dhaproducers, . % were esbl-producers and . % were cmyproducers. all isolates were also multidrug-resistant. cefalosporinases-producer enterobacteriaceae were detected in , the first being a cmy- -producer e. coli. all the esbl-producers were e. coli or k. pneumoniae producing ctx-m-group enzymes. ampicillin-resistance in enterococci was present throughout the years ( , %, n = ). hlgr appeared in enterococci in and was confirmed by the detection of the bifunctional enzyme that confers high level resistance to aminoglycosides ( out of isolates). in this study we showed that in the last decade the emergence of resistance to critically important antimicrobials among uropathogens from companion animals is a concerning fact. the multidrug-resistant enterobacteriaceae may compromise effective therapeutic options, namely third and fourth generation cephalosporins, fluoroquinolones, trimethoprim/sulpha combinations. the emergence of mrsa/mrsp and hlgr among uropathogens is also a therapeutic challenge. the detection of uropathogens with antimicrobial resistance is not only an animal health issue but also a matter of public health, since companion animals may act as reservoirs of antimicrobial resistant bacteria or resistance genes for humans. the author currently receives a phd grant funded by the portuguese foundation for science and technology. in the past, the author received once research support and honoraries from portuguese merial for a project on canine vector borne diseases. the aim of the present study was to use insurance data to estimate morbidity and mortality related to kidney disease in the swedish dog population. insurance company data from veterinary care-insured and lifeinsured dogs during the years - were studied retrospectively. incidence-and mortality rates were calculated for the whole group of dogs as well as divided by sex and breed. for the breeds with the highest incidence-and mortality rates, respectively, the reasons for kidney disease were investigated by dividing the diagnoses into ethiology groups. the total number of veterinary care-insured dogs was , . the total incidence rate of kidney disease in this group of dogs was . ( . - . ) cases/ , dog-years at risk. the number of dogs in the life insurance was , and in this group the total kidney-related mortality rate was . ( . - . ) deaths/ , dogyears at risk. the most commonly reported ethiologies of kidney disease were "ethiology not determined"and "infectious/ inflammatory". the breeds with the highest incidence rate of kidney disease were the bernese mountain dog, miniature schnauzer and boxer. the breeds with the highest mortality caused by kidney disease were the bernese mountain dog, shetland sheepdog and flatcoated retriever. in conclusion, the epidemiological information provided in this study concerning kidney disease in dogs can assist clinicians in establishing diagnoses, and can assist breeders in defining priorities for preventative measures. it can also provide valuable information for future research. the senior author has received money from the insurance company we have used data from to write our study, for another project. jens h€ aggstr€ om and ingrid ljungvall have received financial support for research from sante animale, agria insurance ltd, sveland insurance ltd, forsgren research foundation. both of these authors have also undertaken paid consulatcny work for boehringer-ingelheim, ceva sante animale. mast cell tumours represent the most common cutaneous tumour in the dog. diagnosis of a mast cell tumour can be achieved through cytological examination of fine needle aspirate. however the grade of the tumour is an important prognostic marker and requires so far histologic assessment. a -tier histologic grading system based on number of mitoses, multinucleated cells, bizarre nuclei and karyomegaly was recently proposed by kiupel et al. the aim of this study was to assess if the cytomorphological criteria proposed in the -tier histologic grading system are applicable on cytology specimens. ninety-three mast cell tumour specimens of grade i or grade iii according to patnaik with both histological specimens and fine needle aspirates were retrospectively taken from a data set and histologically and cytologically re-evaluated. according to the kiupel grading system thirty-six were diagnosed histologically as high grades and fifty-seven were considered low-grade mast cell tumours. the cytologic examination of the corresponding specimens revealed thirty-one high grade and fifty-five low-grade tumours. an agreement between histologic and cytologic diagnosis based on the kiupel grading system was achieved in eighty-six cases (accuracy . %, specificity . %, sensitivity . %). five high-grade tumours ( . %) were considered as low grade on cytology. cytologic grading of mast cell tumours in the dog has satisfactory accuracy, sensitivity, and specificity. histologic grading of canine mast cell tumours still remains the gold standard, but cytology already gives reliable information. no conflicts of interest reported. in canines mastocytomas are among the most frequently diagnosed neoplasms of the skin. high grade mastocytomas (grade iii, patnaik classification) are characterized by an uncontrolled growth of neoplastic mast cells (mc) and a poor prognosis. recently, the kit-targeting tyrosine kinase inhibitors masitinib and toceranib have been approved for the treatment of canine mc tumors. these drugs are able to induce responses in mastocytoma patients. however, in many patients, relapses are seen. therefore, research is focusing on new drug targets. recently, the transcription factor stat has been reported to play an important role in the proliferation and survival of human neoplastic mc. the aim of the present study was to evaluate the jak -stat pathway in canine mastocytomas. to address this aim, the canine mastocytoma cell lines c and ni- as well as inhibitors directed against jak or stat were employed. as assessed by immunocytochemistry, c cells and ni- cells were found to express pstat in their cytoplasm and nuclei. intracellular expression of pstat was confirmed by flow cytometry. interestingly, c cells were found to express higher levels of pstat compared to ni- cells. next, we treated c cells and ni- cells with various concentrations of the stat inhibitors piceatannol and pimozide and the jak inhibitors azd and tg . as assessed by h-thymidine uptake, all compounds were found to inhibit the proliferation of canine mc in a dose-dependent manner. drug effects were found to vary in different cell lines, with the following rank-order of potency (ic values): tg : . - . lm; pimozide: . - . lm; azd : - lm; piceatannol: - lm. to further explore the mechanism of drug-induced inhibition of proliferation, we examined cell cycle progression and apoptosis in drug-exposed cells. whereas all drugs tested induced only moderate cell cycle arrests in the g phase, these drugs were found to induce substantial apoptosis in c cells and ni- cells as evidenced by microscopy and annexin-v/pi staining. together, our data show that jak -and stat -targeting drugs exert anti-proliferative and apoptosis-inducing effects in canine mastocytoma cells suggesting that this signaling pathway may be a promising new therapeutic target in canine mastocytomas. the clinical relevance of this observation remains to be determined. no conflicts of interest reported. subcutaneous mast cell tumours (sqmct) in dogs are relatively uncommon compared to their cutaneous counterparts. the veterinary literature describes these tumours as a specific pathological entity with, in general, a low probability of aggressive progression. surgery is considered the main treatment modality, while medical treatment has not been described. the purpose of this study was to determine progression free survival (pfs) for a chemo na€ ıve cohort of dogs presented with non-resectable and/ or metastasized sqmct, which all underwent masitinib-based therapy. data were collected for patients with sqmct presented to participating centres in the netherlands and the uk from / / to / / , which received masitinib-based therapy. treatment protocols employed, included masitinib alone (m), masitinib and prednisolone (mp), masitinib plus vinblastine and/ or lomustine and prednisolone (mpc). response to therapy was measured conforming to recist . . adverse events were graded using vcog-ctcae . . patients were grouped according to presence or absence of metastasis, treatment protocol used, previous surgery, and remission status achieved; simple comparisons were made to evaluate possible significance. twenty-five cases were identified. / were female. median age of occurrence was years ( - ). diagnosis was made by histology in / ; proliferation indices were defined in only dogs. fourteen cases exhibited metastasis at initiation of therapy. pfs for all cases ranged from - days. median/mean pfs (days) according to treatment was m: / d (n = ), mp: / d (n = ), mpc: / d (n = ). median/mean pfs according to metastasis status was m : / d (n = ) and m : / d (n = ). dogs who underwent previous surgery (n = ) had a median/mean pfs of / d compared to those who had no surgery / d. looking at remission status, median pfs of patients who achieved a complete remission was not reached, with a mean pfs of d (n = ). median/mean pfs of patients with partial remission was / d (n = ), stable disease / d (n = ), and progressive disease / d (n = ). / cases experienced suspected adverse events. three dogs, two of which ultimately died, had seven grade - adverse events (anaemia (n = ), hepatotoxicity (n = ), gastrointestinal toxicity (n = )). masitinib-based treatment is effective in the management of sqmct perceived to be aggressive. patients do not appear to benefit from prior surgery. metastatic status did not influence outcome. adding chemotherapy negatively influenced pfs. complete remission is a very favourable prognostic development. the authors have received financial support from ab science to help with the costs of statistical analyses in an unrelated project advances in distinction between morphological subtypes of canine non-hodgkin's lymphomas (nhl) have provided a better understanding of this cancer in dogs. diffuse large b-cell lymphomas (dlbcl) are the most frequent form of nhl in dogs including some distinguished morphological subtypes (mainly centroblastic polymorphic and immunoblastic) according to the who classification. few clinical studies reported dlbcl clinical outcomes under treatment while survival times of the centroblastic polymorphic subgroup were reported. the aim of this retrospective study was to evaluate the response of dlbcl to a standardized multi-agent chemotherapy protocol. medical records from dogs with a diagnosis of dlbcl between and were retrospectively reviewed. inclusion criteria were the availability of complete initial and follow-up information and the application of a standardized multi-agent l-cop chemotherapy protocol as previously described. dogs which received corticosteroids before the initiation of treatment and dogs which died for other reasons than their related disease before the end of the induction period ( d) were excluded. response to chemotherapy was evaluated every week during the induction of treatment, then every to weeks. statistical analysis was performed using kaplan-meier analysis. thirty cases of dlbcl meeting all inclusion criteria were included from the initial population. seven dogs were in clinical stage iii according to the who classification, in stage iv and in stage v. nineteen dogs were in substage a, and in substage b. on dogs which have an adequate response evaluation, dogs ( . %) achieved a complete remission. the median and mean duration of first remission were d and d, respectively (range - d). the median and mean durations of survival time were respectively d and d (range - d). one year and -years survival rates were % and % respectively. according to the statistical analysis, neither clinical stage (p = . ) nor substage at presentation (p = . ) or morphological subtype (immunoblastic vs centroblastic polymorphic, p = . ) were considered as a significant prognostic factor regarding the duration of the first remission and the overall survival time. a complete response was significantly associated with longer survival times (p = . ). to conclude, the dlbcl displayed a good clinical response to l-cop protocol, with a median survival time of days. the only significant prognostic criterion identified was a complete clinical response to the treatment. a prospective controlled study on a larger population is warranted to confirm these results. no conflicts of interest reported. canine histiocytic sarcoma (hs) is an aggressive round cell neoplasm with a poor prognosis. both lomustine and doxorubicin have been evaluated as first line chemotherapy agents with response rates of up to % and median survival times around - months. the aim of this study was to evaluate the response to epirubicin in a population of dogs with hs pre-treated with lomustine. medical records of dogs with a diagnosis of hs that were treated with lomustine and subsequently epirubicin were retrospectively evaluated. fifteen dogs received lomustine followed by epirubicin. there was a measureable response to lomustine in seven of dogs with evident disease, % ( cr & pr). an additional dogs achieved stable disease for an overall biological effective response of %. median ttp following lomustine could be assessed in dogs and was days (range - ). all fifteen dogs received epirubicin as a rescue agent: nine following progressive disease and three with stable disease on lomustine. one dog received epirubicin after completing six doses of lomustine in complete remission and two dogs in partial remission changed to epirubicin due to hepatotoxicity associated with lomustine. response rate to epirubicin was % and biologic effective response was % ( cr, pr, sd, pd) in dogs. one dog was euthanized due to epirubicin associated gastro-intestinal toxicity and dog stopped treatment with no assessment of response. median duration of response to epirubicin was days (range: - ) and dog is still alive and in remission ( days). overall median survival time for dogs receiving epirubicin following lomustine was days (range: - ). single agent epirubicin is a valid rescue therapy after lomustine for canine histiocytic sarcoma and results in modestly improved overall survival times in responding patients. the author received a travel scholarship from zoetis to attend this congress. the incidence of melanocytic lesions is increasing among canine population. canine malignant melanoma could have an aggressive behavior, metastasize early in the course of the disease and be resistant to most current therapeutic regimens leading to the need of finding markers with potential as therapeutic targets. the overexpression of cox- seems to play a key role in melanocytic tumours, having being described an association between high cox- immunoexpression and the malignant behavior. in order to contribute to the understanding of the role of cox- in melanocytic tumours, three main pathways were investigated: angiogenesis, tumour cell proliferation and inflammatory microenvironment (t-lymphocytes and macrophages). fifty one ( ) melanocytic tumours [ cutaneous ( malignant melanomas and melanocytomas) and oral malignant melanomas] were included. all the samples were submitted to immunohistochemical staining carried out by the streptavidinbiotin-peroxidase method, with a commercial detection system with or without melanin blanching, for detection of the following markers (cox- , ki- , factor viii, vegf, cd and mac ). in melanocytic tumours (n = ), both cox- labelling extension and intensity revealed a statistically significant association with angiogenesis by factor viii (p < , ), vegf (p < , ); ki- (p < , ), cd + t-lymphocytes (p < , ) and mac (p < , ). considering only malignant melanomas (n = cases), cox- labelling extension revealed a statistically significant association with angiogenesis (p = , ) and cd + t-lymphocytes (p = , ). cox- intensity was also positively associated with angiogenesis (p = , ) and with mac (p = , ). present study demonstrated a link between high cox- immunoexpression and increased angiogenesis and tumoural t-lymphocyte and macrophage infiltration in malignant melanomas. these findings reinforce the usefulness of using selective cox- inhibitors as a valuable therapeutic tool in malignant melanocytic tumours. this study received financial support from a company (merial). neuter status and risk of malignant neoplasia is not well evaluated in the canine population, when excluding neoplasia not normally believed to be sex-hormone dependent. denmark and the scandinavian countries have a high proportion of intact dogs compared to populations from other parts of the world. in the present study it was hypothesized that there would be no difference in gender and neuter status between the population of canine patients with a non-sex-hormone dependent malignant neoplasia reported to the danish veterinary cancer registry and a general population. from august to march , canine neoplasms were reported to the danish veterinary cancer registry. the total number of malignant ( ) and benign ( ) were comparable ( % and %). malignant neoplasms totalled , when tumors from areas of distribution with known sex-hormone dependency (reproductive organs, mammary gland, perineal), and cases with unknown area of distribution were excluded. the overall distribution of malignant neoplasia was ( %) intact male dogs, ( . %) neutered male dogs, ( %) intact female dogs and ( . %) neutered female dogs. the distribution was even between male and female dogs ( . % and . %). compared to a known standard population of dogs, there was an overall statistically significant association of malignant neoplasia with neuter status in both sexes. for both genders this was significant for lymphoma, mast cell tumors and osteosarcomas,. for neutered females, but not males, there was increased risk of hemangiosarcoma, squamous cell carcinoma and malignant melanoma. these findings indicate that there might be an association between neuter status and development of malignant neoplasia but larger prospective studies are needed to evaluate the risk of non-sex hormone dependent cancers in neutered dogs. no conflicts of interest reported. serum acute phase proteins (apps) are considered biomarkers of the acute phase reaction, and are being increasingly used in human and veterinary medicine in diagnosis and monitoring of neoplastic diseases. in the cat, serum amyloid a (saa) is considered a positive major app, haptoglobin (hp) a moderate app, and albumin and insulin-like growth factor- (igf- ) negative apps. the aim of the present study was to characterize the apps response in cats with mammary tumours. for that purpose, saa, hp, igf- and albumin serum concentrations were determined in female cats with malignant mammary tumours. cats with history of previous tumours or with concomitant tumours or other diseases were excluded. information on cats age, gender, breed, tumour type, histological grade, tumour size and location, skin ulceration, vascular neoplastic infiltration, necrosis, metastasis to regional lymph nodes, thoracic or abdominal organs, and survival time from diagnosis was assessed. blood samples were collected before surgery in all cats, and whenever possible, serial samples collected on control visits. owners gave informed consent. studied population included domestic short-haired cats with ages ranging from eight to years ( , + /- , ). all had carcinomas, including solid carcinomas (n = ), tubulopapillary carcinomas (n = ), one cribiform carcinoma and one carcinosarcoma. at the time of diagnosis, % of cats had an increase in serum concentration of hp and % of saa, and % had a decrease in concentration of albumin. mean and standard deviation values were of , + /- , g/dl for albumin (reference range , - , g/ dl), , + /- , lg/dl for igf- , , + /- , lg/ml for saa (reference value ˂ lg/ml), and , + /- , g/l for hp (reference value ˂ g/l). a positive correlation (r = , ) was detected between increases in serum concentrations of saa and hp. the increase in the size of tumour was significantly associated with the concentration of saa (p˂ , ). serum hp concentrations were significantly increased in tubulopapillary carcinomas (p˂ , ), and igf- decreased in solid carcinomas (p˂ , ). in the cats where serial determinations were performed, development of thoracic metastasis was significantly associated with a decrease of serum concentration of albumin (p˂ , ), and with an increase of saa (p˂ , ). this study suggests that feline mammary tumours are associated with an acute phase response. according with the results obtained, saa, hp, albumin and igf- might be important serum biomarkers in diagnosis and monitoring of the evolution of feline malignant mammary neoplasias. no conflicts of interest reported. histiocytic sarcoma (hs) is a neoplastic proliferation of interstitial dendritic cells or tissue macrophages. dogs with hs can present with local disease or with multifocal (disseminated) involvement. disseminated hs is poorly responsive to therapy and almost always fatal. little is established regarding the aetio-pathology of histiocytic sarcoma in dogs. the purpose of this study was to establish and characterise a hs cell line from fresh tumour samples obtained from a dog with disseminated hs in order to further clarify disease pathogenesis and behaviour. with owner consent, treatment-na€ ıve tumour sections were collected from a dog with disseminated hs that was euthanased. tumour tissue was assessed with immunohistochemistry (ihc) using antibodies against canine cd , cd , and pax- to support the diagnosis of histiocytic sarcoma. primary cell cultures (hscs), established from the tumour were cultured and maintained in modified eagle's medium with % fetal bovine serum, l-glutamine, penicillin and streptomycin, in standard conditions. hscs were characterised by alpha naphthyl acetate esterase (anae) and lysozyme staining while pcr was used to detect cell markers cd a, cd c, mhc ii, cd , ccr , e-cadherin, and cd . cell surface markers were compared to an established canine hs cell line (dh ). phagocytic activity of hsc cells was assessed using cellular uptake of carboxylated fluorescent beads and documented using flow cytometry and fluorescent microscopy. tumour tissue was strongly cd positive and negative for cd and pax- . cultured cells exhibited morphological characteristics consist with dendritic cells, such as projections and pleomorphism. hsc cells stained positively for non-specific esterase (anae) and lysozyme, and pcr indicated cells were positive for cd a, cd c, mhc ii and cd and negative for cd and e-cadherin. hsc cells were positive for mhc ii and ccr while dh cells were negative. phagocytic activity was evident. a novel hs cell line (hsc) was established and characterized from primary tumour tissue collected from a dog with disseminated disease. hsc cells were most consistent with interstitial dendritic cell origin based on cd a, cd c, and mhc ii staining as well as demonstrable phagocytic activity. hsc cells also displayed expression of ccr , unlike the established dh line, supporting a notion that hs consists of a variety of subtypes. ccr has been linked to hs growth and metastasis, suggesting it may represent a possible therapeutic target. further studies establishing and characterising canine hs cells may contribute to the elucidation of mechanisms of tumourigenesis. no conflicts of interest reported. virulent-systemic (vs)-fcv that induce cutaneous edema, ulcerations of the head and feet, and occasionally jaundice have been described in the usa and europe. here we characterize for the first time vs-fcv outbreaks in cats in switzerland and liechtenstein. the four outbreaks occurred in three geographically separated locations: schaan (liechtenstein, shelter ), zurich (switzerland) and lausanne (switzerland, shelter ) between november and january . pcr (fcv and feline herpesvirus- , fhv- ), virus isolation and felv/fiv testing were performed on saliva and blood samples collected from clinically affected cats. furthermore, saliva for pcr was collected from additional cats in shelter . phylogenetic analyses were performed based on the capsid (vp ) gene sequence of fcv. vs-fcv isolates were tested for virus neutralization with sera raised against common fcv vaccine strains. outbreak occurred in a cattery in liechtenstein and involved five non-vaccinated, -months old siblings with fever, edema, skin and tongue ulcerations. outbreak occurred in a small animal clinic in zurich. a -year old cat presented with severe paw edema, fever, tongue and skin ulcerations, progressive hypoproteinemia and hyperbilirubinemia. outbreaks and happened in a cattery in lausanne five months apart and involved two litters of non-vaccinated, -to -months old kittens. the cats presented with fever, nasal discharge, edema and skin and oral ulcerations. all affected cats tested fcv-positive but negative for fhv- , felv and fiv, except for one kitten from outbreak (fiv-positive). all cats in outbreaks and recovered, whereas all cats in outbreaks and died or were euthanized because of clinical deterioration. each outbreak was caused by a phylogenetically distinct vs-fcv strain. in shelter , the queen and three in contact cats remained asymptomatic although infected with the same vs-fcv strain. furthermore, / other cats of shelter were infected with closely related, but distinct fcv strains. the vs-fcv isolates from the two outbreaks in shelter were distinct but phylogenetically related. all vs-fcv isolates from cats from the same outbreak showed a similar virus neutralization pattern, but neutralization differed between different outbreaks. in conclusion, all vs-fcv outbreaks involved multi-cat environments. the same vs-fcv strains with similar virus neutralization patterns were isolated from cats from the same outbreak. not all cats infected with a vs-fcv strain developed disease and mortality varied between the outbreaks. the sera for virus neutralization were provided by merial, france. defined herein as presence of sneezing, nasal-and/or ocular discharge, conjunctivitis and/or keratitis), but also oral cavity lesions, chronic stomatitis, limping syndrome and, rarely, virulent systemic disease. the aims of the present study were to compare cats suspected of fcv (fcv-sc) based on clinical symptoms and healthy controls (controls) and to investigate potential risk and protective factors, such as co-infection with feline herpesvirus- (fhv- ), mycoplasma felis, chlamydophila felis, bordetella bronchiseptica and feline retroviruses, vaccination, gender, age, breed, housing and corticosteroid and antibiotic treatment. oropharyngeal, nasal and conjunctival swabs from fcv-sc and controls were collected into transport medium, processed within hours after collection and analyzed for fcv by virus isolation and for all tested pathogens using molecular assays. the samples were collected by randomly selected veterinary practices in different areas of switzerland ( fcv-sc and controls/ area). to record clinical data, retroviral status and vaccination history of the cats, a questionnaire was filled out by the private veterinarian. the seven tested pathogens were found in the investigated population. the prevalence (fcv-sc vs. controls) was: fcv % vs. %; fhv- % vs. %, c. felis % vs. %, b. bronchiseptica % vs. %, m. felis % vs. %, feline leukemia virus % vs. % and feline immunodeficiency virus % vs. %. fcv-sc were positive for fcv significantly more often compared with controls (or . ) and shed more fcv. co-infections with up to four pathogens were detected; fcv-sc were significantly more frequently co-infected ( %) compared with controls ( %). gingivostomatitis and oral ulceration but not urtd were highly associated with fcv infection. in contrast, c. felis was associated with urtd; fhv- was associated with nasal and ocular discharge and m. felis with conjunctivitis and ocular discharge. risk factors for fcv infection were housing in groups (especially ≥ cats), an intact gender, maine coon breed and corticosteroid therapy. fcv-positive cats with gingivostomatitis were older and more commonly vaccinated than fcv-positive cats without gingivostomatitis. moreover they shed more fcv than cats with urtd. vaccination and primary immunization defined as two vaccinations - weeks apart with the same vaccine brand were protective factors against fcv but not fhv- infection. vaccination was associated with a decreased incidence of urtd in fcv-infected cats (or . ). further analyses will investigate cross-neutralization patterns of the prevailing fcv isolates. conflicts of interest: the study was partially funded by merial, france, and biokema, switzerland. antibody preparations are commonly used for the treatment of feline upper respiratory tract disease (furtd), although their efficacy has not been proven. the aim of this study was to evaluate efficacy of a commercial serum containing antibodies against feline herpesvirus- (fhv- ) and feline calicivirus (fcv) in cats with acute viral furtd. this prospective, randomized, placebo-controlled, double-blind study included cats with acute (< days) clinical signs of fhv- and/or fcv infection (confirmed by quantitative pcr). all cats received symptomatic treatment and either hyperimmune serum (n = ) (≤ weeks ml, > weeks ml, subcutaneously q h, topically into eyes, nostrils, and mouth q h) or saline (n = ) for three days. clinical signs, including a 'furtd score' and general health status, were recorded daily (day to and on day ). fcv shedding was determined on day and . statistical analyses included one-way analysis of variance, mann-whitney u, and student's t-test (improvement of clinical signs), fisher's exact test (fcv shedding), and spearman analysis (correlation clinical signs with virus load). clinical signs and general health status improved significantly in both groups. however, while placebo-treated cats had only improved significantly by day , cats receiving antibodies already significantly improved in their 'furtd score' (p = . ) and general health status (p = . ) by day . there was no significant difference in the number of cats shedding fcv and no correlation between viral load and clinical manifestation. administration of antibodies lead to faster improvement of clinical signs in cats with acute viral furtd, but did not influence fcv shedding. no conflicts of interest reported. different viral and bacterial pathogens can be involved in feline upper respiratory tract disease (furtd). although some clinical signs have been associated with certain pathogens, clinical signs can be variable and non-specific. aim of the study was to compare detection rates of feline herpesvirus- (fhv- ), feline calicivirus (fcv),and chlamydophila felis (c. felis) in cats with furtd on different sampling sites, and to correlate test results and clinical signs. swabs of nose, oropharynx, tongue, and conjunctiva were taken from cats with signs of furtd. on all samples, reverse transcription polymerase chain reaction (rt-pcr) was performed for detection of fcv, and polymerase chain reaction (pcr) for detection of fhv- and c. felis. fisher's exact test was used for all comparisons. the level of significance was p < . . pathogens were detected in . % of cats. of these, . % were positive for fhv- , . % for fcv, and . % for c. felis. fcv was isolated significantly more often from oropharynx ( . % of fcv-positive cats) and tongue ( . %) compared to conjunctiva ( . %) (p < . ). there was no significant difference between the sampling sites for detection of fhv- and c. felis. in addition, there was no preferred sampling site in cats with respective clinical signs, including oral ulceration, conjunctivitis, and keratitis. in cats with furtd, the oropharynx can be recommended as the preferred sampling site for detection of fcv, fhv- , and c. felis. based upon clinical signs it cannot be determined which sampling site should be selected for detection of the pathogens. no conflicts of interest reported. pulmonary haemorrhage syndrome (lphs). s. schuller , s. callanan , s. worrall , t. francey , a. schweighauser , j.e. nally . bern university, bern, switzerland, university college dublin, dublin, ireland leptospiral pulmonary haemorrhage syndrome (lphs) is a severe form of leptospirosis, which has been increasingly recognised in humans and many animal species in the past years. patients with lphs may develop rapidly progressive intra-alveolar haemorrhage, leading to high mortality. the pathogenic mechanisms of lphs are poorly understood hampering the application of effective treatment strategies. studies in humans and experimentally infected guinea pigs have demonstrated deposition of immunoglobulin and complement c in lphs lung tissue in the absence of significant numbers of leptospires, suggesting that lphs is, in part, caused by autoimmunity. the aim of this project was to describe the histopathologic features of lphs in dogs and to investigate whether igg and igm deposition is present in affected canine lung tissue. single-step immunohistochemistry (ihc) for dog igg, igm and leptospiral outer membrane vesicles was performed on lung tissues from dogs with lphs, dogs with pulmonary haemorrhage due to other causes and healthy dog lungs. acute intra-alveolar haemorrhage and oedema in the absence of significant inflammatory infiltrates were present in all lphs lung tissues. three ihc staining patterns were observed in lphs lung tissue: alveolar septal wall staining with (igg n = /igm n = ) and without intra-alveolar staining (igg n = /igm n = ) and staining of intra-alveolar fluid only (igg n = /igm n = ). intra-alveolar staining appeared to favour alveolar surfaces in some cases (igg n = /igm n = ). healthy control lungs showed no staining, whereas haemorrhagic lung showed staining of intraalveolar fluid (igg/igm n = )) and occasional, mild and discontinuous staining of alveolar septa (n = ). leptospiral antigens were not detected in any of the tissues. results indicate that histopathologic features of canine lphs are similar to what has been described in other species. ihc demonstrated that alveolar septal deposition of igg/igm is present in most dogs with naturally occurring lphs. while these findings support a role of the humoral immune response in the development of lphs, our findings do not indicate whether autoimmunity is a primary or secondary event in the pathogenesis of lphs. no conflicts of interest reported. leptospirosis, a zoonotic bacterial disease with a worldwide distribution, is a re-emerging disease in humans and dogs. acute renal and hepatic failure are the most frequently reported clinical manifestations of canine leptospirosis. the aim of this study was to describe clinical, laboratory and radiological features, the outcome as well as the distribution of leptospira serogroups in dogs with leptospirosis ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . medical records of dogs diagnosed with leptospirosis were evaluated retrospectively. diagnoses were based on microscopic agglutination testing (mat), blood/urine pcr, and histopathology (levaditi staining). mat-titers ≥ : against non-vaccine and ≥ : against vaccine serovars or a -fold rise of titers within - weeks were considered diagnostic. dogs met the inclusion criteria. in dogs diagnostic mat-titers were present (mainly against serogroups grippotyphosa ( %), australis ( %), and pomona ( %). at initial presentation, the most common clinical signs were lethargy ( %), anorexia ( %), vomitus ( %), a painful abdomen ( %), diarrhea ( %), oliguria ( %), tachypnea ( %), delayed capillary refill time ( %), pale mucous membranes ( %), fever ( %), hypothermia ( %), and icteric mucous membranes ( %). abnormal findings of the cbc included anemia ( %), thrombocytopenia ( %) and leukocytosis ( %). biochemistry abnormalities included increased creatinine concentrations ( %), increased liver enzyme activities ( %), hyperbilirubinemia ( %), hyperphosphatemia ( %), hyponatremia ( %), and hypoalbuminemia ( %). urinalysis often revealed glucosuria ( %) and an elevated urine-protein/creatinine-ratio ( %). radiological pulmonary changes were detected in % of the dogs initially or during the course of disease. dogs died or were euthanized, of them due to "leptospiral pulmonary hemorrhage syndrome". in this study, non-vaccine serogroups were the most common serogroups detected by mat. in the majority of patients renal ( %) and/or hepatic ( %) disease was detected. a pulmonary form of leptospirosis was present in % of the dogs. lung involvement represented a severe complication causing increased mortality depending on the severity of respiratory signs. no conflicts of interest reported. leptospirosis is a zoonotic disease that can affect multiple organs with renal and hepatic involvement being considered to be the most common. the aim of this study was to evaluate a large number of dogs with leptospirosis for cardiac and/or exocrine pancreatic involvement. a total of dogs were diagnosed with leptospirosis based on clinical signs and either microscopic agglutination test, blood/ urine polymerase chain reaction, and/or histopathology. at the time of admission and, in most patients, after an average of two weeks canine pancreatic lipase immunoreactivity (cpli, as measured by spec cpl â ), ultrasensitive cardiac troponin i (ctni), and c-reactive protein (crp) were analyzed. data were analyzed with non-parametric statistics. the level of significance was set at p < . . upon admission, common clinical signs reported included lethargy (n = ), vomiting (n = ), abdominal pain (n = ), dyspnea (n = ), pale mucous membranes (n = ), oliguria (n = ), hypothermia (n = ), and fever (n = ). anemia (n = ), thrombocytopenia (n = ), leukocytosis (n = ), were frequently reported hematology findings. increased concentrations of creatinine (n = / ), phosphorus (n = / ), alt (n = / ), sap (n = / ) and bilirubin (n = / ) were also frequently recorded. crp (median: . mg/l; range: . - . mg/l, reference interval (ri): . - . mg/l), ctni (median: . ng/l; range: . - . ng/l, ri: - . ng/l), and cpli (median: lg/l; range: - lg/l, ri: - lg/l) concentrations were above the upper limit of the reference intervals in / ( %), / ( %), and / ( %) dogs, respectively and serum cpli concentration was above the suggested cut-off value for a diagnosis of pancreatitis in / ( %) dogs. crp and ctni, but not cpli were higher upon admission compared to the re-check measurement (p = . and . , respectively). dogs with increased serum cpli concentrations also showed a higher proportion of dogs with increased serum ctni concentrations (p = . ). there was no statistically significant correlation of cpli concentrations with a history of abdominal pain and/or vomiting. biochemical results were compatible with multiple organ impairment with involvement of kidneys, liver, heart, and exocrine pancreas where at least two organs were affected in / ( %) dogs. forty ( %) of dogs recovered, ( %) died, and ( %) were euthanized. ctni and cpli were higher in non-survivors, but these differences did not reach statistical significance. however, the number of organs affected and outcome were significantly correlated (p = . ). our data suggest that infection with leptospira is characterized by a systemic inflammation with variable multiple organ involvement and damage, often including the heart and also the exocrine pancreas. the study was funded by texas a&m university. the primary author and two co-authors work at the gi laboratory, texa a&m university. canine bartonellosis is increasingly recognized worldwide and may be associated with diverse clinical manifestations. recent evidence suggests that bartonellosis also causes lameness and polyarthritis in dogs. however, pcr amplification of bartonella dna and isolation of bartonella species from canine synovial fluid (sf) samples have rarely been reported. canine leishmaniosis (canl) due to leishmania infantum is a multisystemic disease commonly associated with polyarthritis. based on the hypothesis that concurrent bartonella infection may be a contributing factor for the development of arthritis in dogs with canl, the main objective of this study was to investigate the microbiological and molecular prevalence of bartonella spp. in dogs with naturally-occurring canl, with or without cytologically documented arthritis. from a previous study, dogs with canl were retrospectively studied for bartonella spp. infection. diagnosis of canl was based on compatible clinical and clinicopathological abnormalities, positive serology, and lymph node or bone marrow (bm) cytology. dogs with serological evidence of other vector-borne infections (anaplasmosis, borelliosis, dirofilariosis and ehrlichiosis) and dogs recently vaccinated or medicated were excluded from the study. arthritis defined as a neutrophil percentage in excess of % of nucleated cells in sf cytology was documented in / ( . %) of dogs. a total of archived specimens from dogs, including edta-anticoagulated blood samples, bm and sf aspirates were tested for bartonella spp. dna using a bartonella alpha proteobacteria growth medium (bap-gm) diagnostic platform. eight ( . %) dogs were infected with one or two bartonella species, including candidatus bartonella merieuxii(n = ), b. henselae sa (n = ) and b. rochalimae (n = ). bartonella spp. dna was amplified from bm in dogs and from blood in dogs but was not amplified from any sf sample. overall, ( . %) dogs with and ( . %) dogs without arthritis were infected with a bartonella species. the prevalence of bartonella spp. dna in the dogs with or without arthritis did not differ (v test for independence, p = . the prevalence of giardia in dogs ranges between . % and . %, with a higher prevalence in puppies. however, the risk factors for giardia infection around weaning have been poorly described. the aim of the study was to evaluate risk factors for giardia infection in puppies during the first weeks of life and to determine an impact of this parasite on feces quality. puppies from litters living in a breeding kennel were followed between and weeks of age. each puppy was treated with fenbendazole (panacur â , msd, france, mg/kg, per os, q h) for consecutive days at , , and weeks of age. for each puppy, fecal consistency was evaluated using a -point scale. excretion of enteropathogens was evaluated by qpcr for canine parvovirus type (cpv ), qrt-pcr for canine coronavirus (ccv), coproantigens quantification for giardia (prospect-giardia, remel), and mcmaster flotation technique for any eggs and oocysts. a generalized linear mixed model (proc glimmix) with giardia infection as a binary outcome was used to assess the following effects: breed size, age, and cpv , ccv and isospora ohioensis infections. a linear mixed model (proc mixed) with fecal score as outcome was used to determine the following effects: breed size, age, and giardia, cpv , ccv and i. ohioensis infections. a total of fecal samples were collected; cpv , giardia, i. ohioensis and ccvwere detected in respectively . %, %, . % and . % of the samples. the risk of giardia infection increased with age (odd ratio= . ; %ci= . - . ; p = . ). neither breed, nor cpv , ccv and i. ohioensis infections influenced risk of giardia infection (p = . ; p = . ; p = . ; p = . respectively). giardia infection did not impact feces quality (p = . ), whereas a significant influence of cpv (p < . ), ccv infection (p = . ) and breed size (p < . ) was evidenced. this study underlines that even with an adapted deworming program the eradication of giardia is difficult to obtain in large dog packs. the higher prevalence of giardia in puppies of weeks and older could be linked with the immunity gap during this period. giardia was not associated in our study with an increased risk of diarrhea. the lack of pathogenicity of the parasite per se could be hypothesized, but also an efficacy of the treatment for the prevention of the clinical signs or a local and systemic immunity limiting clinical signs. financial support from royal canin. hepatic encephalopathy (he) can occur in dogs as a complication of primary liver disease or as consequence of congenital portosystemic shunts (pss). the aim of this study was to assess magnetic resonace spectroscopy (mrs) usefulness in he diagnosis. twenty dogs with a presumptive diagnosis of he were enrolled. inclusion criteria were: a clinical examination, a blood cell count and biochemical panel, at least one plasmatic ammonia determination higher than lmol/l, optional hystopatology of the liver, requirement of magnetic resonance imaging (mri) investigation by the clinician. even though mrs represents a non-invasive procedure, informed consent was obtained from dogs'owners. he diagnosis was confirmed in / : / had a pss, / showed hepatic microvascular dysplasia and / had hepatic cirrhosis histologically confirmed. the control-group was made of patients retrieved from our database that underwent mri without showing any abnormalities on brain scans. the mr protocol included t -weighted fast spin-echo, t -weighted sequences, proton density, and radio-frequency pulses gradient-echo. on mri examination cerebral atrophy was evident in all the patients ( / ), ranged from mild to severe. in / patients symmetrical bilateral hyperintensities in the globus pallidus on t -weighted images were evident. mrs was performed using a short te ( ms) and it was defined a volume of interest in the parieto-occipital region by -mm side cube ( cc of volume). glutamine-glutamate (gln), n-acetylaspartate and n-acetyl aspartyl glutamate (naa), choline derivatives (cho), and myo-inositol (ins) were analyzed. comparing spectra from the he affected dogs with those from the control-group decreased values of ins, cho, naa as well as high field mri combined with brain mrs provide accurate and non-invasive diagnosis of canine he. in accordance with human medicine publications, it could be state that mrs has a role in he diagnosis and follow-up with particular mention monitoring. no conflicts of interest reported. diagnosis of hepatobiliary diseases often requires hepatic tissue sampling for histologic evaluation. the laparoscopic technique is a safe method and allows acquisition of tissue by wedge and needle biopsies from different liver lobes in a minimally invasive way.specimens obtained with an -gauge biopsy needle must be interpreted with caution due to considerable variability in tissue involvement with certain disease processes. we hypothesized that needle biopsy specimens would produce findings divergent from those produced by wedge biopsy specimens. the goal of the study was to compare histological findings from two laparoscopic biopsy methods (wedge and needle) and assess which sampling technic can represent the overall disease process. procedure: all dogs included in this prospective study study were suspected diffuse hepatic disease and underwent laparo-scopic hepatic biopsy (wedge and needle - g) between and . all biopsy specimens were examined on the basis of morphologic criteria and a comparison was made between the two types of biopsies procedures according to wsava liver standardization group morphologic criteria. results: twenty-two dogs were included. no complications were reported during the laparoscopic procedure. the median number of portal triads per needle biopsy specimen was (range, to ) compared to (range ; ) with wedge biopsy specimen. the median length of needle biopsy specimens was mm; (range, to mm) and mm for all wedge biopsies. on the basis of biopsy interpretation, the diagnosis was overall similar with the two methods: dogs had vacuolar hepatopathy, acute cholangitis, non-specific acute form in dogs. chronic hepatitis with cirrhosis was found in cases, dogs had diffuse neoplasia and miscellaneous hepatic disorders. the fibrosis was considered to be severe in dogs, moderate in dogs and mild in dogs. no quantitative and qualitative difference was observed between the two types of biopsies specimen. this study demonstrates that the biopsies with a needle length of at least mm brings satisfactory information for the evaluation of most of the inflammatory, vacuolar hepatopathies, fibrosis and diffuse tumoral infiltrations. wedge biopsies allow to examine the largest number of portal triad, more contributory for certain forms of cholangitis affecting larger canals and for a single case, images of peri-hepatitis were counted at the level of the capsule. fibrosis does not seem to be more important in the sub-capsular zone contrary to what is observed in human pathology. no conflicts of interest reported. indocyanine green (icg), a fluorescence dye, is excreted solely by the liver without enterohepatic re-circulation. hence it has been used for decades as an ideal albeit invasive marker of hepatic function and blood flow in cats and dogs. here we evaluated the feasibility of a minimally invasive transcutaneous icg clearance to assess hepatic function instantaneously. transcutaneous icg clearance was performed in healthy research cats and healthy research dogs with normal liver function (bile acid stimulation test, ammonia tolerance test) using a modified device (kidney int : with an excitation wave length of nm and an emission wave length of nm. the devices were placed on different locations (lateral thoracic wall, ventrolateral abdomen, metatarsus and antebrachium) and fixed with a light bandage. to find a suitable dose to reach adequate transcutaneous peak concentrations escalating doses of icg ( . , . and . mg/kg) were injected intravenously with a wash out period of at least h in-between. measurement was continued for hour after injection in awake animals moving freely. the resulting icg disappearance curves were visually inspected to find best location (minimal artifacts, acceptable background noise) and dose. in all animals a dose of . mg/kg was deemed ideal and the thoracic and abdominal wall gave consistent results. half-life of icg clearance was calculated using a one-compartment model. half-lives in cats were . , . and . minutes, respectively; in dogs: . , . and . minutes, respectively. in conclusion, the transcutaneous assessment of icg clearance is feasible in a clinical setting. results are obtained within one hour and can be assessed instantaneously. the procedures are minimally invasive and well tolerated by the animals. given that most patients with a presumed liver problem undergo abdominal ultrasound no further clipping of hair is necessary as the device might be placed in this area. further studies are necessary to obtain reference values in healthy pets and those with various conditions leading to impaired hepatic function. no conflicts of interest reported. gallbladder diseases like gallbladder mucocele and cholecystitis can reduce gallbladder motility and may lead to cholestasis. since impaired gallbladder emptying contributes to sludge and gallstone formation, the evaluation of gallbladder motility requires accurate and appropriate methodology. three-dimensional ( d) ultrasonography has been shown to be accurate and appropriate tool for measurement of gallbladder volume in humans. therefore, we applied this novel technique for the first time to study preprandial and postprandial gallbladder volume in healthy mixed-breed dogs and compared the results to twodimensional ( d) ultrasonography. the dogs were placed in dorsal recumbency to obtain ultrasonographic measurements of the gallbladder. measurements by both d and d ultrasonography were recorded in preprandial state and after ingestion of full-fat milk. the preprandial and postprandial gallbladder volumes determined by d ultrasonography were significantly higher than corresponding volumes by d ultrasonography ( . ae . vs . ae . and . vs . ml/kg, respectively, p < . ). in d ultrasonography, most dogs ( / [ %]) had a preprandial gallbladder volume ≤ . ml/kg. however, in d ultrasonography, / ( %) of dogs had a preprandial gallbladder volume ≥ . ml/kg. gallbladder contraction index was higher in d ultrasonography than d ultrasonography, however, it did not reach statistical significance (p = . ). in conclusion, d ultrasonography showed larger gallbladder volumes than d ultrasonography in healthy dogs. it seems that d ultrasonography is appropriate adjunct device to d ultrasonography to estimate gallbladder volume when d ultrasonography could not detect whole gallbladder volume. more research is needed to determine clinical value of d ultrasonography in canine gallbladder imaging. no conflicts of interest reported. the aim of our study was to compare high-definition oscillometry (hdo) and doppler ultrasonographic measurements with direct blood pressure measurements in conscious dogs. the doppler study was performed by three investigators and by using different sphygmomanometers with different sized cuffs. devices and measurement sites were changed randomly among the investigators. cuffs were wrapped around the antebrachium in the forelimb or around the mid-metatarsus in the hind limb. in addition to the limb sites, cuffs were also placed around the base of the tail in case of the hdo method. cuff sizes were - % of the measured limb circumferences during the doppler measurement. for the hdo method all measurements were performed by the same investigator and the cuffs provided by the manufacturer were used: the smallest cuff was used for the hind limb and tail, and the medium cuff was used for the forelimb measurements. dogs were gently held in lateral recumbent position, measurement were performed on the nondependent limbs. radio-telemetry transducers were implanted to the right femoral artery some months to a year preceding the blood pressure measurements for reasons unrelated to our study. direct blood pressures varied - mmhg and - mmhg during the doppler and hdo measurements, respectively. two-hundred paired simultaneous doppler and direct measurements from dogs and paired simultaneous hdo and direct telemetric measurements from dogs were obtained. at least successful consecutive measurements could be obtained by the same investigator at the same site during the doppler or hdo measurement in and cases, respectively. thus, the mean of these measurements could be calculated similarly to the established everyday clinical practice. bias (mean difference), precision (standard deviation) and limits of agreements were calculated both from the individual paired measurements and from the means of the consecutive measurements using bland-altman spot analysis. systolic measurement performed on the tail with the hdomethod yielded the smallest bias and deviation and the best limits of agreement during this study. both doppler and hdo-measurements performed on the forelimb overestimated, while hind limb measurement underestimated the direct telemetric pressures. results of all three measurement sites by hdo performed better than forelimb or hind limb doppler-measurements, however hdo-measurements were more difficult to obtain and more often resulted with measurement failure compared to the doppler technique. cuff size above % of the measured limb circumference showed better results than smaller cuff sizes during the doppler measurements. no conflicts of interest reported. the doppler technique is considered the most repeatable indirect method to measure systolic arterial pressure (sap) in dogs. however, recent studies emphasized the effect of body position and used limb on sap measurement. the aim of this study was to determine whether a difference existed in sap measured simultaneously in dogs using different limbs, with two doppler units by two different operators. sixty clientowned dogs, admitted to the veterinary hospital for different reason, were enrolled. they were divided in groups based on body size: small breed dogs (< kg); medium breed ( - kg); large breed (> kg). for each dog the anxiety status was recorded. sap was measured via doppler technique when dogs were in right lateral recumbency in a quite environment. right and left forelimb sap and left forelimb and left hindlimb sap were recorded simultaneously, with two identical doppler units equipped with headphones, by two operators. measurement was performed based on the acvim guidelines. five measurements were recorded, the higher and lower values were discarded from the analysis. the relationship of mean sap for each limb with body weight, sex, anxiety status and sap value was evaluated. mean ae sd sap was significantly higher for the right forelimb ( . ae . ) compare to the left forelimb ( . ae . ) on overall population. the difference was significant for large breed dogs, males and dogs with sap ³ mmhg. sap was higher for the left forelimb ( . ae . ) compare to the left hindlimb ( . ae . ) on overall population. the difference was significant for medium and large breed dogs, females, calm animals and dogs with sap ³ mmhg. the mean sap from the left forelimb recorded by two different operators at two different moments, were compared and no difference was evident. in conclusion, sap measurement from different limbs, in dogs in right lateral recumbency, is poorly correlated. measurement of sap from the left forelimb is more repeatable during time and between different operators. sap trend monitoring should be done using the same measurement site for any animal. no conflicts of interest reported. amlodipine has been considered the treatmenf of choice for hypertension in cats for more than a decade. there is, however, an unmet need for a cat-specific formulation. the aim of the study was to assess the efficacy of chewable amlodipine tablets in reducing systolic blood pressure (sbp) in cats diagnosed with hypertension. seventy-seven client-owned cats were included in the study (mean age years). the study was randomised, double-blind, placebo controlled, and consisted of two phases. in the blinded phase, cats received . mg/kg amlodipine once daily for days. if they responded the dose remained the same to day . for non-responders, the dose was increased to . mg/kg. thirty-five cats received placebo following the same protocol. arterial blood pressure was measured using a high definition oscillometry method. at day a responder was defined as a cat showing a decrease of sbp to ≤ mmhg or a decrease from baseline of at least %. after days all cats continued with amlodipine for - months in an open phase with the placebo cats repeating the same dose escalation protocol as in the blinded phase. the responder rate was % in the amlodipine group and % in the placebo group following the dose escalation from day being applied to % and % of cats receiving amlodipine and placebo respectively. cats receiving amlodipine were . ( % ci . to . ) times more likely to be classified as responders when compared to those receiving placebo (logistic regression model, p = . ). from a baseline value of . ae . and . ae . mmhg the mean sbp decreased to . ae . mmhg with amlodipine and to . ae . mmhg with placebo (repeated measures analysis of covariance model, p < . ) by day . the responder rate was not influenced by factors other than amlodipine treatment (e.g. baseline blood pressure, concomitant ace inhibitor therapy, renal disease). there were no differences between the amlodipine and placebo groups in the frequency of adverse events reported during the -day blinded phase. likewise, there were very few changes in the laboratory values over time in either group. the present study is the first large clinical trial to show that amlodipine is clearly superior to placebo in the treatment of cats with hypertension. the chewable amlodipine formulation effectively reduced sbp, had a good palatability and was well tolerated. it can be used concomitantly with ace inhibitors and in cats with renal disease. conflicts of interest: m. huhtinen and j. aspegr en are employees of the sponsor j. elliott has the following information to disclose: amlodipine is the treatment of choice for feline hypertension. limited published data exist on serum concentrations achieved in hypertensive cats. the aim of the study was to assess serum amlodipine concentrations in cats treated with a new formulation of amlodipine and relate these to the blood pressure reduction achieved. seventy-seven client-owned hypertensive cats were enrolled into a randomized, double-blind and placebo controlled study consisting of two phases. in phase one, cats (group a) received . mg/kg amlodipine once daily for days. if they were deemed to have responded (see below) the dose remained the same to day . for non-responders, the dose was increased to . mg/kg. thirty-five cats (group b) received placebo following the same protocol. blood pressure was measured using high definition oscillometry. a responder was defined as a cat showing a decrease of systolic blood pressure (sbp) to ≤ mmhg or a decrease from baseline of ≥ %. following day (phase ), group a continued on amlodipine and group b switched to amlodipine and the dose was adjusted as per phase . both groups were followed for days on amlodipine. blood was collected at days (group a) and (both groups) and serum [amlodipine] measured by liquid chromatography mass spectrometry. the sbp measured on treatment was calculated as percentage of the baseline sbp and plotted against serum [amlodipine] using a sigmoidal emax model (winnonlin software). data are expressed as mean ae se. the serum concentrations of group a cats that remained on . mg/kg were . ae . ng/ml whereas those switched to . mg/kg were . ae . ng/ml. when data from groups a and b were pooled, a sigmoidal relationship between percentage baseline sbp and serum [amlodipine] was found. estimated values of lowest percentage baseline blood pressure on treatment (emax) was . ae . %, with an ec value of . ae . ng/ ml and a slope function of . ae . . the serum concentration required to reduce blood pressure by % was estimated to be ng/ml. the present study related blood pressure reduction to serum [amlodipine] in feline clinical hypertension. the limitations of this study were the limited number of blood samples collected and lack of information relating to the exact timing of blood sampling relative to dosing in some cats. however, these data could be used to define appropriate therapeutic serum [amlodipine] in hypertensive cats. m huhtinen is an employee of the sponsor; j. elliott has the following information to disclose: consultancy: pfizer animal health / zoetis, ceva animal health, boehringer ingelheim, vetoquinol ltd, orion ltd., elanco ltd, idexx ltd, niche generics ltd. triveristas ltd., virbac ltd., advisory board membership: international renal interest society (supported by novartis) european emesis council (sponsored by pfizer animal health -now zoetis) cardiorenal board -vetoquinol ltd. idexx renal advisory board research grants or contracts: vetoquinol ltd, novartis ltd, pfizer animal health ltd (now zoetis), royal canin ltd, boeringher ingelheim ltd, waltham centre for pet nutrition, ceva animal health orion ltd.; l pelligand has the following information to disclose: in receipt of research grant / contract funding from orion ltd., novartis animal health, transpharmation ltd, deltadot ltd; acted as a consultant for: triveritas ltd. and novartis animal health. commercial assays for the measurement of canine and feline pancreatic lipase immunoreactivity (spec cpl â and spec fpl â , respectively; idexx laboratories, westbrook, me, usa) have been available for a few years and have previously been analytically and clinically validated. recently, new commercial assays for the measurement of these parameters have become available, though neither one of these assays have been analytically or clinically validated in the literature. thus, the goal of this study was to compare these newly available assays to the established assays. leftover serum samples from diagnostic submissions to the gi laboratory were collected based on certain parameters (e.g., results throughout the working range of the assay, good quality sample or hemolytic, lipemic, or icteric sample) and were assigned random sample id numbers. the samples were evaluated by spec cpl â or spec fpl â , sent on dry ice to the klinik am hochberg, and one aliquot of each sample was blindly submitted to laboklin for measurement of cpli and fpli by their newly released in-house assay and also to the gi lab at texas a&m university for repeated analysis by spec cpl â and spec fpl â to exclude any effect of shipping. there was no significant difference between serum cpli or fpli concentrations before or after shipping at the gi lab (pvalues for wilcoxon matched-pairs signed rank tests: . and . , respectively). in contrast, there was a significant difference between serum cpli or fpli concentrations between the newly released assays and the previously established assays (pvalues < . and . , respectively). while there was a significant correlation between the newly released and the previously released assays (spearman r: . and . , respectively), this correlation was very poor for assays that supposedly measure the same analyte. also, the interpretation for serum cpli and fpli results between the previously developed assays and the new assays did not agree for many of the samples. finally, both newly developed assays showed some erratic results. in conclusion, the newly released assays for the measurement of cpli and fpli do not agree with previously established and validated assays, provide different interpretations, and show erratic results. thus, further research is needed before these newly released assays could be recommended for clinical use. dr. steiner serves as director and dr. suchodolski serves as associate director of the gastrointestinal laboratory at texas a&m university. dr. steiner also serves as a paid consultant to idexx laboratories, westbrook, me, usa. both the gastrointestinal laboratory and idexx laboratories offer cpli and fpli testing on a fee-for-service basis. digestive health is a main concern for growth, morbidity and mortality in weaning puppies. fecal immunoglobulin a (iga) has been suggested as a useful noninvasive biomarker for mucosal immunity. the purpose of this study was to evaluate the effect of infection with enteropathogens on fecal iga concentrations in puppies and that of physiological factors such as age and breed size. puppies from breeding kennels were included in the study. puppies were between and weeks of age (meanaestandard deviation (sd): . ae . weeks). depending on the mean adult body weight of their respective breed, the puppies were divided into small (if mean adult body weight < kg) or large (> kg) breed puppies. for each puppy, fecal consistency was evaluated using a -point scale and feces were collected for the evaluation of presence of fecal enteropathogens and fecal iga concentrations. the presence of enteropathogens in fecal samples was evaluated by qpcr for canine parvovirus type (cpv ), qrt-pcr for canine coronavirus (ccv), coproantigen quantification for giardia (prospect-giardia, remel), and mcmaster flotation technique for other parasite eggs and oocysts. fecal iga concentrations were measured by an elisa test. statistical analyses were performed using sas software. a linear mixed model (proc mixed) with fecal iga concentration as outcome was used to determine the following effects: enteropathogen infection, breed size, age, and fecal score. the respective influence of litter and breeding kennel as random effects was also determined. data is presented as mean ae sd. small breed dogs represented . % ( / ) of the total number of dogs included. at least one enteropathogen was identified in . % of puppies ( / ). fecal iga concentration was significantly influenced by fecal enteropathogens (p = . ). puppies infected with at least one enteropathogen had significantly lower fecal iga concentrations than puppies without any enteropathogens ( . ae . lg/g vs. . ae . lg/g). breed (p = . ), but not age (p = . ), influenced iga concentration. small breed puppies had significantly higher fecal iga concentrations than large breed puppies ( . ae . lg/g vs. . ae . lg/g). no significant relationship between fecal iga concentration and feces quality was evidenced (p = . ). this study suggests that fecal iga concentration is a promising marker for subclinical infection by at least one enteropathogen and confirms that digestive physiology varies with the breed size. a link between lower digestive immunity and higher susceptibility to enteropathogen infection needs further investigation. conflicts of interest: financial support of royal canin. canine chronic enteropathies (cce) include diet-responsive, antibiotic-responsive, and immunosuppressive-responsive enteropathies (ire). this prospective study was designed to evaluate a commercial hypoallergenic dry diet a containing oligopeptides as the only protein source for the management of dogs with ire and as an alternative to immunosuppressive therapy over a week period. nineteen dogs across france and quebec entered the study. dogs with food or antibiotic-responsive chronic enteropathy, hypoproteinemia, or treated with immunomodulating drugs were excluded from the study. dogs were included in the study after complete clinical, ultrasonographic, endoscopic evaluation and histopathological evaluation of intestinal biopsies showing signs of intestinal inflammation. the owners were instructed to feed exclusively the study diet a . canine inflammatory bowel disease activity index (cibdai) scores, fecal scores as observed by the dog-owners, and body weight were evaluated at baseline, , and weeks after inclusion. dietary treatment was regarded successful if the cibdai score was reduced by at least %. the protocol has been reviewed and accepted by royal canin ethics committee and owners completed an informed consent. results are presented as meanaesd (range). statistical comparisons were performed with a wilcoxon test. thirteen dogs ( intact males, neutered and intact females) completed the trial. seven dogs were excluded ( diagnosed with giardia, s with no histological evidence of inflammation, with hypoadrenocorticism). mean age was . years ae . ( . - . ), mean body weight . kg ae . ( . - . ). cibdai score was . ae . ( - ) at inclusion, was . ae . ( - ) after weeks and was . ae . ( - ) after weeks (p = . and p = . vs inclusion, respectively). fecal scores after [ . ae . ( - )] and weeks [ . ae . ( - ) ] were improved compared to inclusion scores . ae . ( - ) (p = . and p = . , respectively). the low molecular weight poultry feather hydrolyzed proteinbased dry extruded diet a appears to be effective in the management of idiopathic ibd without any concurrent immunosuppressive drug over the week period of this pilot study. these preliminary findings should be confirmed by a prospective, randomized double blind study. feline pancreatitis is the most common exocrine pancreatic disorder with varied mortality. however, there is no available and reliable method to evaluate the severity and prognosis of the disease. ninety-two cats diagnosed as pancreatitis with acute onset of compatible clinical signs and a positive snap â fpl tm test between october and september were enrolled in this study. all cats were divided into survival (n = ) and nonsurvival (n = ) groups. fifty-two parameters including signalments, clinical signs, physical examinations, clinicopathological examinations, diagnostic images, complications and concurrent diseases were analyzed and compared between the two groups. parameters with p ≤ . were considered for further analyses. the mortality in this study was . %. hematocrit, albumin, bun, creatinine, total bilirubin, calcium, phosphorous, body temperature, systolic blood pressure, the body cavity fluids, complications, e.g. systemic inflammatory response syndrome (sirs) and acute renal failure (arf) were found to be significantly associated with disease severity and prognosis, and were selected for constructing the scores. continuous variables outside the reference interval were separated into quartiles to yield quartile-specific odds ratios (ors) for survival. based on the integer value of the or, the scoring system was then developed by incorporating weighting factors assigned to each quartile. a predictive total score was calculated for each cat by summing all weighting factors. the total scores of each cat ranged from to . the severity scores in this study achieved an area under receiver operating characteristic (auroc) of . . the optimal cut-off point for discriminating outcome was . with the sensitivity of . % and specificity of . %, respectively. the mortality was . % with a score ≥ , whereas . % with a score ≤ . there was significant difference (p < . ) between the two groups of the cut-off point. furthermore, the mortality reached to % when the score more than . the severity scoring system of this study provides a reliable and clinical applicable method to predict clinical outcome in cats with pancreatitis. no conflicts of interest reported. convincing evidence for the role of clostridium (c.) perfringens as a primary pathogen in acute haemorrhagic diarrhoea syndrome (ahds) in dogs was recently found. it is suspected that clostridial toxins, especially c. perfringens enterotoxin, play a relevant role in the disease process. however, to date enterotoxigenic c. perfringens strains have only been described in single case reports. thus, the aim of this study was to indentify the specific c. perfringens genotype involved in adhs. small intestinal biopsies were collected with a sterile single-use biopsy forceps from ten dogs with ahds and immediately cultured. in / dogs, clostridial strains were isolated and identified as c. perfringens by mass spectrometry using maldi-tof ms. c. perfringens colonies from each dog were submitted for specific detection of the four major toxin genes (alpha, beta, epsilon, and iota), the enterotoxin gene, and the beta toxin by multiplex pcr. every clostridial isolate was typed as c. perfringens type a based on the detection of the alpha toxin encoding gene. in / isolates, additionally the beta toxin gene was identified, however, none of clostridial strains encoded for the c. perfringens enterotoxin gene. the results of this study suggest that c. perfringens type a is the most important c. perfingens genotype involved in the disease process of dogs with ahds. although c. perfringens enterotoxinhas been associated with intestinal diseases in humans, dogs, horses, pigs, and other animal species, this enterotoxin is most likely not responsible for the intestinal lesions in dogs with ahds. no conflicts of interest reported. p < . ). lack of treatment response was significantly associated with il (il: / , sre: / , fre: / , are: / ; p < . ). anemia, thrombocytopenia, and increased plasma urea were significantly associated with il (anemia: il: / , sre: / , fre: / , are: / , p < . ; thrombocytopenia: il: / , sre: / , fre: / , are: / , p = . ; increased urea: il: / , sre: / , fre: / , are: / , p = . ). hypoalbuminemia (< g/l) and hypocobalaminemia (< pg/ml) occurred significantly more frequently in dogs with sre (hypoalbuminemia: il: / , sre: / , fre: / , are: / , p < . ; hypocobalaminemia: il: / , sre: / , fre: / , are: / , p = . ). results of this study show that elderly and large breed dogs were more frequently affected with il and sre compared to other etiologies and both il and sre were associated with greater disease severity and/or a negative outcome. in comparison, anemia, thrombocytopenia, and increased plasma urea were most frequently detected in il whereas severe hypoalbuminemia and hypocobalaminemia were significantly associated with sre. no conflicts of interest reported. alpha -proteinase inhibitor (a -pi) is a proteinase-resistent protein that can be quantified in fecal, urine, and serum samples from dogs. recently, increased fecal and urinary canine a -pi (ca -pi) concentrations have been described in dogs with gastrointestinal diseases (e.g., inflammatory bowel disease [ibd] , but also in dogs with exocrine pancreatic insufficiency) and in dogs with chronic hepatitis or chronic kidney disease, respectively. decreased serum ca -pi concentrations have been reported in dogs with ibd, protein-losing enteropathy (ple), and hypocobalaminemia. treatment protocols for dogs with ibd and/or ple commonly include corticosteroids, but the effect of corticosteroid therapy on serum ca -pi concentrations have not yet been reported. the aim of this study was to evaluate the effect of hydro-cortisone on serum ca -pi concentrations in healthy dogs. twelve healthy beagle dogs were randomly allocated to a placebo-group (n = ) and to a treatment group (n = ; hydrocortisone-group). the placebo-group received an empty gelatin capsule po q h, whereas the hydrocortisone-group was treated with hydrocortisone at a dose of . mg/kg po q h. serum samples were obtained at baseline and on day , , , , and during treatment as well as day , , , , and post-treatment for all dogs. serum ca -pi concentrations were measured at all time points using an in-house radioimmunoassay. a mann-whitney u test was used to compare the baseline measurements of both groups. the effect of hydrocortisone-treatment on serum ca -pi concentrations was evaluated by comparing ca -pi at baseline and during treatment and between baseline and posttreatment period using a manova. baseline serum ca -pi concentrations did not differ between the hydrocortisone-and the placebo-group (p > . ). serum ca -pi concentrations increased significantly (p = . ) during the treatment period in the hydrocortisone-group (baseline [median in mg/l: , ] ). in contrast, no difference was observed between both groups when comparing serum ca -pi concentrations at baseline and during the post-treatment period (p > . ). this study showed that hydrocortisone-treatment over weeks did affect serum ca -pi concentrations in healthy dogs. whether corticosteroid therapy has any effects on fecal or urine ca -pi concentrations in healthy dogs remains to be determined. the author works at texas a&m university, whose gi lab currently offer a commercial assay for faecal alpha -proteinase inhibitor. canine chronic enteropathy (ce) is a common, but poorly understood syndrome, with variable response to therapy and prognosis. there is a need for novel biomarkers that are specific for intestinal disease and that provide objective measures of disease severity, progression, and prognosis. serum citrulline is a useful biomarker in human intestinal disease as it is specific to the small intestine and indicates globally reduced enterocyte mass and absorptive function in various disease states. it is used to determine, quantitatively, intestinal integrity at the enterocyte level and is not influenced by nutritional or inflammatory status. the aim of this study was to determine whether serum citrulline can be used as a biomarker for ce in dogs. in this retrospective study, computer records from the university of liverpool small animal teaching hospital were used to identify dogs with ce. disease severity was quantified by cibdai. controls were age-and breed-matched dogs without gastrointestinal disease. serum citrulline was measured by ultra-high performance liquid chromatography with tandem mass spectrometry. in dogs with ce, serum citrulline concentration was measured at presentation and at various time points after starting treatment. serum citrulline was measured in dogs with ce and controls. dogs responded to dietary manipulation (food-responsive enteropathy, fre) and responded to antibacterials (antibiotic-responsive diarrhoea, ard), with a further having invasive mucosal bacteria, of which one responded to antibacterials and one was refractory. dogs were diagnosed with idiopathic ibd (on the basis of exclusion of known causes and failure to respond to therapeutic dietary and antibiotic trials), of which responded to immunosuppressive therapy, were refractory, and were lost to follow-up. serum citrulline concentration did not differ between dogs with ce (median . lg/ml, range . - . ) and controls (median . lg/ml, range, . - . , p = . ). there was also no difference in serum citrulline concentration amongst dogs with fre, ard, ibd, and controls (p = . ). serum citrulline did not differ between dogs that responded well, or were refractory to treatment (p = . ), between dogs with and without protein-losing enteropathy (p = . ), or between dogs that survived and that were euthanased because of ce (p = . ). serum citrulline did not correlate with cibdai (r = . ). these findings do not support the use of serum citrulline as a biomarker in determining diagnosis, prognosis, or quantifying severity in dogs with ce. one of the co-authors (marco caldin) has a diagnostic laboratory offering citrulline assays. chronic enteropathy (ce) is a multi-factorial disease, which involves aberrant immune responses to commensal bacteria or dietary antigens. macrophages have an important role in human disease but little information is available in canine intestine. data to date have relied solely on macrophage identification using mac , an antibody directed against calprotectin, which recognizes both macrophages and neutrophils. in this study an alternative antibody for macrophages, am- k, directed against a scavenger receptor (cd ) was used and distribution of both markers was compared. this antigen is of interest as positive cells accumulate in intestine of humans with ce. endoscopic duodenal biopsies were obtained from seven crossbreed dogs. serial histologic sections were stained with mac or am- k. positively-stained cells were counted from random areas from both villous and crypt regions. stained cell localisation was subjectively evaluated and the percentage of positively stained cells from the total nucleated cells per , lm in the villus or crypt was compared between both antibodies using a wilcoxon signed-rank test. mac and am- k did not co-localize on serial sections. there were significantly more am- k positive cells than mac in the crypts ( . % [ - . ] versus . % [ - . ], p = . ). in contrast there was no difference in expression of either markers in the villi ( . % [ - . ] versus . % [ - . ], p = . ). this study reports for the first time the existence of two populations of macrophages in canine intestine. these results in normal dogs will be used to explore further the distribution and function of macrophages in dogs with ce. no conflicts of interest reported. chronic diarrhea and vomiting are common clinical signs in dogs. primary (e.g., inflammatory, infectious, neoplastic, mechanical, or other) and secondary gastrointestinal diseases (e.g., exocrine pancreatic, hepatic, renal, or endocrine disease) are possible underlying causes. the aim of this study was to evaluate the final diagnoses in dogs with chronic diarrhea and/or vomiting and to determine the prevalence of various primary and secondary gastrointestinal diseases in dogs with these gastrointestinal signs. medical records of dogs presented between july and august with chronic diarrhea (d), vomiting (v) or both (diarrhea and vomiting [vd]) were retrospectively reviewed. dogs were included if a minimum work-up (hematology, plasma biochemistry profile, and fecal parasitology) had been performed and if a final diagnosis was recorded ( / ). a primary gastrointestinal disease was recorded in % of the cases ( / ) and included inflammatory diseases ( / , exocrine pancreatic insufficiency, hypoadrenocorticism, polyendocrinopathy, dilated cardiomyopathy, and leukemia in one dog each). in total, % of the dogs were presented with d ( / ) followed by % with vd ( / ), and % with v ( / ). d and vd were significantly more frequent in dogs with primary gastrointestinal disease (d: / , vd: / ), compared to dogs with secondary gastrointestinal disease (d: / ; vd: / ; p = . , chi square test). v was significantly more common in dogs with secondary gastrointestinal disease ( / ) as compared to dogs with primary gastrointestinal disease ( / ; p = . ). in this study, food responsive enteropathy ( %) was the most commonly diagnosed cause of chronic gastrointestinal signs. chronic pancreatitis was the most frequent cause of secondary gastrointestinal disease ( %). diarrhea was significantly associated with primary and vomiting with secondary gastrointestinal disease. no conflicts of interest reported. matrix metalloproteinases (mmps) and are zinc-dependent endopeptidases that contribute to the control of breakdown and reconstitution of extracellular matrix under both normal and pathological conditions. intestinal mucosal levels of mmp- and - have been shown to be increased in animal models and human ibd. to our knowledge, the presense of mmp- and - has not been studied in the intestinal mucosal samples of healthy dogs as well as in canine spontaneous ibd. thus, the main aim of this study was to identify the presence of mmp- and - in the mucosa of the small and large intestines of clinically healthy beagle dogs using gelatin zymography technique. for the study, historical intestinal tissue samples from four different parts of the intestine (duodenum, jejunum, ileum and colon) were used. the samples were taken and snap frozen in liquid nitrogen during necropsy from healthy laboratory beagle dogs after being euthanized when finishing unrelated long-term trials studying canine intestinal microbiota. based on wsava histology standards, recorded findings of all samples were considered insignificant. pro-mmp- and - activities were found in / ( %) and / ( %) of the samples, respectively. among four different parts of the intestine of dogs, the ileum had the highest positivity rates of / ( . %) and / ( . %) for pro-mmp- and - activities, respectively. however, statistical analysis showed no significant difference of pro-mmp- and - activities between the separate parts of the intestine (p > . ). the enzyme activities ranged for pro-mmp- between . and . arbitrary units (au) and for pro-mmp- between . and . au. none of the intestinal samples showed gelatinolytic activity corresponding to the control bands of active mmp- and mmp- . this study showed that pro-mmp- and - could be detected in the intestinal mucosa of healthy dogs using zymography, which seems to be a useful tool to evaluate the role of mmp- and - in the pathogenesis of canine chronic enteropathies, including inflammatory bowel diseases. no conflicts of interest reported. digestive perforation is called spontaneous when it arises in the absence of foreign body ingestion, gastric dilatation and volvulus, external trauma, or previous digestive surgery. in dogs many predisposing factors have been identified, including antiinflammatory administration, severe hepatic or renal disease, stress, shock, gastric hyperacidity, neoplasia and idiopathic inflammatory bowel disease. spontaneous digestive perforation has been uncommonly reported in cats. the objectives of this study were to describe the clinical characteristics of spontaneous digestive perforation in cats, and to compare the frequency of malignant versus non-malignant causes for these perforations. to be included in this study, the perforation had to be spontaneous and confirmed by exploratory surgery. the medical records of cats diagnosed as having spontaneous digestive perforation between and were reviewed. the mean age of cats was . years ( months to years). five cats had concurrent illnesses including viral upper respiratory tract disease, pancreatitis and chronic kidney disease. the most frequently reported signs included anorexia ( %), vomiting ( %), and lethargy ( %). histological examination was performed in cats and diagnosed alimentary lymphoma in % and inflammatory lesions in the other % of them. six cats had received anti-inflammatory within the previous months. half of them were finally diagnosed with lymphoma. five cats with lymphoma received chemotherapy.three cats died early in the postoperative recovery period, cats were euthanized to days after surgery, and cats were still alive at the end of this study. in the absence of pneumoperitoneum, clinical signs and clinicopathological abnormalities are not specific enough to allow differentiation between cats with gastrointestinal ulceration and those with perforation. in most cases, there is no diagnostic test that individually determine whether perforation has occurred or is impending, and clinicians should use of multimodality diagnostic procedures such as radiography, ultrasonography, endoscopy, and abdominal fluid cytopathology to avoid delay in diagnosis of digestive perforation. histological examination of ulceration is essential as lymphoma should be suspected in all cats presented with spontaneous perforation. the link between anti-inflammatory administration and spontaneous perforation in cats is not established. no conflicts of interest reported. campylobacter species are commonly isolated from faeces of dogs and cats with c. upsaliensis (cu) and c. helveticus (ch) being the most frequently isolated. these two species are usually not considered pathogenic in dogs and cats and are closely related to each other and to c. jejuni, the most common cause of bacterial gastroenteritis in humans in the developed world. interestingly, despite their close genetic relationship, in humans cu is considered a pathogen while ch is not. this study aimed to describe whole genomes of cu and ch isolated from dogs and cats and to in silico investigate their pathogenic potential with comparison to several published genomes of c. jejuni and c. coli. genomic dna was extracted from three isolates of each of cu and ch recovered from the faeces of healthy dogs and cats. sequencing was performed using an illumina miseq to generate base paired reads. reads were trimmed for both length and quality. contigs were assembled using the velvet assembler. the concatenated contigs generated for each assembly were quality ranked (by number, size, maximum length and n ) and the three top ranked assemblies were annotated using the prokka annotation tool. ribosomal mlst nucleotide sequences were used as a proxy for the core genome to compare the phylogeny of cu and ch with other species in the campylobacter genus and visualised as a neighbornet using splitstree. annotated draft genomes were clustered using orthomcl and pathogenic traits were investigated in silico using pathogenfinder and viru-lentpred software. the cu and ch draft genomes were~ . mb and . mb in size, and comprised on average and contigs, and on average and predicted genes, respectively. of these cu had on average and ch hypothetical proteins. using orthomcl, a core genome of and genes resulted for cu and ch, respectively. neighbornet trees based on ribosomal mlst nucleotide sequences and the core genome confirmed the close phylogenetic relationship of ch and cu within the campylobacter genus. pathogenfinder predicted all isolates as human pathogens with probabilities of . - . %. both pathogenfinder and virulentpred identified many pathogenic proteins in cu and ch of different functions (e.g. chemotaxis, transporter and motility systems) but considerably fewer than in c. jejuni and c. coli. this study provides many insights into the pathogenic potential of pet-associated emerging campylobacter pathogens and is to our knowledge, the first to report a draft genome of ch. no conflicts of interest reported. there are only few laboratory markers being evaluated for diagnosing and/or monitoring canine chronic enteropathies, including inflammatory bowel disease (ibd). s a belongs to the s /calgranulin-protein family and has been proposed to play a central role in both innate and acquired immune responses. it has been reported to be increased in stool samples, serum and/or intestinal mucosa in human patients with ibd. myeloperoxidase (mpo) is an enzyme found mostly in granulocytes. intestinal mucosal levels of mpo have been shown to be increased in animal models and human ibd. to date, s a and mpo levels in intestinal mucosal samples have been reported neither from healthy dogs nor from dogs suffering from ibd. to start investigating this aspect in dogs, the objective of this study was to evaluate mucosal s a and mpo levels in the small and large intestines by using enzyme-linked immunoassay (elisa) and spectrophotometric methods, respectively. for the study, historical intestinal tissue samples from four different parts of the intestine (duodenum, jejunum, ileum and colon) were used. the samples were taken and snap frozen in liquid nitrogen during necropsy from healthy laboratory beagle dogs after being euthanized when finishing unrelated long-term trials studying canine intestinal microbiota. based on wsava standards the histologic findings of all samples were considered insignificant. s a concentrations were from the highest to the lowest: ileum, . ( . - . ) lg/l; colon, . ( . - . ) lg/l; duodenum, . ( . - . ) lg/l; and jejunum, . ( . - . ) lg/l. the concentration in the ileum was significantly higher than in all other segments (p < . ), and the colonic mucosal concentration was higher than the jejunal (p < . ). the highest mpo activity was found in the ileum ( . [ . - . ] da/min), followed by jejunum ( . [ . - . ] da/min), duodenum ( . [ . - . ] da/min), and colon ( . [ . - . ] da/min). mpo activity was significantly higher in ileal and duodenal than in colonic mucosal samples (p < . ). the jejunal mpo activity was higher than the colonic and duodenal activity (p < . ). this study showed that using elisa and spectrophotometry allow the detection of canine intestinal mucosal s a and mpo, respectively. the levels on s a and mpo seem to differ between certain parts of the intestinal mucosa of healthy dogs. both assays appear to be useful to further evaluate the role of s a and mpo in the pathogenesis of canine chronic enteropathies, including ibd. dr. heilmann, dr. suchodolski, and dr. steiner have a patent pending that includes the canine s a assay used in this study. the authors declare that they have no further conflicts of interest. the aim of the present study was to establish the incidence of innocent cardiac murmurs in a fairly large number of clinically healthy puppies. a second aim was to evaluate a possible correlation between the presence of an innocent cardiac murmur and a lower hematocrit value. puppies of certain breeds are routinely screened for the presence of congenital porto-systemic shunts in the netherlands. breeders bring their nests to our clinic for individual measurement of blood ammonia concentration. in one year time (from february until january ) dogs of different breeds were examined, with of them being cairn terriers. the age of the dogs varied from to days (mean days). while the breeders were waiting for the blood results, the cardiac auscultation was performed by a single board-certified cardiologist (vsz). hematocrit was measured with an automatized hematology analyzer system from the surplus blood sample. cardiac murmur was found in dogs ( %). in all cases this was a soft ( - out of ) systolic murmur, most of the time with a musical character and with the point of maximal intensity on the left hemithorax, compatible with the description of an innocent cardiac murmur. no murmurs were found that could be compatible with a congenital cardiac anomaly. the hematocrit was significantly (p = . ) lower in the group of dogs with a murmur (mean . %, standard deviation . %) compared to the group without a murmur (mean . %, standard deviation . %). multivariate analysis shows that the presence of murmur is correlated with the hematocrit, but not with the age of the dogs. physiologic anemia has been long suspected to be one of the possible causes of innocent cardiac murmurs in young animals and children. however, according to the authors knowledge, no published reports exist that looked for a possible correlation. which other factors contribute to the presence of an innocent murmur is largely unknown. because of a large overlap between the hematocrit values of dogs with and without a cardiac murmur, measuring hematocrit in a particular pup would not help a less experienced first line veterinary practitioner to decide whether a murmur is innocent or the result of a congenital cardiac anomaly. limitation of this study is that no echocardiography was performed to rule out congenital cardiac anomalies as the cause of the murmurs. neither were the dogs re-checked for spontaneously disappearance of the murmur. no conflicts of interest reported. low intensity systolic murmurs, with point of maximal intensity over the outflow tract on the left side of thorax, are not uncommonly heard during cardiac auscultation of apparently healthy siberian husky dogs, often with excellent exercise tolerance. the origin of these murmurs in athletic dogs such as huskies is unlikely to be due to heart disease but more likely due to turbulent blood flow in the outflow tract caused by a large stroke volume and forceful cardiac contractility in early systole. the differentiation of these murmurs from "pathological"significant murmurs can however be problematic in general practice. the aim of the present study was to investigate the prevalence of murmurs in a sample of successfully racing siberian husky dogs and furthermore to study the phonocardiographic characteristics of these murmurs. phonocardiograms and ecgs were recorded in actively racing siberian husky dogs, with normal or excellent exercise tolerance. normal stamina was confirmed by successful racing. phonocardiograms were easy and rapid to record on a pc laptop connected to the meditron stethoscope in ambulant "field"practice. systole was measured as the duration measured from the onset of the first heart sound to the onset of the second heart sound and the murmur duration from the onset the first heart sound to the end of the murmur. the duration of the first heart sound plus the murmur was measured and calculated as a percentage of the duration of systole. cardiac murmurs of grade - were heard in % of dogs examined. phonocardiogram from these dogs revealed early systolic crescendo-decrescendo or decrescendo murmurs with a duration of maximally % into systole. all dogs with murmurs had a silent pause at the end of systole. ecg was normal in all dogs. murmurs in adult athletic dogs should not be regarded as a definite sign of heart disease. physiological flow murmurs of up to % of systole is a common finding in active siberian husky dogs (prevalence % in the examined sample). phonocardiography is a rapid and practical method for differential diagnoses between pathological murmurs and physiological flow murmurs. no conflicts of interest reported. nt-probnp has a degree of overlap with clinically normal animals, particularly those with mild or subclinical heart disease. prior studies have evaluated the sensitivity and specificity of a point-of-care second generation elisa that utilizes snap technology. the snap feline probnp test uses the same biological reagents as the cardiopet probnp test but provides results in minutes. we sought to prospectively validate the assay in a population of clinically normal cats. cats were recruited based upon the absence of a heart murmur, gallop, and/or arrhythmia. all cats received physical examination, non-invasive blood pressure measurement, complete biochemical analysis including a t , urinalysis and echocardiogram. only cats considered free of underlying cardiac or systemic disease were enrolled. sixteen adult cats were enrolled and blood samples were obtained for nt-probnp concentrations at , hr, hr, hr, hr, hr. samples were placed in edta tubes and centrifuged within one hour and split into two tubes for duplicate samples at each time point and stored at - °c. once all samples were collected, they were shipped on dry ice overnight and run in one batch (idexx laboratories) for measurement of nt-probnp concentrations. snap tests were visually evaluated by one blinded reader. comparison of snap assay vs. quantitative elisa revealed a . (auc) degree of correlation between assays, and that a positive snap test result was associated with a nt-probnp concentration of . pmol/l or greater. the average bnp concentration of abnormal cats ( . ae . ) determined by the snap assay was significantly greater than the normal ( . ae . ). this study was funded through idexx and the university of florida college of veterinary medicine resident grant competition. we acquired d echocardiographic cineloops from the left apical -chamber view optimized for the la, and analyzed atrial longitudinal strain (st) and strain rate (sr) in dogs ( healthy dogs and dogs with mmvd - acvim stage b , stage b and stage c). endocardial la ste curves were obtained and peak atrial longitudinal strain (pals), peak atrial contraction strain (pacs), conduit atrial longitudinal strain (cals); pals-pacs) and contraction strain index (csi -pacs/pals* ) were calculated. la sr curves were similarly obtained to determine the peak positive strain rate (srs) during left ventricle systole, the first negative peak strain rate (sre) during early diastole and the second negative peak strain rate (sra) during atrial contraction. for all variables, a mean of measures was used for the statistical analysis. we compared each of these variables between each acvim stage by kruskal-wallis tests and post-hoc pairwise comparisons, with comparison-wise a= . . normal dogs had higher pals and cals than dogs with mmvd (p < . and p = . ); stage c dogs had lower pals, pacs and cals than all other dogs (p < . , p = . and p = . ), but csi did not differ between groups (p = . ). stage c dogs had lower srs (p = . ), higher sre (p = . ) and sra (p = . ) than other dogs. normal dogs had lower sre and sra than dogs with mmvd (p < . ). our data suggest that ste might be useful in assessing la function in dogs with mmvd, and might potentially differentiate dogs with severe subclinical disease from dogs with congestive heart failure. no conflicts of interest reported. sighthounds are athletic dogs and they have been claimed to have larger hearts compared to similar sized breeds. the left ventricle (lv) may enlarge in response to cardiac disease, but also in response to training, so called athlete's heart syndrome, which is a benign condition. to distinguish abnormal echocardiographic measurements from normal, breed-specific reference values are needed. the aim of this study is to establish normal reference ranges for echocardiographic measurements in the saluki breed. the study comprised clinically healthy salukis ( males and females), mean age months (ae sd months), bodyweight (bw) , kg (ae , kg). case history was ascertained and dogs underwent physical examination, complete blood count, serum biochemistry profile, thyroid profile, blood pressure measurement and -min ecg. standard m-mode and d echocardiographic measurements were obtained. dogs with systolic murmur / , and dogs with mitral valve regurgitation (mr) < % (mr color flow jet area/left atrium areax % in apical view) were considered normal. linear regression models were used to establish reference ranges. heart rate (hr) varied from to bpm ( ae bpm). bw was a significant predictor for lv dimensions, i.e. m-mode lv diameter and d volume in diastole (lvidd and lvedv) and systole (lvids and lvesv), and mitral valve end point septal separation (epss). hr was a significant predictor for fs % (fractional shortening). predicted values ( % prediction intervals) were calculated from regression models where mean bw ( , kg) and age ( months), and median hr ( bpm) were used. normal reference ranges were: lvidd , mm ( , - , ), lvids , mm ( , ) , lvedv , ml ( , - , ), lvesv , ml ( , - , ), fs%: , % ( , - , ), ejection fraction ef%: , % ( , - , ), epss , mm ( , - , ), sphericity index , ( , - , ), interventricular septum in diastole , mm ( , - , ) and systole , mm ( , - , ), lv free wall in diastole , mm ( , - , ) and systole , mm ( , - , ), left atrial (la) diameter , mm ( , ) , aortic (ao) diameter , mm ( , - , ) , la/ao , ( , - , ), and aortic and pulmonic flow velocity , m/s ( , ) and , m/s ( , - , ), respectively. this study provides echocardiographic values for normal salukis which can be used as a reference values. no conflicts of interest reported. in mitral valve disease, atrial remodeling is an indicator of evolution and prognosis, the duration of the p wave being considered suggestive of the dilatation of the left atrium. in humans' studies, neurological conditions have a significant impact on cardiac electrophysiology by altering the electrical impulse conductibility. the aim of this study is to examine the duration of the p wave in dogs suffering from mitral valve disease in comparison to dogs diagnosed with different neuropathies without cardiac abnormalities. we analyzed standard electrocardiograms ( min of ecg, on peripheral leads) performed on three polymorphic groups of dogs (different age, weight and breed): group (n = ) healthy dogs, group (n = ) dogs diagnosed with mitral valve disease and group (n = ) dogs suffering from different neuropathies (without any associated or previously diagnosed cardiovascular disease). the duration of the p wave was measured for all dogs (five consecutive p waves without anomalies or artifacts) and reported to the degree of atrial remodeling, assessed by left atrium/ aorta ratio on echocardiography. the interpretation of the ecg and echocardiography was made by the same examiner (md). the results were statistically evaluated in a specialized program (ibm spss vs. ). the p wave recorded average values was . ae . seconds for the mvd group with significant differences between the stages of heart failure (p = . ). no correlations were found between its increase and the dilation of the left atrium (r = . ). there was no statistically significant difference regarding p wave duration when compared dogs of the neuropathy group and those of the mitral valve disease group (the p wave recorded average values = . ae . sec.). both, atrial tissue lesions (as in mitral valve disease) and autonomic nervous system anomalies (secondary to a neurological condition), may change the conductibility of the electrical impulse in the left atrium. the conductibility of the electrical impulse at this level does not seem to be influenced by its actual dilation, but by the impairment of the intra-atrial and inter-atrial conduction pathways. caution must be given when p wave is analyzed in dogs with concurrent cardiologic and neurologic condition. no conflicts of interest reported. newfoundland dogs were prospectively recruited among those undergoing screening for congenital and acquired heart disease. screening includes patient history, physical examination, and systemic arterial pressure measurement by doppler flow meter and transthoracic echocardiography (m-mode, d and echo-doppler). screening is performed on conscious dogs of at least year of age. dogs without historical, clinical, electrocardiographic and echocardiographic signs of cardiovascular disease were included in the study. unpaired, two-tailed student's t-test and linear regression were performed to evaluate the influence of gender, age and body weight (bw) on echocardiographic parameters. echocardiographic measurements were compared to previously reported reference values. the reference limits of echocardiographic parameters in the newfoundland dogs were calculated. forty-six healthy adult newfoundland dogs of both genders ( males and females), to years of age (mean . ae . years), to kg (mean . ae . kg) fulfilled the inclusion criteria. significant but weak correlations were detected between aortic diameter (ao) and age (p = . , r = . ), left atrial to aortic ratio (la/ao) and age (p = . , r = . ), e-point to septum separation (epss) and bw (p = . , r = . ), m-mode left ventricular internal diameter (lvid) in diastole (d) and systole (s) and bw (respectively p = . , r = . and p = . , r = . ), and between ao and bw (p = . , r = . ). none of the echocardiographic measurements was statistically different between males and females. left ventricular internal diameter in diastole, lvids, ao, epss increased with bw, as expected. the aorta appears to become wider with advancing age. a proportion of the studied population had m-mode parameters below the allometric scaling reference range, suggesting that this method can over-estimates m-mode parameters in this breed. these findings stress the importance to report newfoundland breed specific normal ranges for echocardiographic parameters. no conflicts of interest reported. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease usually diagnosed by thoracic ct-scan that mainly affects west highland white terriers (whwt). pulmonary hypertension (ph), a severe co-morbid condition with a challenging diagnosis, may develop in cipf dogs. the ratio between the right pulmonary vein and pulmonary artery (pv/ pa) has been described as an echocardiographic indicator of ph in cipfdogs. this study was intended to investigate whether ct-scan angiography cardiac findings are ) altered in dogs with cipf compared to healthy control dogs and ) correlated with pv/pa measured by echocardiography (pv/pa us ). thoracic cta images from whwt with cipf (group a) and healthy controls from various breeds (group b) were retrospectively reviewed by one observer. all measurements were obtained in transverse post-contrast images displayed in a soft tissue window. pv and pa were measured dorsal to the right atrium, perpendicular to the long axis of these vessels. in addition, pulmonary trunk (pt) was assessed just ventral to the division of pulmonary arteries, perpendicular to its long axis. ascending aorta (ao) was also measured perpendicular to its long axis. transverse reformatted images were obtained to have a view equivalent to the standard chambers-echocardiographic view where right ventricle (rv) and left ventricle (lv) were measured. three ratios were calculated pv/pa ct , pt/ao and rv/lv, compared between groups and correlated with pv/pa us in both bi-dimensional (bd) and m-modes (mm). statistical analyses were performed with xlstat â software. values are given as mean ae sd. statistical significance was set at a p ≤ . . pv/pa ct was lower in group a ( . ae . ) in comparison to group b ( . ae . , p = . ) and correlated with pv/pa us (bd: r = . , p = . ; mm: r = . , p = . ). pt/ao was higher in group a ( . ae . ) compared to group b ( . ae . , p = . ) and correlated only with pv/pa us measured in bd mode (r = - . , p = . ). the rv/lv ratio was increased in group a ( . ae . ) in comparison to group b ( . ae . , p = . ) and a correlation between rv/lv and pv/pa us was found (bd: r = - . , p = . ; mm: r = - . , p = . ). in conclusion, in whwt with cipf, pv/pa ct , pt/ao and rv/lv ratios measured on thoracic cta images are correlated with pv/pa us and may serve in the assessment of ph. no conflicts of interest reported. companion animals presenting to the emergency room in distress need to be assessed rapidly and accurately to implement life-saving therapies. focused cardiac ultrasound (focus) can be a useful adjunct to the physical examination in assessing dyspneic animals in the emergency room. rapid bedside ultrasound evaluations performed by ec are commonly used in human medicine, however feasibility and utility of focus by ec in veterinary medicine has not been fully evaluated. the purpose of this study is to determine the baseline accuracy of focus performed by ec and whether or not a basic training session could improve accuracy compared to evaluation by a cardiology specialist. fifteen ec including boarded emergency-critical care specialists and emergency res-idents performed focus on four animals; a normal cat and dog, and a cat and dog with severe valvular and myocardial heart disease, respectively. ec semi-quantitatively assessed thoracic and echocardiographic parameters including left atrial dimension, left ventricular systolic function and wall thickness, right heart dimension, and presence or absence of pleural or pericardial effusion before and after a structured didactic lecture and hands-on practical session. primary outcome was the level of agreement with examination performed by a cardiologist. level of agreement regarding ec assessment of all parameters improved from . to . after training (p < . ). level of agreement concerning left atrial diameter improved from . to . (p < . ). ec confidence in their overall focus evaluation and findings improved from % to % (p < . ). in summary, ec accuracy and confidence in semi-quantitatively assessing basic cardiac parameters using focus were improved following a simple structured training session. focus might be a valuable tool to rapidly assess simple thoracic and cardiac parameters in the emergency setting. no conflicts of interest reported. obesity is an increasing health problem in dogs. success of weight-loss programs is often limited by compliance issues. the purpose of this study was to determine the effectiveness of a new dietetic weight management food (ndwmf)* in achieving weight loss in overweight/obese, client-owned dogs, under typical household conditions. the objectives were ) to evaluate weight loss parameters in dogs fed a ndwmf* and ) to assess the owner's perception of the dog's quality of life. overweight/obese, otherwise healthy, client-owned dogs (> / body condition score -bcs) were enrolled in the study (n = ). initial veterinary evaluation included physical examination, nutritional assessment, determination of ideal body weight (ibw), and development of weightloss feeding guidelines. daily energy requirement (der) for weight loss was calculated as der = x ibw kg . . initial and follow-up evaluations (monthly for months) encompassed determination of body weight, bcs, body fat index (bfi), muscle condition score (mcs), and feeding practices. quality of life assessment by owners included dog's level of energy, happiness, appetite, begging behavior, flatulence, stool volume, and fecal score. statistical analysis comprised scatterplots, regression analysis, summary statistics as appropriate for the type of analyses performed (continuous or categorical variables, distribution), and a mixed model anova to assess changes over time (with statistical significance at p < . ). ninety four percent of the dogs lost weight (n = ) with an average weight loss of . % (sem, . %) over months and an average weekly weight-loss rate of . % (sem, . %). the mean duration of weight loss was days (sem, . days) with an average of days (sem, . days) between rechecks. thirty nine percent of dogs achieved ibw ( . , ci: . - . ). fifty five percent of dogs ate more calories from ndwmf* than the recommended der for weight loss (median fed above der= %) and % of these dogs ( . , ci: . - . ) still lost weight. thirty six percent of dogs received treats. bcs and bfi decreased significantly over time compared to baseline. owners perceived a significant increase in energy and happiness in the dogs that lost weight without changes in appetite or begging behavior. in conclusion, this clinical study confirmed the effectiveness of the ndwmf* in achieving weight loss in overweight/obese client-owned dogs in spite of higher than recommended caloric intake. owners reported significant improvements in dog's quality of life without negative side effects. * haptoglobin is a moderate acute phase protein in cats. as a part of the innate immune system its concentration rises within - hours after tissue damage. aim of the study was to validate an elisa which was recently developed for the measurement of feline haptoglobin and to compare it with a commonly used spectrophotometric assay. the concentration of haptoglobin was measured in healthy and sick cats using a sandwich-elisa (tecomedical group, rheinbach, germany). the validation included the detection of intra-assay and inter-assay variation, dilution linearity, spike recovery and lower detection limit. a spectrophotometric assay (tridelta development ltd, maynooth, ireland) was used as a reference method. all samples were measured in duplicate. statistical analysis was performed using ibm â spss â statistics (ibm corporation â ) and included descriptive statistics, spearman correlation (rs) and coefficients of variation (cv). the coefficients of variation were . %, . % and . % for intra-assay variability and . %, . % and . % for inter-assay variability. the ratio of observed to expected dilutional parallelism of serum samples diluted times ranged from to %. the ratio of observed to expected spike recovery of serum samples ranged from % to %. the lower detection limit was . mg/ml. the correlation between the assays was significantly strong (rs = . , p < . ). the recently available sandwich-elisa provides a high accuracy and precision and can therefore be used for the measurement of feline haptoglobin. the rd and th author (m. hennies and c. wienen) work for the company tecomedical group that developed the elisa which was evaluated in the study. they provided the kits and they helped with performing the tests, but they did not have any influence on the results and the interpretation of the data. canine idiopathic pulmonary fibrosis (cipf) is a progressive interstitial lung disease that mainly occurs in the west highland white terrier (whwt) breed. the cipf diagnosis commonly relies on thoracic high-resolution computed tomography (hrct) findings and ultimately on histopathology. as those tests are not easily performed in practice, identification of measurable markers of fibrosis, that might help to diagnose and/or monitor the course of cipf, is helpful. vegf is an angiogenic regulator involved in a variety of physiological and pathological processes. in human ipf, serum vegf concentration has been shown to be higher in ipf patients compared to healthy volunteers and may reflect the severity of the lung disease. the aims of the present study were ( ) to investigate the potential role of vegf as a peripheral blood biomarker in cipf; and ( ) to investigate possible breed-related differences in basal vegf concentration, that might explain the high predisposition of the whwt breed for cipf.therefore, vegf was determined by elisa (canine vegf quantikine elisa kit, r&d systems) in the serum of whwt with cipf confirmed by hrct and/or histopathology (median age years, range - ), healthy whwt ( , - ), and healthy dogs of other breeds, including: scottish terrier (st) ( , - ), jack russell terrier (jrt) ( , - ), maltese ( , - ), king charles spaniel (kcs) ( , - ), labrador retriever (lr) ( , - ) and malinois belgian shepherd ( , - ). health status was based on clinical examination, serum biochemistry and haematology in all healthy dogs and a thoracic hrct was performed in / healthy whwt. the khi² test with the threshold % was used for the statistical analysis (xlstat â software). eight cipf whwt ( %) have serum vegf concentrations above the kit detection limit ( . pg/ml) compared to whwt ( . %) in the group of healthy dogs (p = . ). concerning inter-breed differences in healthy dogs, most values obtained were below the kit detection limit with only kcs ( %), jrt ( %), lr ( %) and st ( %) having vegf serum levels above . pg/ml (p = . ). results of the present study show that ( ) vegf might be an interesting blood biomarker for cipf; ( ) canine vegf quantikine elisa kit is not appropriate for measurement of serum vegf levels in healthy canine populations. no conflicts of interest reported. the total protein (tp) concentration and cell count of pleural and abdominal fluid is used to differentiate a transudate from an exudate. tp can be measured by automated wet chemistry analyser or more easily using a refractometer. the aim of this study was to assess if refractometer values of tp are useful for this purpose. retrospectively samples from canine pleural and abdominal effusions in which tp concentration was measured both with a refractometer as well using pentra (abx horiba, montpellier) were included. samples were collected into heparinized tubes and analysed within hours. bland-altman diagrams were created and correlation between both measurements was calculated by spearman s nonparametric correlation. over a -months period, pleural and abdominal effusion samples were analysed with both techniques. median (range) tp concentrations in pleural effusion measured by refractormeter or by pentra was ( - ) g/l and ( - ) g/l, respectively. median (range) tp concentrations in abdominal effusions measured by refractometer or pentra was ( - ) g/l and ( - ) g/l, respectively. tp measurement between refractometer and pentra values were significantly correlated in pleural (r = . , p < . ) and abdominal (r = . , p < . ) effusion. the bland-altman graph showed a bias in the thorax and abdomen of . and . . the refractometer is an acceptable, rapid and efficient method for determination of total protein concentration in pleural and abdominal effusions in dogs to differentiate transudates from exudates. no conflicts of interest reported. coagulation factor vii (fvii) deficiency has been reported in beagles since the 's. deficient dogs show a mild hemorrhagic tendency, but often remain asymptomatic and are incidentally discovered by an isolated prolonged prothrombin time due to < % plasma fvii activity. factor vii deficiency occurs commonly in beagles, alaskan klee kais and scottish deerhounds. in these breeds it is caused by a single missense mutation (c. g>a, p.gly glu) in the second epidermal growth factorlike domain of fvii, which drastically reduces the secretion and activation of fvii. research beagles were also commonly affected which may have pharmaco-toxicologically affected studies but specific dna screening programs have been established. we report here on the discovery of fvii deficiency in welsh springer spaniels (wss) in finland based upon a novel screening panel for~ known mutations underlying inherited disorders in different canine breeds (www.mydogdna.com). among wss initially tested, were heterozygously ( %), and homozygously affected for the same fvii mutation, which was confirmed by sequencing in all dogs. in order to determine whether the mutation causes fvii deficiency also in this breed, we recruited littermates and their mother. none of these wss had shown an increased hemorrhagic tendency, but affecteds bled excessively following blood collection. we found that the homozygous affected dogs of the litter exhibited markedly prolonged prothrombin time but normal partial thromboplastin time. they also had drastically reduced fvii activities but normal to high fviii and fix activities compared to their littermate controls. the heterozygous carriers tested did not show any prolongations in their prothrombin time, but had half normal fvii activity. in conclusion, we document here the presence of fvii deficiency in wss based upon dna and coagulation activity testing. the common gly glu mutation must have arisen prior to the separation of the very different fvii deficient breeds. there is no knowledge of an advantage of the heterozygote state. while there is only a mild hemorrhagic tendency, bleeding dogs could be treated with fresh frozen or cryo-poor plasma or human recombinant fviia. this preliminary study indicates a high carrier frequency in wss. screening by new platform dna methods for this and other ancestral defects is helpful to detect additional hereditary diseases and genetic predispositions in different breeds, while other mutations are new and restricted to one or related breeds. authors are affiliated with genetic disease screening test laboratory. remarkably little has been published on haematological and serum biochemical phenotypes of the domestic dog. information on the signalment and complete blood cell count of all dogs with normal red and white blood cell parameters judged by existing reference intervals was extracted from a veterinary database; similar information was collected from all dogs with normal serum biochemical profiles, considering all parameters other than glucose as inclusion criteria. normal haematological profiles were available for dogs, of which also had machine platelet concentrations within the reference interval; normal serum biochemical profiles were available from dogs, of which also had accompanying normal serum glucose concentrations. for the haematological data, pure breeds plus a mixed breed control group were represented by or more dogs, while for the serum biochemical data, pure breeds plus a mixed breed control group were represented by or more individuals. all measured haematological parameters except mean corpuscular haemoglobin concentration (mchc), and all serum biochemical analytes except sodium, chloride and glucose, varied with age. concentrations of white blood cells (wbcs), neutrophils, monocytes, lymphocytes, eosinophils and platelets, but not red blood cell parameters, all varied with sex, as did total protein, globulin, potassium, chloride, creatinine, cholesterol, total bilirubin, and activities of alanine aminotransferase (alt), creatine kinase (ck), amylase and lipase. neutering status had an impact on haemoglobin concentration, mean corpuscular haemoglobin (mch), mchc, and concentrations of wbcs, neutrophils, monocytes, lymphocytes and platelets, as well as all serum biochemical analytes except albumin, sodium, calcium, urea and glucose. principal component analysis (pca) of haematological data revealed pure breeds with distinctive phenotypes, while pca of serum biochemical data revealed over pure breeds with distinctive phenotypes. furthermore, all haematological parameters except mchc and all serum biochemical analytes except urea and glucose showed significant differences between specific individual breeds and the mixed breed group. twenty-nine breeds had distinctive haematological phenotypes and breeds had distinctive serum biochemical phenotypes when assessed in this way. tentative breed-specific reference intervals were generated for breeds with a distinctive phenotype identified by comparative analysis. this study represents the first large-scale analysis of haematological and serum biochemical phenotypes in the dog and underlines the important potential of this species in the elucidation of genetic determinants of haematological and biochemical traits, triangulating phenotype, breed and genetic predisposition, as well as the urgent need for breed-specific reference intervals in clinical practice. the author has received funding from bbsrc, petplan charitable trust, and cruk), but none of thesegrants were for this study. for each cat aged years or older, irrespective of their suspected thyroid status, presented to eight veterinary practices in portugal, the veterinarian and the pet owner had to complete a questionnaire and the veterinarian had to take a venous blood sample (into a plain tube) from the cat, after obtaining signed owner consent. the veterinary questionnaire included history, attitude, activity, heart rate and thyroid palpation. cats aged < years and those diagnosed previously with hyperthyroidism were excluded. blood samples were centrifuged and the serum harvested and stored frozen until collection by the laboratory within days of sampling. total t was measured using a chemiluminescent method (immulite , siemens). cats were classified as hyperthyroid, equivocal or euthyroid based on a total t concentration of > nmol/l, - nmol/l or < nmol/l, respectively. repeat measurement of total t after - weeks was recommended for all equivocal cases. the individual cat was the statistical unit. descriptive statistics was used to summarise the data and associations between different clinical signs analysed using chi-square, fisher's exact test or the mann-whitney u test. the level of significance was set at . . thirty cats were excluded from the prevalence analysis because they were aged < years (between and years, n = ) or their age was not stated (n = , four of these cats were hyperthyroid). by the end of february , samples had been submitted from cats that met the inclusion criteria. based on the thyroid hormone analysis, there were / ( %) hyperthyroid, ( %) equivocal and ( %) euthyroid cats. very few follow-up blood samples were taken. hyperthyroidism appears to be not uncommon in portuguese cats. getting owners to return for follow-up blood sampling appears to be problematic. under-reporting of hyperthyroidism appears to be a significant problem in portugal, as has been reported for some other countries. thyroid palpation should form part of routine physical examinations, especially of middle aged and older cats. older cats in portugal should be screened for hyperthyroidism even in the absence of a detectable thyroid nodule. both authors are employees of msd animal health. msd animal health funded the study. msd animal health has an approved veterinary medicinal product for the treatment of feline hyperthyroidism. this product is available commercially in some eu markets but not in portugal. diabetes mellitus is one of the most commonly encountered endocrinopathies in cats and its prevalence has increased in the past. similar to human type diabetes, feline diabetes is associated with comparable lesions occurring in the pancreatic islets, namely islet amyloidosis and beta-cell loss. studying the pathophysiology of feline diabetes and the molecular mechanisms through which glucose metabolism is disturbed is largely hampered by the lack of a method for the isolation of pure pancreatic islets. the aim of this project was to improve a previously established method for the isolation of pancreatic islets; in particular enhancing the purity of isolated islets in this species. cats that died or were euthanized due to severe illness other than pancreatitis or other pancreatic disease were enrolled. pancreata were perfused post-mortem with ml collagenase type iv ( . mg/ml) through the pancreatic duct. the perfused organ was then digested for ', ' and ' at °c in a water-bath and purified using a filtration method. islet cell viability and purity were determined by thiazolyl blue tetrazolium bromide (mtt assay) and dithizone staining, respectively. perfusing the pancreas through the pancreatic duct allowed collagenase to access the islets using anatomical structures and to improve islet yield compared to previously established protocols in this species. the digestion time of ' provided the best islet yield. after digestion, feline pancreatic islets remained satisfactorily viable for days in the culture system following regular media changes. the current study has successfully optimized the isolation, purification and culture maintenance of feline islets. the successful yield and viability of islets isolated through the suggested protocol may provide promising potential as a source of islets for diabetes research in cats. no conflicts of interest reported. nesidioblastosis describes a syndrome of acquired hyperinsulinaemia and associated hypoglycaemia secondary to focal or diffuse (non-neoplastic) beta cell hyperplasia within the pancreas. beta cell dysregulation is thought to occur secondary to pancreatic injury. this syndrome has been reported in humans with increasing frequency, but it has not previously been described in domestic pets. a six year old, de-sexed female british shorthair cat presented with acute onset weakness and mental dullness. upon initial presentation the cat was mildly hyperglycaemic ( . mmol/l; . - . mmol/l). over the following hours the cat developed central blindness, tremors, intermittent seizures and opisthotonus. repeat blood sampling revealed a marked hypoglycaemia ( . mmol/l). an insulin level (performed on serum obtained while the cat was hypoglycaemic) was inappropriately elevated ( pmol/l; reference range - pmol/l). an intravenous bolus of % glucose resulted in rapid resolution of all clinical signs and mild transient hyperglycaemia ( . mmol/l). despite frequent feeding, the hypoglycaemia ( . mmol/l) recurred, so an intravenous glucose continuous rate infusion was commenced. an abdominal ultrasound was unremarkable, although three cranial mesenteric lymph nodes were noted to be prominent ( mm in width). an exploratory laparotomy revealed a firm and erythematous left limb of the pancreas. the body and right limb of the pancreas appeared grossly normal. following surgical resection of the left limb of the pancreas, the cat returned to a euglycaemic state after a brief rebound hyperglycaemia. histopathology revealed pancreatic fibrosis with marked multifocal micronodular hyperplasia of exocrine and endocrine cells, mild lymphoplasmacytic inflammation and ductular ectasia. synaptophysin immunohistochemistry confirmed nodular beta cell hyperplasia. mild granulomatous lymphadenitis and hydropic change within hepatocytes was also noted. the cat recovered uneventfully without any further intervention. it gained weight and remained euglycaemic over the following six months. while beta cell hyperplasia has been reported as an incidental histopathological finding in euglycaemic young beagles, this is the first reported case of clinically significant hypoglycaemia secondary to nesidioblastosis in a domestic pet. while this condition is rare, nesidioblastosis is being increasingly recognised in the human field and it is an important differential to consider when investigating hypoglycaemia as it cannot be differentiated from insulinoma without histopathological evaluation. age of onset may provide a clue to this non-neoplastic disease, as this cat was much younger than all previously reported cases of feline insulinoma (all > years of age at diagnosis). while recurrence has been reported in humans, a favourable outcome is anticipated following partial pancreatectomy. no conflicts of interest reported. hyperthyroidism is the most common feline endocrinopathy of geriatric cats worldwide. nonetheless, data concerning the accurate prevalence of feline hyperthyroidism (fh) is scarce; and apparently exhibit geographical variation, which can be an important instrument in investigating risk factors through the analysis of exposure to different factors in areas of high and low prevalence. in europe, fh is considered more frequent in the northern than in the southern countries. the aims of this study were to determine the occurrence of fh in a region of portugal, to characterize clinical presentation and potential risk factors. during an -month period, geriatric cats ≥ eight years from aveiro (central region of portugal) were selected. cats were excluded if presented in shock or moribund, or in treatment with drugs that might affect total t (tt ) serum concentration. the tt concentration was determined through chemiluminescence (immulite â , siemens), and diagnosis of fh established if tt serum concentration ≥ . lg/dl (reference values . - . lg/dl) associated with compatible clinical signs. information on age, gender, breed, weight, housing conditions (indoor vs outdoor), use of external parasiticides, food (dry vs canned food and flavor), use of litter box, environment, clinical signs and laboratory data was collected. all owners gave informed consent. population studied included males ( . %) and females ( . %), mainly domestic short-haired cats ( . %). ages ranged from eight to years old ( . + /- . ). eight ( . %) cats were diagnosed with hyperthyroidism. if only cats ≥ years of age were considered (n = ), prevalence raised to . %. hyperthyroid population comprised four males and four females, ranging from to years old ( . + /- . ). increasing age (p = . ), polyphagia (p˂ . ), weight loss associated with increased (p˂ . ) or normal appetite (p˂ . ), presence of thyroid uni or bilateral nodules (p˂ . ), vomiting (p = . ) and hyperactivity (p = . ) were significantly associated with hyperthyroidism in the geriatric population studied. environment was also significantly associated with development of fh (p˂ . ), with cats from urban or semi-rural areas at higher risk of developing the disease than cats living in a rural environment. no other significant associations were found between hyperthyroidism and other factors analyzed. in our knowledge, no epidemiologic studies on fh have been performed in portugal, a country where the occurrence is believed to be low, but in which the population of pet cats, the feline geriatric population and the clinical cases diagnosed have been increasing. conflicts of interest: the study was partially supported by laborat orio segalab s.a. and dechra veterinary products. canine diabetes mellitus (cdm) has been proposed to be a spontaneous animal model of human autoimmune diabetes, and comparative research can be undertaken to investigate the interaction between genetic and environmental factors. most epidemiological studies of cdm have been performed in northern european and north american populations. our aim was to evaluate the epidemiology and clinical features of the diabetic dog population from the canary islands, with special focus on immune-mediated disease. dogs attending our veterinary teaching hospital were included from january to january . previously diagnosed and new cases were considered. prevalence was calculated as number of cdm/total number of dogs attending the hospital and incidence as newly diagnosed cases divided by the same value per year. anti-insulin antibodies were assessed by elisa. genotyping for dog leukocyte antigen (dla) and measurement of canine anti-gad and anti-ia antibodies by radio-immunoprecipitation assay were performed in dogs with suspected immune-mediated diabetes. twenty-nine dogs with cdm were identified from a mean population of ( - ) dogs per year (mean prevalence . % and mean incidence cases per year per , ). age at diagnosis was . years (range: . - y). most dogs were not neutered ( % females; % males). nine breeds were represented, including poodle ( %) and andalusian wine-cellar rathunting dog ( %). seasonality was observed in the diagnosis with peaks in december and march-april. diabetes was classified as dioestrus diabetes ( %), idiopathic/immune-mediated ( %), iatrogenic ( %) and secondary to pancreatitis ( %) or other endocrine disorders ( %). insulin-treated dogs were negative for anti-insulin antibodies (n = ). from the suspected immune-mediated cases (n = ), autoantibody reactivity was shown in two cases (anti-gad , n = ; anti-ia , n = ). no previously described, diabetes-risk dla-types were identified. although age, prevalence and incidence did not differ from previous studies, the high proportion of entire females likely explained the high frequency of dioestrus diabetes. the andalusian wine-cellar rat-hunting dog was identified as a high-risk breed for cdm. most of the dla-types seen have not been previously described, but at least two have been associated with increased risk of autoimmunity in dogs. further population-based studies are needed in different regions, to assess the heterogeneous nature of this disease. no conflicts of interest reported. the cortisol-dehydroepiandrosterone (dhea)-ratio is widely used in human medicine as a marker for stress however it is not clear whether it could also help in distinguishing hyperadrenocorticism (hac) from other diseases which might have a negative impact on the outcome of a dexamethasone low dose test. therefore the aim of the study was to evaluate the cortisol-dhea-ratio as an additional diagnostic marker for hac in dogs. to achieve this aim, a reference range of this ratio depending on the sex should be evaluated in healthy dogs and compared with dogs having a hac. in healthy dogs (age: - . years) and in dogs with hac (age: . - . years) of different breeds the plasma concentration of cortisol (immulite system, siemens healthcare diagnostics) and dhea (beckman coulter) was measured and the ratio was calculated. all dogs were patients of the small animal clinic except five of the healthy dogs which were recruited from the institute of pharmacology, toxicology and pharmacy of the university. with these data the cortisol-dhea-ratio was calculated for male dogs (healthy dogs n = ; dogs with hac n = ), neutered males (healthy dogs n = ; dogs with hac n = ), female dogs (healthy dogs n = ; dogs with hac n = ) and spayed females (healthy dogs n = ; dogs with hac n = ). the statistical analysis was performed with sigma stat. the plasma cortisol-dhea-ratio of healthy male dogs was the lowest ratio of all sexual categories (mean average . ae ) and it differed significantly to all other sexes (neutered males = ae , p = . ; females = ae , p < . and spayed females ( ae . , p = . ). the cortisol-dhea-ratio showed no significant difference between male and female dogs with hac. spayed females with hac had significantly higher cortisol-dhea-ratios ( ae ) than healthy spayed females (p = . ) but no significant differences were found in other sexual categories. this preliminary data indicates that the cortisol-dhea-ratio might not be a very promising tool for the diagnosis of hac. in addition, the significant gender-dependency of this parameter has to be considered and may generally limit its clinical usefulness. this study is financially supported by the bruns-stiftung. no conflicts of interest reported. hyperthyroidism is common in older cats. the aim of this study was to assess the prevalence of feline hyperthyroidism and potential intrinsic risk factors in a hospital population in southern germany. total thyroxine (t ) was prospectively measured by enzyme immunoassay (eia) in sera of cats older than years that were presented to the clinic of small animal medicine. a standardized physical examination was performed, and body condition score (bcs) and thyroid palpation score (tps) were assessed. association between signalement, bcs and tps was analyzed by student s unpaired t-test, chi-square, and mann-whitney test. level of significance was set at . . fifty nine cats were diagnosed with hyperthyroidism leading to a prevalence of . % (ci . - . ). hyperthyroid cats were older than non-hyperthyroid cats (p < . ) and more often female (p = . , odds ratio . ). domestic short or long hair cats were more often affected than pedigrees (p = . ). hyperthyroid cats had higher tps (p < . ) and lower weight than non-hyperthyroid cats (p < . ) although bcs was not different (p = . ). in ( . %) cats, the elevated t was an incidental finding. in of those, the disease was confirmed later (the others were dead due to unrelated diseases). in patients, hyperthyroidism was considered a differential diagnosis and was confirmed in ( . %) cats although in cats additional diagnostic means were necessary. older female domestic cats are predisposed to hyperthyroidism which is frequently diagnosed after the initial clinical suspect. in a few affected cats an elevated t is not present or can precede clinical signs. conflicts of interest: the study was partially funded by msd intervet. the main endocrinopathy affecting both humans and pet felines is diabetes mellitus. accurate diagnosis is the most important aspect in the future outcome of the disease. a computer based decision support system (dss) is targeted on assisting clinicians with one or more steps of the diagnostic process. the novelty of our dss emerges from the possibility of assisting both clinical and paraclinical diagnosis stages of diabetes mellitus and all common combination of disorders associated with this endocrinopathy. the motivation behind the development of such system is the desire to maximize the reliability of clinical decisions. the design of our feline diabetes mellitus dss emerges from the syndrome of polyuria-polydipsia, with the possibility of spotting the accompanying pathologies. fuzzy logic is used for dealing with knowledge representation and uncertainty. the fuzzy rules proposed to represent this knowledge emerge from anamnesis, clinician's input, clinical and paraclinical description, and confirmation diagnostic tests. clinical signs such as polyuriapolydipsia, persistent hyperglycemia, polyphagia, weight fluctuations, administration of drugs with a diabetogenic potential, were considered decisive in the pattern of diagnosis establishment. registered medical records of cats, males and females, whit ages from to years old, were analyzed in order to validate the dss. using matlab software, the dss was implemented and tested. for any case with polyuria-polydipsia the system provides, via a friendly graphical user interface, the diagnosis with the highest probability. the set of diagnoses which can be generated by the dss consists in: a) diabetes mellitus; b) diabetes mellitus induced by (b. ) hypersomathotropism, (b. ) hyperthyroidism, (b. ) hyperadrenocorticism and (b. ) diabetogenic medication; c) diabetes mellitus in association with (c. ) chronic kidney failure and (c. ) heart failure; d) ketoacidodic diabetes mellitus; e) pancreatitis. the dss was applied with success on all cases, revealing the following diagnoses / no of cases: (a) - , (b. ) - , (b. ) - , (b. ) - , (c. ) - , (c. ) - , (d) - . an adequate treatment protocol requires an accurate and complete diagnosis. advanced computational systems accompany clinicians in their decision making, leaving a reduced space for medical errors and superfluous, expensive and time consuming tests. future work will be targeted on exploring the possibilities of combining the dss with an artificial neural network model for diabetes mellitus. this can be the foundation of a complete case oriented management system for feline diabetes mellitus and associated disorders. no conflicts of interest reported. activins are cytokines belonging to the transforming growth factor (tgf)-b superfamily. it is thought that activins may be the key intermediary in tgf-b mediated fibrotic response. activin a has been suggested to participate in the pathogenesis of human idiopathic pulmonary fibrosis (ipf), but studies regarding the role of activin b are still spares. canine ipf (cipf) is a chronic, incurable interstitial lung disease occurring particularly in west highland white terriers (whwts). during the disease course, acute exacerbations (aes), with poor prognosis, can occur. histopathologically aes of cipf are featured by diffuse alveolar damage, which is also a key feature in acute respiratory distress syndrome (ards). our objective was to study the expression of activin a and b by immunohistochemistry in the lung tissue of cipf whwts (n = ), cipf whwts with concurrent ae (n = ), and dogs of various breeds with ards (n = ), and to compare these findings to healthy whwts (n = ). in addition, western blot analysis of activin b from bronchoalveolar lavage fluid (balf) of cipf whwts (n = ) and healthy whwts (n = ) was conducted. we demonstrated that activin b, but not activin a, is strongly expressed in the altered alveolar epithelium in lungs of diseased whwts as well as in ards lungs. furthermore, activin b was detected in balf of cipf whwts, most notably in samples from dogs with ae, but not in balf of healthy whwts. this novel finding suggests that activin b participates in the pathophysiology of cipf and might act as a potential marker of alveolar epithelial damage. no conflicts of interest reported. dogs of the breed nova scotia duck tolling retriever (nsdtr) are affected by several immune-mediated diseases, in particular steroid-responsive meningitis-arteritis (srma) and an immune-mediated rheumatic disease (imrd). imrd is a systemic lupus erythematosus-related disease characterized by chronic stiffness and pain in several joints. the aim of this study was to investigate the morbidity in nsdtrs and to test the hypothesis that nsdtrs are predisposed to srma and imrd. insurance data from a swedish insurance company (agria insurance company, stockholm, sweden) from - was used for the study. approximately one third of swedish dogs are insured by agria and the insurance database is a validated tool for epidemiological studies. assessment of morbidity was based on veterinary care events. disease diagnoses were grouped in both general and specific disease categories. individual diagnoses that were likely to represent imrd were combined. morbidity was defined as incidence rates and presented as number of cases per dog years at risk (dyar). relative risk (rr) for nsdtrs compared to other breeds combined was calculated. the study included dogs, were nsdtrs. the most common general causes of veterinary care for nsdtrs were injuries followed by gastrointestinal and musculoskeletal disorders with significant increased risk (rrs between . and . ) for nsdtrs compared to other breeds. the highest relative risk for nsdtrs was for systemic lupus erythematosus (rr . ). compared to other breeds, nsdtrs had an increased risk for srma (rr . ) and imrd (rr . ) with an incidence rate of . cases per dyar for srma and . cases per dyar for imrd. the incidence rate for srma and imrd in nsdtrs were also compared to dogs of other retriever breeds. the comparison revealed that nsdtrs also had a significant increased risk for both srma (rr . ) and imrd (rr . ) when compared to other retrievers only. this study is the first to investigate the morbidity for imrd in nsdtrs, which is important for further research and breeding practice. for several reasons the incidence rates might be underestimated and exact numbers should be interpreted with caution. however underestimation of incidence rates should not differ between dogs of different breeds, therefore not affecting the risk calculations. it can be concluded that nsdtrs are predisposed to the diseases srma and imrd with an increased risk compared to other breeds and to other retrievers. brenda n. bonnett consults with agria insurance company on various projects. agria insurance company has also funded work leading to the development of the insurance data base that my study was based on. canine infectious respiratory disease (cird) is a multifactorial contagious disease caused by respiratory viruses and selected bacterial pathogens. cird has been shown to be a predisposing factor in the development of bacterial pneumonia (bp) in dogs housed in dense populations such as kennels and rehoming centers. the aim of this study was to determine the prevalence of viral co-infection and to assess its effects on disease severity in household dogs diagnosed with bp. a prospective cross-sectional observational study was conducted and dogs diagnosed with bp caused by opportunistic bacteria were included. dogs with chronic (> days) tracheobronchitis caused by bordetella bronchiseptica were included as controls for virus analysis. diagnosis was confirmed by thorough clinical examinations as well as with cytological and bacterial analysis of bronchoalveolar lavage (bal) or transtracheal wash (ttw) samples. canine parainfluenssavirus (cpiv), canine adenovirus, canine herpesvirus, canine distempervirus, canine respiratory coronavirus (crcov) and canine pneumovirus were analysed in bal or ttw samples using rt-pcr assay. cpiv was detected in / ( %) and crcov in / ( %) respiratory samples in dogs with bp. respiratory viruses were not detected in dogs with chronic tracheobronchitis. there were no significant differences in the duration of hospitalization (p = . ) or arterial pao at presentation (p = . ) between bp dogs with and without a viral co-infection. these results indicate that co-infections with respiratory viruses are common also in household dogs with bp. additionally, viral co-infections did not cause a more severe course of bp. the author's researcjh is financially supported by the finnish foundation of veterinary r and the finnish veterinary foundation. esvim-p- causes of canine anemia in taiwan: a five-year retrospective survey. e.c.y. lin , p.c. liu , l.l. chueh , b.l. su . graduate institute of veterinary medicine, national taiwan university, taipei, taiwan, institute of veterinary clinical sciences, national taiwan university, taipei, taiwan anemia is a common hematologic disorder in dogs, however, few data are available regarding epidemiology and causes in taiwan. to investigate the causes of anemia, anemic cases (pcv< %) collected between january and december at national taiwan university veterinary hospital (ntuvh) were analyzed. most dogs ( . %, n = ) presented with a mild form ( %≦pcv< %), which was followed by a moderate form ( %≦pcv< %; . %, n = ) and a severe form (pcv< %; . %, n = ). among the dogs with identifiable causes, . % ( dogs) were induced by single cause, whereas . % ( dogs) by multiple causes. neoplasia-related anemia (n = ), infectious pathogens-related anemia (n = ), renal disease-related anemia (n = ) and post-surgery/ traumarelated anemia (n = ) account for . , . , . and . % of single-cause cases, respectively. furthermore, of them ( . %) presented with severe anemia. severe anemia primarily resulted from infectious disease-related anemia ( . %), followed by imha ( . %), and tumor-related anemia ( . %). of the infectious disease-related severe anemic dogs, the most common diagnosed pathogen was babesia gibsoni ( . %, n = ), followed by ehrlichia canis ( . %, n = )and babesia canis ( . %, n = ). taken together, tumors, infectious diseases, and renal failure are the most frequently causes of canine anemia in taiwan, furthermore, b. gibsoni appeared to be the most important infectious pathogen causing severe anemia which may be associated with the climate in this geographical area. no conflicts of interest reported. bordetella bronchiseptica (bb) is one of the primary causative agents of canine infectious respiratory disease (cird). this contagious disease, commonly seen in young dogs, is often self-limiting, although a wide range of respiratory signs can be found, from mild illness to severe pneumonia leading to death. although mycoplasma cynos (m. cynos) was recently identified as an emerging and possibly lethal pathogen in cird , the role of m. canis and m. cynos as primary respiratory pathogens still remains unclear. detection of these bacteria is now improved by quantitative polymerase chain reaction (qpcr). in dogs with cird due to bb, the frequency of co-infection with mycoplasma spp, in par-ticularm. cynos, and their possible role in the severity of the clinical signs are unknown. the aim of the present study was to investigate the presence of m. canis and m. cynos in a population of dog infected with bb, compared with other populations: healthy dogs and dogs with bacterial bronchopneumonia where bb was not involved (bbp). therefore, bb, m. canis and m. cynos were detected by qpcr in the bronchoalveolar lavage fluid (balf) sample in dogs with bb (mean age = . y, mean bw = . kg), dogs with bbp ( . y, . kg), and healthy dogs ( . y, . kg). bordetellosis was diagnosed based on clinical findings together with demonstration of pleiomorphic cocci/coccobacilli adhering to the cilia of the epithelial cells on cytospin balf preparations, and positive qpcr on balf. a clinical severity index (csi to ) was assigned based on clinical signs (cough - , dyspnea - , lethargy - , fever - ), thoracic radiographic pattern ( - ), and balf score ( - ). bbp was diagnosed based on clinical findings, balf cytology and culture. m. canis was indifferently detected in healthy ( / , %), bbp ( / , %) and bb dogs ( / , %) while m. cynos tended to be more frequently detected in bb group ( / , %) than in healthy ( / , %) and bbp dogs ( / , %) (khi² test, p = , ). in bb dogs, no correlation could be detected between csi and presence of m. cynos (khi² test p = , ). in conclusion, the present data suggest that, in cird, coinfection with bb and m. cynos is frequent, but is not correlated with clinical disease severity. further studies are required to investigate whether coinfection of bb and m. cynos deserves specific therapeutic considerations. no conflicts of interest reported. canine idiopathic eosinophilic bronchopneumopathy (ebp) is a disease characterized by eosinophilic infiltration of the lung and bronchial mucosa in young adults. aetiology remains unclear although immunologic hypersensitivity is clearly suspected, while inciting antigens are generally unidentified. in humans as in cats, infections with mycoplasma spp. have been discussed as potential triggers in inflammatory bronchial disease , . bordetella bronchiseptica (bb) is a recognized pathogen agent of canine infectious tracheobronchitis. detection of bb and mycoplasma spp, especially mycoplasma cynos (m. cynos), and their potential role of in canine inflammatory bronchitis, have not been investigated. the aim of the present study was to investigate the frequency of bb, mycoplasma canis (m. canis) and m. cynos in canine ebp. therefore, presence of bb, m. canis and m. cynos were retrospectively assessed by quantitative polymerase chain reaction (qpcr) in bronchoalveolar lavage fluid (balf) samples from dogs with ebp (mean age = . y, mean body weight = . kg) as well as in dogs with aspecific chronic bronchitis ( . y, . kg). based on clinical signs, a clinical severity score (css, - ) was assigned each ebp dog. although all balf culture and cytology were negative for this bacteria, bb was more frequently detected by qpcr in ebp dogs ( / , %) than in cb dogs ( %) (khi² test, p = , ). presence of bb in ebp dogs was independant of age but significantly associated with css (khi² test, p = , ). results of qpcrwere positive for m. canis and m. cynos in ( %) and ( %) ebp dogs and in ( %) and ( %) cb dogs, respectively. there was no difference between the groups for any of the organisms. any relation between age or css and presence of m. spp in ebp dogs was observed. in conclusion, m. canis and m. cynos do not seem to be predominantly involved in the pathogenesis of canine ebp. however, bb is more frequently detected in balf from ebp dogs than from dogs with aspecific cb and its presence is associated with clinical severity. whether bb is able to trigger eosinophilic inflammation or is only more easily collected in an inflamed environment is unclear. but ebp dogs could potentially act as bb carriers and source of infection. therefore, bb should be systematically searched for in canine ebp cases and treated accordingly. no conflicts of interest reported. distal renal distal renal tubular acidosis (drta) was recently reported in three dogs with imha. the purpose of this study was to explore the hypothesis that drta is an underdiagnosed concurrent disorder in dogs with imha. we report the clinical presentation and outcome of three dogs where the combination of imha and drta was strongly suspected. the medical records of dogs diagnosed with imha at the university of edinburgh hospital for small animals between january and may were reviewed to identify cases where venous blood gas analysis and urinalysis had also been carried out. for the purpose of this retrospective study imha was defined by the presence of anaemia with pcv < %, and one or more of the following criteria; a positive slide agglutination test, positive coombs' test or moderate to marked spherocytosis. the criteria for diagnosis of drta included moderate to marked hyperchloremic metabolic acidosis with a normal anion gap; urine ph (> . ) in the face of metabolic acidosis; hypokalaemia (< . mmol/l). fifty-seven records were evaluated, with cases being excluded due to insufficient clinical information, including inability to determine urinary ph due to the severity of pigmenturia in four cases. of the cases where there was sufficient clinical data to assess the likelihood of drta only one case fulfilled all the criteria; two cases fulfilled all but one of the criteria and drta was strongly suspected based on clinical progression and persistence of urine ph > in the face of severe metabolic acidosis. of the three cases where concurrent imha and drta was suspected, two survived to discharge; one was still alive at the time of writing ( months after discharge) and the other was euthanased months after discharge following the development of multiple joint effusions and skin lesions suggestive of sle. venous blood gas analysis and assessment of urine ph should be considered in all cases of imha to exclude the possibility of concurrent drta, particularly where persistent hypokalaemia is detected. prospective evaluation of a larger cohort of imha cases is required to determine the actual incidence of concurrent drta. no conflicts of interest reported. persistent renal proteinuria is considered an early marker of chronic kidney disease (ckd) and it is listed among the initiation factors and progression factors according to kdoqi guidelines. nevertheless, few data are available about the prevalence of proteinuria in cats affected with ckd, in which it is assumed that nephropathy is mainly characterized by tubulointerstitial damage. the aim of this study is to determine the prevalence of proteinuria in cats affected with ckd and to valuate the relations between urine protein to creatinine ratio (upc) or iris substaging by proteinuria, towards purebred, sex, age, haematology, biochemistry and urinalysis. wilcoxon test, linear regression and chi-square test were used for the statistical analysis. data from cats were considered. non-renal proteinuria was an exclusion criterion. proteinuric cats (upc> . ) were . % in ckd cats, while . % could be substaged as bordeline proteinuric ( . ) in cats, proteinuria tends to increase with aging (p < . ) and with worsening of the nephropathy (p = . ). proteinuria was related to the anaemic state in ckd cats: upc significantly increases with rbc count, hb, ht and mch decreasing (p < . and p = . respectively). proteinuria tends to increase with wbc count (p = . ) and neutrophils increasing (p = . ), while tends to decrease with lymphocytes increasing (p = . ). furthermore, upc significantly increases in presence of an inflammatory serum protein electrophoretic pattern. upc tends to increase with phosphorus and alp increasing (p < . and p = . respectively); while the role of phosphorus in ckd is well known, the increase of alp is questionable: it has been hypothesized that higher alp levels in ckd could be related to b-alp increase due to bone remodelling in secondary renal hyperparathyroidism. considering urine parameters, upc increases when urinary specific gravity and ph decrease (probably related to worsening of ckd and development of a metabolic acidosis) and when glicosuria is present, regardless of the cause. furthermore, proteinuria increases in presence of rbc in urinary sediment and in samples where casts were observed, in particularly when rbc casts (considered always pathological and indicative of glomerular damage) were present. upc values assessed in proteinuric cats and data analysis suggest the need of deepen the analytical variability of upc and the opportunity to reconsider the intervals of substaging by proteinuria in cats. no conflicts of interest reported. the aim of this retrospective study was to evaluate: a) the relations between urine culture results and urinalysis parameters; b) the results of the antimicrobial susceptibility tests. urine samples were collected by cystocentesis from dogs and cats, whose diagnostic workup included a differential diagnosis of uti: all samples underwent a complete urinalysis, upc ratio assessment and urine culture. infected vs sterile results were related to urine physical, chemical parameters and observations from urinary sediment analysis. statistical analysis was performed using jmp . (sas institute inc.). a p value < , was considered significant. urine culture resulted positive in dogs ( %) and cats ( %). the presence of uti was significantly related to urine physical properties (color and turbidity), usg and leukocyturia: infections tended to be more frequent in urine samples characterized by a light yellow color, cloudy or sub-limpid aspect and low usg. nevertheless, urine was limpid in % of infected samples, and a normal usg was found in . % of dog's uti but only in . % of cats. although leukocyturia tends to become higher in infected samples both in dogs and cats (p < . ), in . % of infected sediments wbc count was normal. haematuria detected by dipstick was significantly related to uti in dogs but not in cats, nevertheless the rbc count in sediment was not related to infection in both species: rbc count was normal in . % of infected feline samples and in . % of canine samples. no significant relation between presence or absence of uti and albuminuria, bilirubinuria, glycosuria was detected, while upc tends to become significantly higher in dogs. although the chi-square test showed a significant relation between infection and the detection of bacteria in urinary sediment, a pseudobacteriuria was found in . % of samples; furthermore bacteria weren't observed in . % of infected samples (usg< . ). e. coli was isolated in the majority of samples ( , %), compared to other species: staphylococcus( . %), proteus ( . %) and streptococcus. ( . %). the urinalysis pitfalls and the high antibiotic resistance verified towards the most widely used molecules (penicillins, cephalosporins, quinolones) strongly indicates the importance to perform antimicrobials susceptibility tests to avoid the risk of failure associated with the use or abuse of empiric therapies in utis. no conflicts of interest reported. azotemia in dogs with chronic heart failure may reflect impaired renal function not only because of inadequate renal perfusion, but also due to organic renal injury. impaired renal function is observed in % of dogs with heart failure. altered renal hemodynamics due to decreased cardiac output results in renal hypoperfusion, and resultant elevation of blood urea nitrogen and creatinine, defined as azotemia. azotemia is a prognostic factor in dogs with mitral regurgitation, therefore, preservation and/or restoration of renal function is thought to improve prognosis. medical treatment for heart failure, however, includes angiotensin converting enzyme inhibitors and loop diuretics, which has been shown to increase the risk of developing azotemia. we hypothesized that mitral valve repair surgery ameliorates renal function by improvement of systemic hemodynamics. the change in renal function in dogs with mitral regurgitation was assessed by evaluating time-dependent changes in glomelular filtration rate by inulin clearance before and after cardiac surgery. eighteen dogs with severe mitral regurgitation with azotemia (plasma urea nitrogen level > mg/dl, plasma creatinine level > . mg/dl) were included in this study. the glomerular filtration rate in all dogs were evaluated by determining inulin clearance before and months after surgery. serum atrial natriuretic peptide level, plasma nt-pro brain natriuretic peptide level, plasma urea nitrogen concentration, and plasma creatinine concentration were measured at each time point as well as during the initial staging of heart failure based on the international small animal cardiac health council (isachc). left atrial/aorta ratio by echocardiography and vertebral heart size by thoracic radiographs were also measured. glomerular filtration rate significantly increased months after surgery ( . ml/min/m [ . - . ], . ml/min/kg [ . - . ]) compared to before surgery ( . ml/min/m [ . - . ], . ml/min/kg [ . - . ]) (p < . ). the isachc stage of heart failure was improved at months after surgery compared to before surgery. in addition, serum atrial natriuretic peptide level, plasma nt-pro brain natriuretic peptide level, plasma urea nitrogen concentration, la/ao and vhs significantly decreased after surgery (p < . ). the use of diuretics decreased after mitral valve repair surgery and consequently, a decrease in plasma urea nitrogen and creatinine levels were observed. therefore, this suggests that the main cause of azotemia in dogs with mitral regurgitation may be due to inadequate renal blood flow and exacerbation by the use of diuretics. no conflicts of interest reported. glomerular filtration rate (gfr) is generally considered to be the gold standard measurement of kidney function. gfr can be calculated by measuring serum iohexol clearance using concentrations at , and hours following a bolus injection. for validation, serum samples were spiked at low ( . mg/ ml), medium ( . mg/ml) and high ( . mg/ml) iohexol concentrations. they were analysed, along with standard calibration curves ( concentrations ranging from . to . mg/ml), using deltadot's label-free high performance capillary electrophoresis (hpce) system. data were analysed using deltadot's general separation transform (gst). clinical and spiked serum samples were also sent for analysis by mass spectrometry (ms) at a reference laboratory ( samples for comparison). concentrations obtained by hpce and ms were compared in a bland altman plot. gfr for clinical samples was calculated from the measured iohexol concentrations using the method reported by bexfield ( ) . a validated method was produced, with a lower limit of detection of . mg/ml and an lower limit of quantification of . mg/ml. the upper limit of quantification was . mg/ml. the standard curve had excellent linearity (r = . ). maximum inaccuracy was less than . % of the true value, except at lloq, where it was within . %. average within day variability was less than . % at all levels, while between day variability was less than . %, except at lloq, where it was less than . %. agreement between the results obtained by measurement with hpce and ms was good (bias . %, lower and upper limits of agreement of - . and . %, respectively). method specificity was confirmed by the absence of matrix effect in six serum specimen obtained from clinical dogs. clinical samples were analysed and gfr reported with a day turnaround time. in conclusion, hpce provides an accurate and precise method for measuring iohexol in canine serum. conflicts of interest: l pelligand has the following information to disclose: in receipt of research grant / contract funding from orion ltd., novartis animal health, transpharmation ltd, deltadot ltd; acted as a consultant for: triveritas ltd. and novartis animal health; s williams is an employee of the rvc and works in collaboration with deltadot ltd; j. elliott has the following information to disclose: consultancy: pfizer animal health / zoetis, ceva animal health, boehringer ingelheim, vetoquinol ltd, orion ltd., elanco ltd, idexx ltd, niche generics ltd. triveristas ltd., virbac ltd., advisory board membership: international renal interest society (supported by novartis) european emesis council (sponsored by pfizer animal health -now zoetis) cardiorenal board -vetoquinol ltd. idexx renal advisory board research grants or contracts: vetoquinol ltd, novartis ltd, pfizer animal health ltd (now zoetis), royal canin ltd, boeringher ingelheim ltd, waltham centre for pet nutrition, ceva animal health orion ltd. esvonc-p- cystic pancreatic neoplasia in cats. c.m. borschensky , k. steiger , a. staudacher , m. schlitter , i. esposito , h. aupperle . laboklin gmbh&co. kg, bad kissingen, germany, tu m€ unchen, institute of pathology, m€ unchen, germany, veterinary clinic dr. staudacher, aachen, germany pancreatic neoplasms in the cat mostly exhibit a solid growth pattern and are diagnosed as carcinomas. in contrast, only few reports about cystic pancreatic lesions exist. until now, only benign cystic pancreatic lesions are described in the literature. according to the histological pattern, they have been termed as cysts, (acinar) cystadenoma or pseudocysts. in man, cystic pancreatic neoplasms are classified according to the localisation (intra-/extraductal), growth pattern and differentiation (mucinous, (tubulo)papillary, serous, acinar). the aim of this study was to characterise feline pancreatic neoplasms in more detail, based on the human classification system with a special view on cystic lesions. pancreatic masses sent to laboklin from domestic cats ( - years) were investigated routinely macroscopically and by histological methods (h.&e. stain). the neoplasms showed a cystic (n = ) or solid (n = ) pattern. cystic pancreatic tumors were up to cm in diameter and were classified as benign variants in five and malignant variants in three cases. based on the human classification system, they were classified as tubulopapillary (n = ), acinar (n = ) and mixed (n = ) adenomas and mixed carcinomas (n = ), respectively. solid pancreatic nodules were diagnosed as carcinomas with a tubular (n = ) or acinar (n = ) differentiation pattern. in summary, the gross structure (solid versus cystic) seems to be of prognostic relevance. in contrast to solid tumors, cystic pancreatic lesions in the cat behave benign in a higher percentage of cases, resulting in a better prognosis. therefore, surgical excision of these cystic masses can be recommended. with respect to the human classification system, three different subtypes of cystic pancreatic neoplasms were detected in the cat that have not been described before in veterinary medicine: tubulopapillary, acinar and mixed. to best of our knowledge, this is the first report of cystic adenocarcinomas in feline pancreas. further corresponding clinical and histological investigations are needed for a better diagnostic (ultrasound, mri) and prognostic characterisation of cystic lesions in feline pancreas. no conflicts of interest reported. the immunohistochemical detection of cyclooxygenase- (cox- ) expression in canine mast cell tumours was recently described by our team (prada et al., ) . however its prognostic value needs to be established. the aim of the present work was study the prognostic value of cox- expression by investigating the relationship with several clinical and pathological variables including the overall survival (os) time. we included dogs with mast cell tumours ( grade i; grade ii and grade iii). cox- immunohistochemical expression was carried out by a streptavidin-biotin method. for the cox- immunoreactivity evaluation were considered the number of positive cells (cox- extension), the intensity and the score of cox- . the following clinical and pathological features were considered: animal age, sex, tumour anatomical location, tumour size, skin ulceration, histological grade, histological safety margins and number of mitosis. cox- expression was correlated with the clinical and pathological data and with the overall survival. cox- intensity was statistical significantly associated with skin ulceration (p = , ); histological grade (p = , ) and absence of histological safety margins (p = , ), high mitotic number (p = , ) and with overall survival (p = , ). both cox- extension and cox- immunohistochemical score present no statistical relationship with the variables considered neither with the overall survival. our results suggest that cox- have an important role in dog mast cell tumours progression and could constitute a promising therapeutic target in this neoplasia. however, our study also demonstrated that in mcts, is the cox- intensity that has the prognostic value, not the number of cox- positive cells (cox- extension) and not the cox- immunohistochemical score. consequently, cox- intensity should be elected for evaluating the cox- positivity in mcts immunohistochemical studies. merial provided financial support for immunohistochemical analayis. the research centres has also received financial suppoprt from cecav, ceca and citab. dogs which were radiated for a subcutaneous sarcoma between and were included. medical records were reviewed and patient characteristics, treatment protocols, adjuvant therapies and outcome were analysed. follow-up information was obtained from medical records and by phone conversations with veterinarians or pet owners. thirty-two dogs were included into this study. mean age was years and mean body-weight was kg. male dogs were slightly overrepresented ( . %). curative intent radiotherapy was applied in dogs and palliative intent in dogs with a mean total dose of and . gray, respectively. in dogs microscopic disease was radiated. five dogs received liposomal doxorubicin concomitantly with radiotherapy, two received adjuvant doxorubicin and one intralesional cisplatin. overall median survival time was days with curative and days with palliative treatment. overall median survival time in dogs with macroscopic disease was days and in patients with microscopic disease it was not reached. radiotherapy was generally accepted as new treatment modality by pet owners and referring veterinarians. comparable to the literature, best outcome was achieved for dogs radiated with microscopic disease conflicts of interest: no conflicts of interest reported. oncept â , is indicated for the treatment of stage ii or iii oral melanoma after local control with survival times significantly increased following vaccination. a similar improvement in survival times has also been reported with digit melanoma. medical records of dogs diagnosed with melanoma between march and december were retrospectively evaluated. inclusion criteria were a histopathological diagnosis of melanoma, surgical excision of the tumour, and vaccination using the oncept â vaccine. dogs met the inclusion criteria. nificant renal involvement in dogs with cvl. this result indicates staffordshire terrier ( ), bouvier, giant schnauzer, maltese, irish setter, kerry blue terrier, golden retriever, scottish terrier, and great dane ( of each). dogs had stage ii digit melanoma with an equal sex distribution and a median age of . years (range - ). currently still alive and one dead, the latter following surgery for resection of a rib osteosarcoma the median survival time of the dogs still alive is . months (range - ) versus . months (range - ) for the dogs that have died. none of the dogs showed any adverse effect to the vaccine infected macrophages can cause injury in different organs, including the kidney. cvl is known as a common cause of glomerulonephritis. thus, this study aimed to investigate and characterize the renal lesions in dogs seropositive for leishmania sp. in brazil. this project was approved by the animal ethics committee of uece, brazil. twenty adult dogs seropositive for cvl from center for zoonosis control were randomly selected for this experiment. cvl was diagnosed by immunofluorescence and elisa. urine and blood sampling and kidney harvesting were performed immediately after euthanasia that the glomerulonephritis is a common sequelae related to leishmaniasis infection. even dogs in stage of ckd showed significant renal histopathological changes. animals infected with leishmania sp. may have severe renal damage and risk of progressive chronic kidney disease even when no increase of creatinine levels or proteinuria is detected.conflicts of interest:the authors received funding to pay the phd scholarship of one student (conselho nacional de pesquisa e desenvolvimento -cnpq-brazil) and received a research grant from fundac ßão cearense de apoio ao desenvolvimento cient ıfico e tecnol ogico -funcap. anaplasma phagocytophilum, the causative agent of canine granulocytic anaplasmosis, is an obligatory intracellular bacterium transmitted by ixodes ticks. transmission via blood transfusion has rarely been described in human medicine and once in a dog. in the berlin/brandenburg area the seroprevalence rate in dogs was % regardless of health status.the aim of this study was to evaluate pcr screening results for a. phagocytophilum in canine blood donors between - in order to estimate the risk of transfusion-transmitted infection. edta blood samples from dogs were submitted for a. phagocytophilum real-time pcr testing (targeting the msp gene). altogether dogs were tested up to times. clinical and laboratory data were examined before each donation. statistical analysis was performed using spss . .the pcr test was positive for of the samples. none of the dogs tested pcr positive more than once. positive results were most often detected in june ( ), may ( ), and july ( ), but also in five other months. in three dogs a mild increased in rectal temperature (≥ , °c) was documented. mild laboratory abnormalities were noted in dogs: thrombocytopenia ( ), leukocytosis ( ), leukopenia ( ), anemia ( ) and hyperproteinemia ( / ); four dogs had more than one abnormality. there was no significant difference between the pcr negative and positive blood samples in regard to laboratory abnormalities.altogether, . % of blood samples from healthy canine blood donors were pcr positive for a. phagocytophilum. therefore, blood donors should be screened by pcr in endemic areas all year round. no conflicts of interest reported. the study population consisted of cats, including control cats recruited from veterinary practices across the country. among the disease cats, cats presented urtd, cats had conjunctivitis and cats suffered chronic gingivostomatitis, many of them presenting more than one clinical sign. pcr for the above-mentioned pathogens was performed from pooled conjunctival and oropharyngeal swabs for each cat. a questionnaire regarding signalment (age, breed, sex, neuter status), environment (indoor, number of cats in household) and vaccination history was obtained. data was analysed by multivariable logistic regression with alpha equal to < . .the prevalence for the four pathogens has been previously reported in detail. briefly, the prevalence among the four groups (including controls) ranged from to % for fhv- , - % for fcv, - % for chlamydophila felis and - % for mycoplasma felis.in the univariate analysis, age, neutering status, being purebred, indoor keeping, number of cats in the household and body weight were variably associated with the different groups of disease and the presence of the pathogens. in the multivariable analysis, only the following factors remained significant. in the multivariable analysis, only the following factors remained significant: urtd was significantly associated with positive results for fhv- , chlamydophila felis and mycoplasma felis (in addition to being male and not castrated); conjunctivitis was significantly associated to positive results for fhv- and chlamydophila felis (in addition to being young, not castrated and purebred) and cgs was significantly associated to positive results for fcv (in addition to being young, male and purebred). not being properly vaccinated was a significant risk factor only when all three groups were analyzed together. the number of cats in the household was an independent risk factor for detecting each of the pathogens studied. the age was also a significant factor in cats with fcv and chlamydophila felis, being older cats predisposed to fcv and younger cats predisposed to chlamydophila felis.the present study describes important epidemiological data for cats presenting urtd, conjunctivitis and/or cgs, and emphasizes the complex interrelationships occurring among the different pathogens. our results also support the role of fcv in cats with chronic gingivostomatitis.conflicts of interest:the study was funded and designed by merial laboratories. reports of methicillin-resistant staphylococci (mrs) in animals have become more frequent in last years. various studies have demonstrated the transmission of mrsa between animals and humans in daily contact with animals, however there is only limited data so far available on the transmission of methicillinresistant coagulase-negative staphylococci between animals and humans. the objective of this study was to investigate the frequency of methicillin-resistant staphylococci (mrs) carriage in healthy veterinarians, veterinary nurses, veterinary assistants, veterinary students and farm workers from several veterinary hospitals, clinics and farms.nasal swabs were collected from veterinarians ( small animal veterinarians and pig veterinarians), veterinary nurses, veterinary students, veterinary assistants and farm workers. mrs were screened on brilliance tm mrsa agar (oxoid) or chromid tm mrsa (biom erieux). after - h of incubation at °c, suspected colonies on both media were subcultured onto blood agar plates. species identification was obtained by species-specific pcr. methicillin-resistance was confirmed by pcr amplification of the meca gene. mrsa isolates were characterized by mlst.thirty-nine mrs were identified in humans ( veterinarians, veterinary nurses, veterinary students, veterinary assistants and farm workers). the mrs isolates were identified as staphylococcus aureus (mrsa, n = ), s. epidermidis (mrse, n = ), s. pseudintermedius (mrsp, n = ), s. haemolyticus (mrsh, n = ) and mrs coagulase-negative staphylococci. the frequency of colonization by mrs was similar in both small animals and pigs veterinarians (ae %). one veterinary student was colonized simultaneously with an mrse and an mrsh. the predominant st in humans in contact with small animals was st and in humans in contact with pigs was st .in our study the frequency of colonization by mrsa was high, but the frequency of mrse should not be underestimated. mrsa isolates in this work belonged mainly to the st lineage which is the most frequent in small animals and humans in europe. humans in daily contact with animals can become colonized by mrs of animal origin and thus are important keys for infection control programs in veterinary hospitals and farms.conflicts of interest: dr pomba currently receives research funding from the government and national programmes (fundac ßão para a ciência e a tecnologia). in the past, she has occasionally received research support or honoraria for lectures from pharmaceutical companies including zoetis and atral cipan. she is vice-chair of the antimicrobial working party (awp) and member of the antimicrobial advice ad hoc expert group (ameg) of the european medicines agency (ema). , species not determined [ ]) did not. all cats underwent antibiotic treatment (doxycycline or a fluoroquinolone); cats received blood transfusions and/or oxyglobin â . three cats were euthanatized within days due to concurrent disease (fiv, pancreatitis/cholangitis) or financial constraints, one cat due to persistent anemia after weeks. four cats were lost to follow-up. the remaining cats underwent follow-up for a period of - weeks (median ). hemoplasma pcr analysis was conducted - times on blood samples at variable time points from of the follow-up cats. the first negative pcr in cases occurred after (cmhm, during antibiotic treatment), (cmhm, during antibiotic treatment), (cmhm, during antibiotic treatment) and (mhf, after completion of antibiotics) weeks. one cat remained pcr positive (cmhm) at , , and (all during antibiotic treatment) weeks, and another cat (cmhm) was pcr positive at weeks. reactivation of the hemoplasma species (documented by hemolysis and positive pcr) occurred in cats (both cmhm) and times, respectively, up to weeks after initial presentation. reactivation was suspected (no pcr testing available) in additional cases (cmhm [ ], mhf [ ]). four of the follow-up cats were euthanatized after - weeks (median ) due to concurrent disease (cardiomyopathy, immune-mediated thrombocytopenia, postoperative complications, diabetes mellitus). infection with hemoplasmas is often chronic, can reactivate months later and is rarely the reason for euthanasia. no conflicts of interest reported. canine distemper (cd) is a worldwide occurring infectious disease caused by a morbillivirus of the family paramyxoviridae. cdv infection can result in a systemic infection. dogs presented with neurologic signs revealed the terminal stage of the disease and usually failed to therapy. additional passive immunotherapy is hypothesized to be beneficial in the early stage of cdv infection. porcine anti-cdv antibody subunit f (ab') [f(ab') ] was produced by animal technology laboratories, agriculture technology research institute. eighteen cdvnaturally infected dogs showing respiratory signs but no neurological signs were treated with the combination of f(ab') and supportive therapy (group ). group included dogs in a similar clinical signs (without neurological signs) that received only supportive therapy. the survival rate was . % ( / ) in group and . % ( / ) in group , respectively, with a significant difference between the two groups (p < . ). the progressive rates of developing neurological signs during therapy of group and group were . and . %, respectively. there was no significant difference between the two groups. the survival rates of dogs developing neurological signs during therapy were % ( / ) in group and . % ( / ) in group , respectively, with a significant difference between the two groups. in conclusion, additional administration of porcine anti-cdv antibody subunit f(ab') before developing of neurological signs could decrease the mortality and furthermore reduce the rate of developing neurological signs. no conflicts of interest reported. key: cord- -w ysjf authors: nan title: th international symposium on intensive care & emergency medicine: brussels, belgium. - march date: - - journal: crit care doi: . /s - - - sha: doc_id: cord_uid: w ysjf nan ventriculostomy-related infection (vri) is a serious complication in patients with hemorrhagic stroke. in such patients, diagnosis of vris is complicated by blood contamination of csf following ventricular hemorrhage. we aimed to evaluate the diagnostic potential of white blood cells count (wbc), c-reactive protein (crp), and procalcitonin (pct) to identify vris in patients with hemorrhagic stroke during the time of external ventricular drain (edv) in situ. this retrospective study was conducted at the neurosurgical-icu, university hospital of zurich. a total of patients with hemorrhagic stroke and an external ventricular drain (evd) were admitted over a years period at the icu. of those, patients with vris ("vri"), defined by positive csf bacterial culture and increased wbc in csf (> /ul), and patients without vris and with serial csf sampling ("no-vri") were analyzed. patients with csfcontamination or suspected vri (negative csf cultures but antibiotic treatments) were excluded. wbc, crp, and pct were measured daily. csf was sampled routinely twice a week or by t> °c. for the analysis, mean peak values of wbc, crp, pct during the time of evd in situ were compared between groups (t test). data are expressed as mean with ci %. results: between groups, wbc and crp were similar (wbc: . g/l and . g/ l, p= . and crp: . mg/l and . mg/l, p= . in the group vri and no-vri, respectively) ( figure , panel a and b ). in the group vri, pct was low and significantly lower than in the group no-vri ( . ug/l and . ug/l, p= . in the group vri and no-vri, respectively) (panel c). wbc in csf were similar between groups ( . /ul and . /ul p= . in the group vri and no-vri, respectively). in this study, serum-inflammatory markers were not able to screen patients with vris. their routine measurement should be carefully evaluated. introduction: central nervous system (cns) infections constitute a potentially lifethreatening neurological emergency. patients admitted to the intensive care unit (icu) usually present with a severe disease and organ failure, leading to high mortality and morbidity. we have performed a retrospective analysis during a -year period of patients admitted to a polyvalent icu. clinical, demographic and outcome data were collected to evaluate its clinical impact on the outcome of patients with cns infections. we identified patients with the diagnosis of meningitis, meningoencephalitis and ventriculitis, where the median age was , years (range - ). upon clinical presentation, their most frequent signs were fever ( %), meningeal signs ( %), seizures ( %), and a glasgow coma scale score < ( %). all needed ventilation support and % needed cardiovascular support. a definitive microbiological diagnosis was achieved on patients and antibiotic therapy was adjusted on of them. most common microorganisms were streptococcus pneumoniae (n= ), listeria (n= ) and pseudomonas aeruginosa (n= ) (figure ). other gram negative microorganisms were detected and lead to more adverse outcomes. meningitis was the cause of admission on patients and on a minority (n= ) meningitis was considered to be a secondary diagnosis on patients admitted for other causes (traumatic brain injury, subarachnoid or intraparenchymal hemorrhage, postoperatively of neurosurgical tumor). patients that eventually died had at least one risk factor (age> , immunocompromised due to diabetes, corticotherapy, hiv or heart transplantation). patients admitted to the icu were not so aged, but had some comorbidities and risk factors leading to more uncommon microorganisms, increasing the risk of adverse outcomes. this lead to an increase of mortality: % in the icu and an overall of %. study of selenium levels in unresponsive wakefullness (uws) patients with systemic inflammatory response syndrome (sirs) e kondratyeva , s kondratyev , n dryagina the objective of this study was to evaluate the pharmacokinetics (pk) of levetiracetam (lev) in critically ill patients with normal and augmented renal clearance (arc), and determine if the recommended dosage regimen provides concentrations in the therapeutic range ( - mg/l) [ ] . a prospective observational study was conducted in a tertiary hospital. six blood samples were taken during a dose interval at steady state and lev was quantified by hplc. a population pk study was carried out. statistical analysis was conducted to evaluate the differences in pk between patients with and without arc. the suitability of drug concentrations was also assessed. results: seventeen patients were included, with normal creatinine clearance (crcl) ( - ml/min) and with crcl≥ ml/min (arc). ten patients received mg q h, one mg q h and two mg q h. the data were best fitted to a two-compartment model. figure shows lev concentrations during the dosing interval. mean clearance (cl) was l/h and mean volume of distribution of central compartment (v) was l. interindividual variability was and % for cl and v, respectively. no differences were identified between both groups (p> . ) in pk parameters. no correlation was found between lev cl and crcl. trough levels were below the minimum concentration (c min ) mg/l of the therapeutic range in all patients except . furthermore, between - h % of samples were below the c min . conclusions: administered doses were not able to maintain lev concentrations in the recommended therapeutic range. other dosage strategies, such the extension of infusion time with higher doses, could be evaluated in order to obtain a more favourable profile. no correlation between lev cl and crcl was found. the mechanical properties of muscles such as tone, elasticity, and stiffness are often affected in chronic critical ill (cci) patients. a hand-held device known as the myotonpro demonstrated acceptable relative and absolute reliability in a ward setting for patients with acute stroke [ ] . the technology works on the principle of applying multiple short impulses over the muscle bulk via the testing probe. the aim of our study is to assess the feasibility of objective measurement of muscle tone in cci patients with neurological dynamics and serum biomarkers. the study included cci patients with neurological disorders (stroke, traumatic brain injury, neurosurgical intervention for brain tumors) with more than a -weeks stay in icu. dynamic measurements of the muscle properties were taken on the deltoideus, brachioradialis, quadriceps femoris, gastrocnemius using the myo-tonpro. to identify the leading factor in impaired muscle tone also were measured neurological (s , nse), inflammatory (il- ), bacterial load (pct) biomarkers using elecsys immunoassay and the serum level of microbial metabolites using gc-ms (thermo scientific). results: all patients were divided into groups depending on positive and negative clinical dynamics. significant differences were obtained in parameters characterizing changes in muscle tone of lower limbs -f gastrocnemius (tone) - . vs . hz, r quadriceps femoris (the mechanical stress relaxation time) - . vs . ms (p < . , respectively). some significant correlations between five parameters of muscle tone biomarkers and microbial metabolites were revealed. the results of a quantitative measurement of muscle tone objectively reflect the dynamics of neurological status, which in the future may be promising technique for the personalized approach cci in patients. introduction: changes in hormonal status in patients with unresponsive wakefulness syndrome (uws) remains poorly understood. methods: patients in uws were examined at the period from to . patients ( men) with tbi and patients ( men) after hypoxia. acth, cortisol, tsh, free t and t , sth, prolactin and natriuretic peptide were studied in the period from to months uws. in men, the level of total testosterone, lh and fsh was additionally studied. the obtained data was compared with the uws outcome in - months (crs-r scale assessment). none of the studied hormones of the hypothalamic-pituitary-adrenal axis were a reliable criterion for predicting the outcome of uws. most often and consistently was revealed a tendency of disrupt the rhythm of cortisol secretion, with higher rates in the evening hours. the average value of sth was higher in men with the consequences of head injury who had recovered consciousness than in those who remained in uws. significant decrease in testosterone levels, regardless of age, was found in patients with a consequence of tbi. mean levels of lh were higher in patients with tbi and hypoxia who remained unconscious than in patients who later restored consciousness. the average level of fsh was higher in patients who had recovered consciousness . the increase of natriuretic peptide level was observed both in patients who remained in chronic uws and in those who restored consciousness. no certain endocrine background, characterising this category of patients was found. violations of some hormones secretion rhythms, in particular, cortisol can be considered usual for uws patients, especially in patients with tbi. therapeutic hypothermia has not been used before our research in chronically critically ill (cci) patients. temperature decrease in neuronal cells is a strong signal that triggers endogenic cytoprotection programs using early response genes expression. our goal is to determine influences of craniocerebral hypothermia (cch) on level of consciousness in cci patients. we examined patients with different types of brain injuries. males and females, mean age . ± . . patients were divided into groups: main group - patients (vegetative state (vs) - , minimally conscious state (mcs) - ), comparison group - patient (vs - , mcs - ), groups were equal on main parameters (severity, functional state, comorbidity). patients from main group received courses of cch, duration - minutes, scalp temperature - °С, cerebral cortex cooling up to - o c, session end was without slow reheating period, and session's amount was set -until signs of consciousness recovery. cortex temperature check done noninvasively by using detection of brain tissue emi in shf-range. consciousness recovery in vs and mcs patients controlled using crs-r scale. results: cch sessions significantly increased level of consciousness in vs and mcs patient groups. in vs patients vegetative state increased until minimally conscious state and mcs +, and in mcs group until lucid consciousness (p < . ) (figure ). craniocerebral hypothermia is used in chronically critically ill patients for the first time. our research results demonstrated effectiveness of cch as an additive treatment tool in such patients. this let us optimistically determine the perspective of inclusion of cch method in chronically critically ill patient's rehabilitation to increase level of consciousness. despite the clinical benefit of endovascular treatment (evt) for large vessel occlusion (lvo) in ischemic stroke, space-occupying brain edema (be) represents a common complication during the course of disease. routinely, ct imaging is used for monitoring of these patients, notably in the critical care setting, yet novel and easy bed-side techniques with the potential to reliably predict be without repetitive imaging would be valuable for a time and cost effective patient care. we assessed the significance of automated pupillometry for the identification of be patients after lvo-evt. we enrolled patients admitted to our neurocritical-care unit who received evt after anterior circulation large vessel occlusion. we monitored parameters of pupillary reactivity [light-reflex latency (lat; s), constriction and re-dilation velocities (cv, dv; mm/s), and percentage change of apertures (per-change; %)] using a portable pupilometer (neuroptics®) up to every minutes during the first hours of icu stay. be was defined as midline-shift ≥ mm on followup imaging within - days after evt. we assessed differences in pupillary reactivity between patients with and without be (u-test) and evaluated prognostic performance of pupillometry for development of be (roc analysis). in patients ( women, . ± . years) without be, , assessments were compared to assessments in patients ( women, . ± . years) with be. on day , day , and day after evt, patients with be had significantly lower cvs and dvs, and smaller perchanges than patients without be, whereas lat did not differ between both groups. roc-analyses revealed a significant negative association of cv, dv, and per-change with development of be. conclusions: automated pupillometry seems to identify patients at risk for be after evt. a prospective study should validate whether automated pupillometry harbors the potential to reduce unnecessary follow-up ct imaging. the aim of this preliminary analysis is to detect differences between the qualitative and quantitative evaluation of the pupillary function carried out by doctors and nurses of an intensive care unit (icu) of a tertiary level hospital. secondary purpose is to investigate new indications for the use of pupillometry in a population admitted in icu methods: the study has been conducted (currently in progress) at the intensive care unit and ecmo referral center at careggi teaching hospital (florence; italy). the enrolled patients are adult subjects (> years) with alteration of consciousness defined by a glasgow coma scale (gcs) < , following a primary brain injury and/or the use of sedative drugs. the studied parameters, obtained with neurolight pupillometer ® (id-med, marseille, france) are analyzed, integrated and visual/qualitative evaluation of the pupil function shows a lower reliability if compared to automated pupillometry. the estimated error in the proper determination of photomotor reflex is . % (p< . ). no significant difference is reported between quantitative and qualitative pupillometry in the detection of anisocoria. our preliminary results are compatible with previously reported data [ ] [ ] [ ] , even if there was no difference in anisocoria determination. interestingly, a longer latency period among patients treated with opioids has been observed. other results are still in progress. introduction: due to the dynamic of critical care disease, a rapid bedside, noninvasive and highly sensitive and specific method is required for diagnosis. in this study we set out our experience with trancranial color-coded duplex ultrasound (dxt) [ ] . the dxt study identifies cerebral arteries as well as hemorrhagic phenomenon, hydrocephalus, mass-occupying lesions and midline shift. this is the main difference between dxt and conventional transcranial doppler (dtc) which is a blind study and do not provide any image. descriptive, cross-sectional and observational study from december to june . patients were included. inclusion criteria: neurocritical patients. exclusion criteria: no acoustic window, presence of ultrasound artifacts. data collection was performed. it was used a lowfrequency transducer from . - . mhz with trancranial duplex preset ( figure) . the patterns were defined as normal, vasospasm, high resistance, hypermedia and cerebral circulatory arrest, depending on the cerebral flow velocity, lindegaard ratio (lr) and pulsatility index (ip). results: men ( . %) and women ( . %). average age . ( - ). patients diseases: subarachnoid hemorrhage , traumatic brain injury , av malformation , stroke , hemorrhagic cerebrovascular accident and mass occupying lesions . normal pattern: patients (rel. freq . ). vasospasm: patients (rel. freq . ). high resistance: patients (rel. freq . ). hyperemia: patient (real. freq . ). cerebral circulatory arrest: patient (rel. freq . ) conclusions: dxt should be part of the routine of neuromonitoring, it allows real time images especially useful in unstable conditions. although it will be needed a large amount of patients to be statistical significant, dxt is useful considering a non invasive study, bedside and it allows early identification of different clinic conditions. introduction: embolization of the draining vein during endovascular treatment of arteriovenous malformation (avm) may result in venous outflow obstruction and hemorrhage. anaesthesiologist can use deliberate hypotension to reduce blood flow through avm which may be somehow helpful to prevent this scenario. adenosine-induced cardiac arrest may facilitate the embolization too. the goal of our study was to improve the results of endovascular treatment of avm using adenosine-induced cardiac arrest. methods: after obtaining informed consent patients ( male, female) were selected for adenosine-induced cardiac arrest during endovascular avm embolization. main age was , ± years old. of them were evaluated as iii class asa, as iv. endovascular treatment in all cases was performed under general anaesthesia. propofol, fentanyl, rocuronium were used to induce anaesthesia, then all the patients were intubated and ventilated with parameters to keep etco - mm hg. sevoflurane , - , vol% ( cases) or desflurane vol% ( case) were used to maintain anaesthesia. hemodynamic monitoring consisted of ecg, pulsoximetry, non-invasive blood pressure measurement. onyx or/and squid were used as embolic agents. ct was performed to every patient just after procedure as well as neurological examination. results: adenosine dosage was . - . mg/kg. time of consequent cardiac arrest was - sec. there were cases we administered adenosine for time, in one case we had to administer it twice, in one fig. (abstract p ) . circle of willis and pulsed-wave doppler mode of middle cerebral artery - times and times in one more case as well. hemodynamic parameters recovered without any particular treatment in all the patients. embolization has been performed in all the cases uneventfully. postoperative ct showed no hemorrhage. nobody from investigated group had neurological deterioration in postoperative period. our study shows that adenosine-indused cardiac arrest is not very difficult to perform method and it can be useful during avm embolization. a major risk factor for stroke is atrial fibrillation (af). to treat af anticoagulation is needed. there are now several anticoagulants available. however, a lack of head to head data as well as the absence of accurate techniques makes it difficult to compare them and measure determine there efficacy. stroke is known to produce an abnormal clot microstructure which is a common factor in many thrombotic diseases. this pilot study aims to use a functional biomarker of clot microstructure (d f ) and clotting time (tgp) to investigate the therapeutic effects of different anticoagulants in stroke and af. we recruited patients ( af and stroke & af). two samples of blood were taken: before anticoagulation (baseline) and post anticoagulation ( - weeks) . patients were either given warfarin ( %) or axipaban ( %). d f and tgp were measured and compared before and after anticoagulation. results: warfarin increased t gp ( ± secs to ± secs (p< . )), and decreased d f ( . ± . to . ± . (p< . )). apixaban increased tgp ( ± sec to ± sec (p< . )) but did not change df ( . ± . & . ± . ). interestingly we found that in the apixaban group tgp significantly correlated (p= . ) with blood drug concentration levels. in this study we show that d f and tgp can quantify and differentiate between the therapeutic effects of two different oral anticoagulants. showing that warfarin prolongs clotting and weakens the ability of the blood to form stable clots. conversely apixaban prolongs clotting time but does not affect the bloods ability to form stable clots. this shows the utility of the d f and tgp biomarkers in comparing two different treatment options, something no other current marker has proven able to do. where d f and tgp may prove useful tools in a personalized approach to anticoagulation treatment and monitoring in an acute setting. hospital mortality compared to the model with the original hairscore. patients with poor-grade aneurysm subarachnoid hemorrhage (asah) world federation of neurological surgeons (wfns) grades iv and v, have commonly been considered to have a poor prognosis ( - % mortality). though early intervention and aggressive treatment in neuroicu has improved outcome in the past years, it is controversial because most of the patients left hospital severely disabled. the objective of this study was to investigate the clinical and social outcomes in intracranial aneurysm patients with poor-grade asah underwent different intervention therapies. a single center observational registry of poor-grade asah consecutive patients, defined as wfns grades iv and v, treated at tertiary chilean referral center from december to march were enrolled in this study. the clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm size and location, radiologic features, signs of cerebral herniation (dilated pupils), and functional neurologic outcome were collected. clinical outcomes were assessed via gose and and sociooccupational outcome, both at discharge and at months. figure ). % mortality is less than previously reported, and survivors had a favorable recovery, confirmed with neuro psychological test. poor-grade asah patients in our study shows a more positive outcome than previously considered. prognosis of subarachnoid hemorrhage (sah) is scarce, indeed almost half patients die or become severely disable after sah. outcome is related to the severity of the initial bleeding and delayed cerebral infarction (dci). infection and more precisely pneumonia have been associated with poor outcome in sah. however, the interaction between the two pathologic events remains unclear. therefore, we hypothesized that dci may be associated to pneumonia in sah patients. thus the aim of our study was to analyze the association between delayed cerebral infarction and pneumonia in patients with sah. in this retrospective, observational, monocentric cohort study, patients included in the analysis were admitted in neurosurgical intensive care unit or surgical intensive care unit in the university hospital of brest (france) for non-traumatic sah. primary outcome was diagnosis of dci on ct scan or mri months after sah. multivariate analysis was used to identify factors independently associated with dci. a total of patients were included in the analysis (female male ratio / , median age [ - ] years). multivariate analysis was adjusted on sedation, intracranial surgery, fisher classification of sah severity, pneumonia occurrence and non-pneumonia infectious event occurrence ( figure ). pneumonia occurred in patients ( . %) and other causes of infections in patients ( . %). dci was found in patients ( . %). factors independently associated with dci were pneumonia (or . [ . - . ]; p= . ) and non-pneumonia infectious events (or . [ . - . ]; p= . ). interestingly severity table (abstract p ). correlation of safety and efficacy markers of thrombolysis and thrombolysis time with distance from stroke centre results expressed as odds ratio with % confidence interval of initial bleeding evaluated by fisher scale was not independently associated with dci. dci is independently associated with the occurrence of pneumonia or other cause of sepsis. those results may highlight the need for rigorous approach for prevention protocol, early diagnosis and treatment of hospital acquired infectious diseases in sah patients. introduction: traumatic brain injury (tbi) can have devastating neurological, psychological and social sequelae. increased psychiatric morbidity after tbi has been shown in both adult and the pediatric population. also, critical illness as such is a risk factor for psychiatric problems in youth. our aim was to assess risk factors for later being prescribed psychiatric medication in survivors of intensive care unit (icu)-treated pediatric tbi. we used the finnish intensive care consortium (ficc) database to identify patients - years of age, treated for tbi in four icu in finland during the years - . we examined electronic health records and ct scans and collected data on drug prescription after discharge. we used multivariable logistic regression models to find statistically significant risk factors for psychiatric drug reimbursement. we identified patients of which patients received psychiatric drug prescription ( %) during follow up. the median time to prescription was months after tbi (interquartile range [iqr] - months). patients received antidepressants, received stimulants and received antipsychotics. increasing age showed a positive association with all drug prescriptions except for stimulants, where an inverse relationship was observed (table ) . using multivariable analyses, we could not find any admission or treatment related factors that significantly associated with being prescribed psychiatric medications. teenage survivors with moderate disability (glasgow outcome scale [gos] ) showed high numbers of psychotropic drug utilization ( % received any medication, % received antidepressants, % received antipsychotics). our data suggests, that the risk of psychotropic drug prescription after tbi depends on factors other than those related to injury severity or treatment measures. the incidence of drug prescription is especially high in patients with moderate disability. the effects of -adamantylethyloxy- -morpholino- -propanol hydrochloride on the formation of steroid neurotoxicity in rats with brain injury a. semenenko , s. semenenko , a. solomonchuk , n. semenenko depending on the nature of the brain injury and the severity of the victims, mortality in traumatic brain injury (tbi) ranges from to % [ ] . one of the targets for pathogenetic influence on the course of tbi is the use of pharmacological agents that are able to counteract the negative effects of excess concentrations of glucocorticoids on brain. the therapeutic effect of new pharmacological derivative adamantylethyloxy- -morpholino- -propanol hydrochloride (ademol) in rats with tbi was evaluated for days. the pseudoperated animals and control group received . % nacl solution and the comparison group received amantadine sulfate. cortisol levels were used to determine the efficacy of the test drugs in tbi. in rats treated with ademol, the level of cortisol in the blood ranged from to ng/ml (p -p ) and was . -fold lower (p< . ) compared to control pathology group on the day of therapy. instead, the effect of amantadine sulfate on the level of cortisol in the blood was significantly less than that of ademol. the concentration of cortisol in rats with amantadine sulfate in the blood ranged from - ng/ml (p -p ), was . times lower (p< . ), compared with the control pathology group, and by . % (p< . ) exceeded the corresponding value in animals treated with ademol. therapeutic treatment of rats with severe tbi with a solution of ademol, preferably better than rats in the group with . % nacl and amantadine sulfate protect the brain from the formation of steroid neurotoxicity by cortisol (p< . ). although cerebrovascular pressure reactivity (prx) well correlate to patient's outcome [ ] , it requires continuous monitoring and mobile average calculation for its determination. we therefore hypothesized that a simplified model of variation between mean arterial pressure (map) and intracranial pressure icp over the first three days of admission would have been able to predict patient outcome: we call this new parameter cerebrovascular pressure correlation index (cpc). we performed a retrospective observational study of all adult patients with severe tbi admitted to icu from january to april inclusive. all consecutive patients with a clinical need for icp monitoring were included for analysis. both for icp and map data were mean value over -hours registration, for a total of observations/day, cpc was therefore calculated as the pearson correlation coefficient between icp values (x axis) and map values (y axis), obtaining one single value every hours. variables included in the model (i.e. cpc, cpp, icp, systemic glucose, arterial lactate, paco , icp, and internal body temperature) were collected for the first days since trauma. for the main outcome only the minimum value of cpc fit the regression analysis (p = . ). the correspondent roc curve showed an auc of . . the associated youden criterion was ≤ . (sensitivity = . ; specificity = . ). of all the variables considered for the secondary outcome only cpcmin fit the regression model (p = . ). table reports the median and iqr range for sg and nsg of all the variables considered in the model. this observational study suggests that cpc could be a simplified model of variation between map and intracranial pressure icp over the first three days of admission predicting patient outcome. introduction: impaired cerebrovascular reactivity (car) after traumatic brain injury (tbi) is a marker for disease severity and poor outcome. it is unclear how dynamic changes in body temperature and fever impact car and outcome. we calculated the pressure reactivity index (prx) using the center-tbi high-resolution intensive care unit cohort, as a moving correlation coefficient between intracranial pressure (icp) and mean arterial pressure (map). minute and hourly values of prx and temperature were averaged in patients with simultaneous recording of icp and abp. demographic data was based the core registry (v . ). linear mixed models were calculated based on minute-by-minute data using r with lme v . - and ggeffects v . . . generalized estimating equation models were used to analyze changes during effervescence (increase of temperature of > °c within hours). we assessed high frequency physiological data during days of patients admitted to the icu with predominantly a closed injury type (n= / ). median age was years (iqr - ), baseline gcs was (iqr - ), and % had at least one unreactive pupil. the main measurement site for temperature was the urinary bladder / ( %). half of the patients ( / ) developed fever(> h with mean t ≥ . °c) with a total of h fever and a median of h fever(iqr - ) per patient. of effervescence episodes ( %) reached the febrile threshold of . °c which was associated with an increase in prx from . (±sd . ) at baseline ( h before) to . (±sd . ) during the febrile peak (p= . ) (figure -a) . linear mixed models showed a quadratic relationship between prx and temperature (p< . ) with an increase in predicted prx with febrile and hypothermic temperatures ( figure b ). the association of increasing body temperature with worsening of car supports prevention of fever in severe tbi. prospective studies are needed to further differentiate between mechanisms involved (i.e. inflammation) and central autonomic dysregulation. fig. (abstract p ) . the patients with a good -month outcome (gose> ) after severe traumatic brain injury showed an increase in root mean square of successive differences between normal heartbeats (rmssd) (compared to baseline -minutes before tracheal succtioning) acute kidney injury (aki) is relatively common in patients with severe traumatic brain injury (stbi) and it can contribute to morbidity and mortality [ ] . nephrocheck is a point-of-care urine test that flags two biomarkers that indicate if a critically ill patient is at risk for aki. we investigated the incidence of subclinical aki in patients with stbi. we performed a prospective observational study of all adult patients with severe tbi admitted to icu from january to april inclusive. all consecutive patients with a clinical need for icp monitoring were included for analysis. urine samples of severe tbi patients was collected at icu admission from patients to measure nephrocheck (nc) test [igfbp ] x was performed using the nephrocheck® astute ™ meter. serum creatinine was collected at admission, during the first three days, at icu dismission and -days follow up to assess renal recovery. the diagnosis of aki was based on kdigo criteria. hemodynamics, electrolytes, peep, p/f, kind of fluid administered, fluid balance, % fluid overload, length of stay, the sequential organ failure assessment score, injury severity scores and mortality were collected. a total of patients ( %) presented a median nc higher values at icu admission. one patient with positive nc value experienced aki at hrs. the positive nc group had more plasma transfusion (p-value . ) and a lower median hematocrit at hrs (p-value . ), but similar hospital length of stay (p= . ) and mortality rate (p= . ) conclusions: nc at icu admission identifies subclinical aki in tbi patients and it maight be used to predictclinical aki. hemodilution (but not fluid overload) seems to be associated with development of subclinical aki. higher nc at icu admission is not associated with worst longterm outcome in tbi patients. severe traumatic brain injury (tbi) is considered a serious public health problem in europe. partly because of the heterogeneity of tbi, considerable uncertainty may exist in the expected outcome of patients. the international mission for prognosis and analysis of clinical trials in tbi (impact) and the corticosteroid randomization after significant head injury (crash) prediction models are considered the most widely validated prognostic models [ , ] . however, studies using these prediction models for benchmarking of outcomes have been scarce. we aimed to compare actual outcomes in a tbi cohort of critically ill tbi patients with predicted outcomes in a quality of care initiative in an academic hospital. in this retrospective cohort study, we included consecutively admitted tbi patients to the icu adults of erasmus mc, university medical center, rotterdam, the netherlands between january and february . we included patients with tbi. -day mortality was %, sixmonth mortality was % and six-month unfavourable outcome was %. the impact core+ct+lab model predicted % -month mortality (vs % actual, p= . ) and % unfavourable outcome (vs % actual, p= . ). the -day mortality prediction by crash prognosis calculator was % versus actual -day mortality of only % (p= . ), whereas -month unfavourable outcome prediction by crash was % (vs. % actual, p= . ) ( figure ). the impact model, although developed more than a decade ago, seemed appropriate for benchmarking purposes in this single center cohort in the netherlands, while crash predictions were less applicable to our setting. introduction: out of hospital cardiac arrest (ohca) continues to be associated with significant mortality and morbidity. centralisation of care has considerably improved patient survival but has resulted in increased morbidity in the form of neurological deficit. accurate neurological prognostication remains challenging incorporating repeated clinical examination and ancillary investigations [ , ] . data was collected retrospectively and analysed for patients admitted post ohca from october to october . patient arrest demographics were collected in conjunction with extensive inpatient investigation findings including ct, traditional pupil assessment, pupillometry and eeg. results: % of patients survived to hospital discharge. patients presenting in a shockable rhythm continue to have higher survival rates ( table ) . % of patients who received immediate cpr survived to hospital discharge in comparison to % of patients who did not receive immediate cpr. % of patients underwent non-contrast ct head. % of patients had traditional pupillary examination performed on arrival. pupillometry was introduced in december ; out of a possible patients had pupillometry during their inpatient stay. eeg was undertaken in % of cases. our data shows receiving immediate cpr and presenting with a shockable rhythm remain positive prognostic factors. ct head as a stand-alone prognostic modality is unreliable with % of patients who survived to discharge, with intact neurology, had an admission ct head reported as hypoxic brain injury. a new neuroprognostic strategy is required in our unit that adds further certainty to likely clinical outcome. this includes increased use of tests such as eeg and pupillometry and the introduction of biomarkers such as neuron specific enolase, somatosensory evoked potential testing and magnetic resonance imaging. introduction: post-resuscitation care of patients following an out-of-hospital cardiac arrest (oohca) is set out by the uk resuscitation council [ ] . this is in line with the european resuscitation council guideline [ ] . the aim of this audit was to review compliancy to this guideline at the intensive care unit at the bristol royal infirmary . a retrospective audit was performed over a six-month period in adults who were admitted to the intensive care unit at the bri following an oohca whom later died during that admission ( patients). the focus was on whether the neuroprognostication and end-of-life (eol) care received was as per the standards set by the uk resuscitation council. the main neuroloical examinations documented were pupillary reflex ( %), corneal reflex ( %) and motor response to pain ( %). . % of patients received an ssep analysis > hours post-rosc, . % underwent an eeg and . % had > serum neuron-specific enolase measurements recorded. all patients ( %) underwent a ct head during their admission. . % of patients were referred to palliative care during their admission. % of patients were prescribed all eol medications. most common prescriptions included alfentanil ( . %) and midazolam ( . %). finally, % of appropriate patients were referred to be potential organ donors. the audit reflected our local practice and that some parameters were not being maintained as set by uk resuscitation guideline. multiple introduction: the prognostication of neurological outcome in comatose out-ofhospital cardiac arrest (ohca) patients is an integral part of post cardiac arrest care. biochemical biomarkers released from cerebral cells after hypoxic-ischemic injury represent potential tools to increase accuracy in predicting outcome after ohca. currently, only neuronspecific enolase (nse) is recommended in european prognostication guidelines. in this study, we present the release dynamics of gfap and uch-l after ohca and evaluate their prognostic performance for long-term neurological outcome in ohca patients. serum gfap and uch-l were collected at , and h after ohca. the primary outcome was neurological function at -month follow-up assessed by cerebral performance category scale (cpc), dichotomized into good (cpc - ) and poor (cpc [ ] [ ] [ ] . outcome prognostic performance was investigated with receiver operating characteristics (roc) by calculating the area under the receiver operating curve (auroc) and compared to nse. results: of included patients had at least one serum gfap or uch-l value at , or h after ohca. gfap and uch-l levels were significantly elevated in patients with poor outcome. gfap and uch-l discriminated excellently between good and poor neurological outcome at all time-points (auroc gfap . - . ; uch-l . - . ) and overall predictive performance measured by auroc of gfap and uch-l was superior to nse (auroc . - . ) ( figure ). however, the roc at the highest specificities of uch-l and gfap overlap those of nse and comparing the sensitivities for uch-l and gfap with those of nse for the highest specificities (> %) revealed higher sensitivities for nse than for uch-l and gfap at and h. gfap and uch-l predict poor neurological outcome in patients after ohca excellently and with a higher overall accuracy than nse, but both biomarkers perform inferior to nse at specificities over % at and h limiting their clinical use to guide decisions on prognosis. blood pressure after cardiac arrest and severity of hypoxicischemic encephalopathy c endisch , s preuß , c storm introduction: blood pressure management in post cardiac arrest (ca) patients ensures sufficient cerebral perfusion to avoid secondary brain injury. in local chain-of-survival improvements affect p-ohca survival [ ] [ ] [ ] [ ] [ ] . also initial rhythm in p-ohca is an important predictor of survival [ , ] . little is known about the relationship between initial rhythm in p-ohca and long-term outcome [ ] [ ] [ ] . our aim was to establish the relation between shockable rhythm and favorable long-term outcome in pohca. all children aged day- years who experienced non-traumatic ohca between - and were admitted to the sophia children's hospital in rotterdam were included. long-term outcome was determined using a pediatric cerebral performance category score at the longest available follow-up interval. the primary outcome measure was survival with favorable neurologic outcome, defined as pcpc - or no difference between pre-and postarrest pcpc. the association between shockable rhythm and the primary outcome measure was calculated in a multivariable regression model, adjusted for the pre-defined variables. from the patients included in the year study period ( %) patients survived to hospital discharge of which patients ( %) had favorable neurologic outcome (median follow-up duration of months). the rate of favorable neurologic outcome rose from % in to % in (p < . for trend) (fig. ) the odds of favorable neurologic outcome at the longest follow-up duration were significantly higher after a shockable initial and unknown rhythm. secondly, trend analysis showed an increase in aed defibrillation and shorter cpr duration. this was followed, finally, by a rise in rosc, survival to hospital discharge and favorable neurologic outcome rate. low socioeconomic status is associated with worse outcome after cardiac arrest. this study aims to investigate if patients´socioeconomic status impacts the chance to receive early coronary angiography after cardiac arrest. in this nationwide retrospective cohort study, patients admitted alive after out-of-hospital cardiac arrest (ohca) and registered in the swedish registry for cardiopulmonary resuscitation were included. individual data on income and educational level, prehospital parameters, coronary angiography results and comorbidity were linked from other national registers. in the unadjusted model there was a strong correlation between income level and rate of early coronary angiography where % of patients in the highest income quartile received early angiography compared to % in the lowest income quartile. when adjusting for confounders (educational level, sex, age, comorbidity and hospital type) there were still higher chance of receiving early coronary angiography with increasing income, or . (ci . - . ) and . (ci . - . ) for the two highest income quartiles respectively compared to the lowest income quartile. when adding potential mediators to the model (initial rhythm, location, response time, bystander cardiopulmonary resuscitation and if the arrest was witnessed) no difference in early angiography related to income level where found. the main mediator was initial rhythm (figure ). higher income is strongly related to the rate of early coronary angiography after ohca. this finding is consistent when adjusting for known confounders. however, the association between income and early angiography seems to be mediated by initial rhythm. patients with low income more often presents with non-shockable rhythms which lowers the likelihood to undergo early coronary angiography. a. the total amount of mortality as a stacked bar: in light-red the number of patients who deceased at scene, in green the number of patients deceased during admission, in red patients who died after discharge. the grey line is the total number of inclusions. b. the rate of bystander aed use, rate of initial shockable rhythm, rate of less than minutes of cpr and rate of favorable neurologic outcome over time. p for trend significant for bystander aed use, less than minutes of cpr and favorable neurologic outcome. trend analysis performed using binary logistic regression for dichotomous data (and a kruskal-wallis test for non-normally distributed continuous data) effect of simulation teaching of cardiopulmonary resuscitation for nursing v spatenkova introduction: simulation teaching is a modern type of critical care (cc) education. the aim of this study was to assess the effect of simulation teaching of cc on a comparison of final examination in different model levels of cardiopulmonary resuscitation (cpr) after the first (cc ) and third, final cc . the success rate of cpr was tested in prospective study ( ) ( ) on two groups with a total of students in cc and cc at the faculty of health studies. three semester of undergraduate nursing simulation education (lectures and training) used the laerdal simman g. quality of cpr was evaluated according to parameters: compression depth, compression rate, chest release and time of correct frequency. we tested if cpr quality differed between the two groups. for the compression depth and compression rate parameters, first the conformity of variance was verified and then two-sample t-test. as the chest release and time of correct frequency are recorded as percentages, the wilcoxon rank-sum test was conducted for these parameters. to ensure good resuscitation, all recorded parameters must be properly performed during resuscitation. thus, pivot tables were used to generate statistics and test if the number of correctly performed resuscitation parameters for cc and cc differ. the compression depth parameter was statistically significantly higher for the cc than for the cc (p= . ). there were no differences in compression rate (p= . ), chest release (p= . ) and time of correct frequency (p= . ). it was also tested how many of the parameters were performed correctly by students at cpr. the chi-square test shows the relative frequency of cpr success is higher for the cc group than for the cc group. at least out of parameters were correctly performed by % of cc students compared to % of cc students. the study showed a significant improvement of cpr in the final cc and supported the three semester simulation education. changes in blood gases during intraoperative cardiac arrest jj wang, r borgstedt, s rehberg, g jansen protestant hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, transfusion medicine and pain therapy, bielefeld, germany critical care , (suppl ):p introduction: blood gas analysis (bga) is a common approach for monitoring the homeostasis during surgery. while it is well known that cardiac arrest (ca) leads to circulatory collapse and disturbances in homeostasis, little is known about changes of blood gas during peri-operative ca. we retrospectively analysed patients ≥ years who suffered from peri-operative ca during non-cardiac surgery from / to / . peri-operative ca was defined as need for cardiac compression during anaesthesia care. collected data included ph, paco , pao , return of spontaneous circulation (rosc) and -day mortality after ca. within the study period, we observed peri-operative ca (m= , f= ; age ± ) during anaesthesia procedures (rosc occurred in patients ( %). days after ca, the mortality was % (n= ), % (n= ) were discharged, and % (n= ) still in hospital. % (n= ) of ca patients had an invasive blood pressure monitoring, % (n= ) had bga before and % (n= ) during peri-operative ca. prior to ca, the average values were: ph . ± . , paco ± and pao ± . during ca, the average values were ph . ± . , paco ± and pao ± . table shows the distributions of blood gas before and during ca. there were no statistical differences between the groups (ph: p= . ; paco : p= . ; pao : p= . ). hypercapnia and respiratory acidosis is common in peri-operative ca. these data suggests inadequate ventilation during peri-operative resuscitation. further studies should focus on its impact on the outcome. ]. comparing cases with and without rosc, there were significant more diagnostics done in the group without rosc but more therapeutic consequences seen in the rosc-group (table ) . icu-ca is frequent. diagnostics to detect reversible causes of ca were used rarely in icu-ca ( %), even in patients without rosc. notably, diagnostics often had therapeutic consequences particularly in rosc. further studies are required to define standardized diagnostic algorithms during icu-ca. continuous monitoring of cardiac patients on general ward were improved short term survival of in-hospital cardiac arrest uj go introduction: the importance of early detection in the in-hospital cardiac arrest (ihca) is emphasized. previous studies have reported that clinical outcomes are improved if ihca is witnessed, or if a patient admitted to a monitored location [ , ] . this study aimed to evaluate the association between continuous monitoring and survival of ihca on general ward. a retrospective cohort study of ihca in patients admitted to ward at an academic tertiary care hospital between january and december was performed. the primary outcome was return of spontaneous circulation (rosc). the secondary outcomes were hour survival and survival to hospital discharge. (table ) . cardiac patients with continuous monitoring on general ward showed improving rosc and -hour survival but not survival to hospital discharge in ihca. in-hospital cardiac arrest is associated with poor outcomes. although steroids are frequently used in patients with septic shock, it is unclear whether they are beneficial during cardiac arrest and after return of spontaneous circulation (rosc). of cardiac arrest patients evaluated, were enrolled. advanced life support was conducted according to the resuscitation guidelines. forty-six patients were randomly assigned to receive methylprednisolone mg during resuscitation, and to receive saline (placebo). after resuscitation, steroid-treated patients received hydrocortisone mg daily for up to days, followed by tapering . there was no significant difference between the two groups in scvo andall the secondary outcomes (p> . for all comparisons). the present study found no significant physiologic benefit of corticosteroid administration during and after resuscitation in hospitalized patients with cardiac arrest. the experiences of ems providers taking part in a large randomized trial of airway management during out of hospital cardiac arrest, and the impact on their views and practice. results of a survey and telephone interviews m thomas introduction: the aim is to explore ems experiences of participating in a large trial of airway management during out-of-hospital cardiac arrest (air-ways- ), specifically to explore: . any changes in views and practice as a result of trial participation. . experiences of trial training. . experiences of enrolling critically unwell patients without consent. . barriers and facilitators for out-of-hospital trial participation. an online questionnaire was distributed to ems providers who participated in the trial. in-depth telephone interviews explored the responses to the online questionnaire. quantitative data were collated and presented using simple descriptive statistics. qualitative data collected during the online survey were analysed using content analysis. an interpretive phenomenological analysis approach was used for analysis of qualitative interview data results: responses to the online questionnaire were received from % of airways- study paramedics and study paramedics were interviewed. paramedics described barriers and facilitators to trial participation and changes in their views and practice. the results are presented in five distinct themes: research process; changes in views and practice regardingairway management; engagement with research; professional identity; professional competence. conclusions: participation in the airways- trial was enjoyable and ems providers valued the training and study support. there was enhanced confidence in airway management as a result of taking part in the trial. study paramedics expressed preference for the method of airway management to which they had been randomized. there was support for the stepwise approach to airway management, but also concern regarding the potential to lose tracheal intubation from 'standard' paramedic practice. causes of medical care-associated cardiac arrest on the intensive care unit s entz introduction: cardiac arrest on intensive care unit (icuca) following therapeutic interventions is of imminent importance, because the interventions are comparatively predictable and precautions can potentially be taken. this study investigates medical care associated complications that led to icuca. intensive care database was screened for patients ≥ years who experienced icuca in a tertiary hospital with five icu (two medical, two surgical, one interdisciplinary, with a sum of icu beds) in germany from - . icuca was defined as receiving chest compression and/or defibrillation after admission on icu and classified as "medical care associated" if it was preceded by a therapeutic intervention (i.e. induced by medication, bedding procedures, iatrogenic injuries, procedure associated). subgroups included patients with recurrence of spontaneous circulation (rosc) vs. no-rosc and patients with vs. without vasopressor therapy before intervention. there were icuca in patients of totally , icu patients. medical care associated complications leading to icuca were detected in cases ( %) [incidence . / , (ci . - . )]. icuca following therapeutic interventions occurred because of circulatory insufficiency [n= ( %)], respiratory failure [n= ( %)] and airway associated problems [n= ( %)]. nine of the patients ( %) with care-associated icuca died. table demonstrates therapeutic interventions followed by icuca. care-associated complications were common reasons for icuca. most of events were induced by circulatory insufficiency due to induction of anaesthesia and bedding procedures. further investigations should focus on preventive strategies, such as vasopressor infusion before therapeutic interventions. in-hospital cardiac arrest (ihca) is a lethal event. however, ihca has received less attention than out-of-hospital cardiac arrest (ohca). there have been some studies on ihca; however, there is a lack of information on the evidence and clinical features of ihca compared with information for ohca. we therefore conducted this study to clarify important aspects of the epidemiology and prognosis of ihca in patients with code blue activation. we carried out a retrospective observational study of patients with code blue events in our hospital during the period from january to october . we obtained information on the characteristics of patients including age and gender, ihca characteristics including the time of cardiac arrest, event being witnessed, presence of bystander cardiopulmonary resuscitation (cpr), initial shockable rhythm, vital signs h or h before cardiac arrest, survival to hospital discharge (shd), and the cardiac arrest survival postresuscitation in-hospital (caspri) score. the primary endpoint was shd. we performed univariate and multivariate logistic regression analyses. a total of code blue events were activated during the study period. finally, patients were included in this study. overall, the shd rate was . %. the median time of cpr was min (interquartile range, - min). the rate of initial shockable rhythm was . %. there were significant differences in cpr duration, shockable rhythm, and caspri score between the shd group and non-shd group by univariate-logistic regression analysis. caspri score was found to be the most effective predictive factor for shd (or= . , p= . ) by multivariate-logistic regression analysis. our results demonstrated that caspri score is associated with shd in cpa patients with in-hospital code blue events. caspri score in ihca patients would be a simple and useful adjunctive tool for management of post-cardiac arrest syndrome (pcas). peri-operative cardiac arrest in prematurityincidence and causes at a tertiary care hospital between - g jansen, j popp, e lang, r borgstedt, b schmidt, s rehberg protestand hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, bielefeld, germany critical care , (suppl ):p the peri-operative care of premature pediatric patients requires special expertise and is therefore reserved for specialized centers. although premature birth is described as a risk factor for peri-operative complications and cardiac arrest (poca) there are no data on its incidence and causality in this particular population [ ] . the present study investigates the incidence and causality of pediatric poca at a tertiary care hospital and level i perinatal center in germany. in the anesthesia database of the study center, all anaesthesiological procedures in patients < years of age were examined for poca in preterm infants (gestational age < th week of gestational age) between and . the peri-operative period was defined between the beginning of anesthesiological care up to minutes after anesthesia and/or sedation. we defined cardiac arrest as the necessity of chest compressions. the perioperative phase and the cause of the poca, gestational age and birth weight were recorded. between and , ( . %) of the , pediatric anesthesiological procedures were performed on premature infants. in total, poca occurred in of these patients (f= , m= ; average gestional age ± days; average birth weight ± g (incidence . %, ci . - . %). the time of occurrence and the causes of poca are shown in table . poca in premature babies is rare and has an incidence of . %, which is significantly higher than the non-premature babies. the main causes are problems or complications associated with the respiratory tract and its management, as well as massive hemorrhage. introduction: peri-operative cardiac arrest (poca) in children's anesthesia care is a dreaded event. depending on the country and population, studies describe incidences between . - . per , children's anesthetics. there are no data on the current incidence of pediatric poca in germany. the present study investigates the incidence of poca at a tertiary hospital and level i perinatal center in germany. in the anesthesia database of the study center, all anaesthesiological procedures in patients < years were examined for poca. the peri-operative period was defined between the beginning of anesthesia care up to minutes after anesthesia or sedation. cardiac arrest was defined as the necessity of chest compressions. age, weight, asa status, cause of death and survival after days were recorded. results: poca (median weight was g [q ;q ( )]) were observed in , anaesthesiological procedures (incidence . ± . per , [ci . - . ]). table shows the distribution of the individual age groups, incidences and mortalities of poca. peri-operative -day mortality was per , [ci [ ] [ ] [ ] [ ] [ ] . three children died intraoperatively as a result of hemorrhagic shock, one on the picu as a result of malignant hyperthermia. days after poca, more children had died on the icu due to their underlying disease. poca is a rare event. risk factors are an age < days and an asa status ≥ iii. the main cause of peri-operative death in patients < years of age is massive hemorrhage, the -day mortality is determined by the underlying disease. in-hospital cardiac arrest -predicting adverse outcomes t partington, j borkowski, j gross northwick park hospital, anaesthesia/critical care, london, united kingdom critical care , (suppl ):p introduction: cardiac arrest occurs in . per hospital admissions in the uk. return of spontaneous circulation (rosc) is achieved in approximately half of resuscitation attempts, but rate of survival to hospital discharge is substantially lower [ ] . in our centre, post-arrest care accounts for . % of icu admissions. premorbid social function is purported to affect outcomes, but comorbidity scores are more often used for risk stratification. using a novel social function score alongside an existing comorbidity scale, we aimed to identify trends to inform management of patients at risk of deterioration. a six-month prospective observational study was conducted in a major uk hospital from october to april . for all adult inpatient cardiac arrests, medical notes were reviewed and data collected on the following domains: patient demographics comorbidities and functional status admission details post-arrest events statistical analysis was performed using student's unpaired t-test. results: cardiac arrests occurred. % were in medical patients, with the majority male ( %) and aged over ( %). % were emergency admissions, with mean duration of hospital stay pre-arrest days. in cases ( %) sustained rosc was achieved. however, seven of these ( %) were not subsequently admitted to the icu. only six patients ( %) survived to hospital discharge. pre-admission function and comorbidity were worse in patients who did not survive to discharge ( fig. ), but these were not statistically significant in view of small survivor group size. in an increasingly frail inpatient population, a substantial proportion of patients in whom circulation is restored after cardiac arrest are subsequently considered unsuitable for icu admission. given our understanding of inferior outcomes in patients with poor physiological reserve, we encourage early discussion regarding the appropriateness of cpr in selected patients, guided by social function and comorbidity. references: . national cardiac arrest audit / introduction: there are studies that determine events related to poor outcome in cardiac arrest [ ] . in our study, following parametres were determined ohca patients; age median years, asian/europe/syrian, bystander cpr, bystander aed, ems defibrillation, initial cardiac rhythm, prehospital rosc, corneal and pupillary light reflex and day survival. we determineted poor prognostic sign with post-cardiac arrest patients. in this study, we identified the causes of poor outcome in patients with ohca. this was a single-centre, retrospective study. we determined incidence and epidemiological factors including: demographics, initial cardiac rhythm. our study population were non-traumatic ohca. our icu, all ohca patient were evaluated wtih echo, and fluid, inotrope and vazopressor were added according to cardiac performance. results: during our study, patients who were admitted to intensive care unit between - were screened. of these patients were out-of-hospital arrest and of them were in-hospital arrest. development of cerebral oedema during treatment in hospital remains a poor prognostic sign. the evaluation of initial cardiac ritm is useful to predict neurological outcome in post-cardiac arrest patients. survival after ohca remains low. the evaluation of initial cardiac ritm is useful to predict mortality and neurological outcome in postcardiac arrest patients. basic life support (bls) education and training for school children is active in japan. however, the bls action by schoolchildren may be limited by school rules. this study aimed to analyse the time factors for basic life support performance and outcome in classmatewitnessed out-of-hospital cardiac arrest (ohca) and to investigate how schoolchildren act when they detect ohca. methods: nation-wide database for , school children cases with ohca and local extended database for , ems-unwitnessed ohca, both of which were prospectively collected during the period of - , were retrospectively analysed. proportion of schoolchildren-detected ohca was low in classmate cases ( . %, / ) in nationwide database and extremely low in all ems-unwitnessed ohcas ( . %, / , ) in local database. nationwide database analyses revealed that both emergency call and bystander cpr were delayed when a classmate witnessed the ohca case: median, vs. min and vs. min, respectively. classmate-witnessed cases were associated with higher incidences of shockable initial rhythm, aed use and traumatic causes. the rate of neurologically favourable outcome was . % and . %, respectively in classmate-witnessed and other cases: adjusted or; % ci, . ; . - . . of cases detected by schoolchildren in our prefecture, ( %) cases had presumed cardiac aertiology and ( . %) cases were caused by suicide attempts (hanging and fall). school children placed emergency calls as the first action only in ( . %) cases. emergency calls were largely delayed when school children dialled other numbers or left the scene to seek adult help. school children were rarely involved in bystander cpr ( %) and aed placement ( %). school children are rarely involved in entire bls. emergency calls and bystander cpr are delayed when schoolchildren act to seek help. because schoolchildren detect suicide-related ohcas, psychological care to schoolchildren involved in bls may be necessary. prognostic value of neutrophil/lymphocyte and platelet/ lymphocyte predicting cardiopulmonary resuscitation with spontaneous circulation recovery c li the affiliated suzhou hospital of nanjing medical university, suzhou, china critical care , (suppl ):p to investigate the predictive value of peripheral blood neutrophil-tolymphocyte ratio (nlr) and platelet-to-lymphocyte ratio (plr) on inhospital mortality in patients with spontaneous circulation recovery after cardiac arrest. a retrospective analysis was made of patients who recovered from cardiac arrest in our hospital from april to november and were admitted to the intensive care unit for more than hours. they were divided into survival group and death group according to the outcome of discharge.the dynamic changes and differences of nlr and plr in hours and - hours after admission to icu between the two groups were analyzed and compared. multivariate analysis and roc curve were used to explore the predictive value of nlr and plr for in-patient mortality. compared with the survival group, plr in the dead group was significantly lower within hours of admission to the intensive care department (p < . ), while nlr in - hours was significantly higher (p < . ). the nlr of surviving group was significantly lower than that of hours (p < . ), while the nlr and plr of death group were not significantly different (p < . ) from that of hours (p < . ). multivariate logistic regression analysis and roc curve showed that nlr of - h in icu was an independent risk factor for predicting in-patient mortality, and had high sensitivity and specificity in predicting death outcomes. neutrophil to lymphocyte ratio, platelet to lymphocyte ratio can help to judge the outcome of patients with cardiac arrest and recovery of autonomic circulation after cardiopulmonary resuscitation. [ , ] patients with sofa score > (vs sofa score ≤ ) had a higher free iron level ( . μmol/l vs μmol/l, p = . ) ( figure ). we found a positive correlation between free iron level at h and changes of sofa score between h and h (r= . ic [ . ; . ]). out-of-hospital cardiac arrest is associated with a significant change of plasma free iron level. free iron level at admission is associated with short term outcome. further research is warranted to better determine the significance of such changes. the optimal level of arterial oxygen in the post-resuscitation period is unknown. recent studies show conflicting results in regard to hyperoxia and its association with survival after out-of-hospital cardiac arrest (ohca) [ ] . the aim of this trial is to study the association between early hyperoxia after ohca with return of spontaneous circulation (rosc) and -day survival. observational study using data from three swedish national registers (i.e. intensive care, cardiac arrest and national patient registries after a successful resuscitation, a systemic inflammatory response occurs, and the c-reactive protein (crp) level represents the degree of inflammation [ ] [ ] [ ] . this study examined the association between increased inflammation and early-onset pneumonia (eop) in patients treated with extracorporeal cardiopulmonary resuscitation (ecpr) after out-of-hospital cardiac arrest (ohca). this retrospective study included data of patients with ohca treated with ecpr admitted to st. luke's international hospital between april and april . the exclusion criteria were as follows: age < years, therapeutic hypothermia withdrawal due to death or circulatory failure, or sepsis as a suspected cause of cardiac arrest. patients were diagnosed with eop according to clinical signs and symptoms acquired after a hospitalization period of > h and within days of admission. the crp levels were measured daily from admission to day . we studied patients with a median age of years (interquartile range: - years). furthermore, ( %) patients were males, and the median time interval from collapse to adequate flow was ( - ) min. all patients received prophylactic antibiotics, and ( %) of them had favorable neurological outcomes (cpc, - ). eop occurred in ( %) patients, with a significantly higher crp level on day than that in those without eop ( . categorizing reasons for death after ecpr is important for comparing outcomes to other studies, assessing benefits of interventions, and better define this heterogeneous patient collective. a categorizing for death after cardiac arrest in both in-hospital (ihca) and outof-hospital (ohca) arrests has been proposed in non-ecpr patients by witten et al. here, we adopt this categorization to ecpr patients. single-center, retrospective, cohort study of patients without rosc after ihca or ohca and ecpr between and . patients with survival below hours were excluded. patients were allocated to one of five predefined reasons for death. results: va-ecmo patients were included (age . ± . , . % female, % ecpr, day survival . %). reasons for death for patients with va-ecmo for shock (survival %) and ecpr ( %) were: neurological withdrawal of care ( % vs %), comorbid withdrawal of care ( % vs %), refractory hemodynamic shock ( % vs %), respiratory failure ( % vs %), and withdrawal due to presumed patient will ( % vs %) ( figure ). the differences in reasons for death among the two groups were significant (p < . ), driven by withdrawal due to neuroprognostication, comorbidity and hemodynamic instability. categorizing death after va-ecmo into five categories is feasible. there are significant difference between patients with va-ecmo for shock and ecpr. interestingly, only a quarter of patients after ecpr died due to brain damage. introduction: scarcity of potential dead brain donors and the persistent mismatch between supply and demand of organs for transplantation has led the transplant community to reconsider donation after circulatory death (dcd) as a strategy to increase the donor pool. normothermic regional perfusion (nrp) by extracorporeal membrane oxygenation (ecmo) may be the most effective method for preserving abdominal organs in dcd, especially in liver transplantation [ , ] . a pitfall of this method is its complexity and the unavailability of this resource in some hospitals, especially in regional hospitals, where potential dcd donors may exist. aim of this study is to report the use of mobile ecmo team in controlled dcd. from june to november our group has worked as a mobile ecmo team for cdcd outside our center. portable equipment included cannulation material and the ecmo device. the transplant team consisted of transplant coordinator (anesthesiologist-intensivist, ecmo operator and organ extraction supervisor), cardiac surgeon (cannulation), interventional radiologist (cannulation) and one cardiovascular perfusionist (ecmo operator). twenty-five cdcd donations were performed. characteristics of donors and organs retrieved are summarized in figure . from cdcd, livers, lungs, kidneys were obtained. the evolution of grafts and receptors was favorable at day post-transplant. mobile ecmo teams may enable cdcd in hospitals without these resources, thereby increasing the pool of donors and optimizing graft outcomes. what is the useful coagulation and fibrinolysis marker for predicting extracorporeal membrane oxygenation circuit exchange due to intra-circuit thrombus? y izutani, k hoshino, s morimoto, k muranishi, j maruyama, y irie, y kawano, h ishikura fukuoka university hospital, emergency and critical care center, fukuoka-shi, japan critical care , (suppl ):p a thrombus formation is one of the most frequent and adverse complications during extracorporeal membrane oxygenation (ecmo) support. previous studies have reported that increased d-dimer is a useful predictor of thrombus formation within the ecmo circuit. the purpose of this study was to identify coagulation/fibrinolysis markers for predicting the replacement of ecmo circuit due to intra-circuit thrombus during ecmo support. fourteen patients who underwent veno-venous ecmo for acute respiratory failure between january and december were enrolled. these patients received a total of days of ecmo support. of these, days (times) on which the ecmo circuits were replaced was regarded as the replacement group, while the remaining days were considered as the non-replacement group. the several coagulation/fibrinolysis markers were routinely measured every day during ecmo support. we compared with the levels of these markers between two group to identify the most relevant marker for ecmo circuit replacement due to thrombus. the mean duration of ecmo support was ± days, and the mean number of ecmo circuit replacement was . ± . times per patient. ddimer, thrombin-antithrombin complex (tat), plasmin-α plasmin inhibitor complex (pic), and soluble fibrin (sf) were significantly higher in the replacement group rather than in the non-replacement group (p < . , respectively). according to a multivariate analysis, sf was the only independent predictor of ecmo circuit replacement due to thrombus. the odds ratio ( % confidence intervals) for sf ( μg/ml) was . ( . - . ). the area under the curve and optimal cut-off value were . and ng/ml for sf, respectively (sensitivity, %; specificity, %). from these results, we concluded that sf may be the useful marker rather than d-dimer for predicting the replacement of ecmo circuit due to intra-circuit thrombosis. inhomogeneity of lung elastance in patients who underwent venovenous extra corporeal membrane oxygenation (v-v ecmo)-a computed tomography scan study rd di mussi , ri iannuzziello , fm murgolo , fd de carlo , e caricola , na barrett , lc camporota , sg grasso università degli studi di bari "aldo moro", department of emergencies and organ transplant, bari, italy; università degli studi di bari "aldo moro", bari, italy; department of adult critical care, guy´s and st thomas´nhs foundation trust, king´s health partners, london, uk critical care , (suppl ):p in patients with acute respiratory distress syndrome (ards), nonaerated, poorly aerated, and normally aerated regions coexist to variable degrees in lung parenchyma. the recruitment maneuvers aim to reopen collapsed lung tissue. in a theoretical point view, this strategy may also prevent the normal aerated lung tissue hyperinflation [ ] . the objective of our study was to evaluate lung characteristics in terms of hounsfield units (hu), volume and elastance before and after a recruitment maneuver. in patients with severe ards who underwent v-v ecmo, computed tomography scans (ct-scans) at cmh o of continuous positive airway pressure (cpap) and cmh o were performed. the same ct image was selected at the two different levels of pressure. the distribution of lung opacities, in terms of hu, was classified using the "ucla" colour coding table (osirix image processing software, geneva, switzerland). correspondent lung regions of about voxels were selected. the quantitative analysis, in terms of volume air (vair) was performed with maluna software (version . ; maluna, goettingen, germany). elastance was calculated as the pressure(cmh o)/ vair (ml) ratio. results: see figure . lung inhomogeneity occurs also after recruiting maneuvers. our data confirm that the elastance of recruited lung regions is higher than the elastance of the normal aerated lung regions at low positive end-expiratory pressure (peep) (baby lung). on the contrary the "baby lung" frequently develops hyperinflation. the unpredictable pattern of distribution of volume after recruitment maneuverers may explain the controversial role of peep during the ards treatment. . formal recommendations on target, timing, and rate of at supplementation are lacking. we conceived this study to evaluate the effect of prolonged at supplementation in adult patients requiring veno-venous ecmo for respiratory failure on heparin dose, adequacy of anticoagulation and safety methods: before ecmo start patients were randomized to either receive at supplementation to maintain a functional at level between and % (at supplementation group) or not (control group) for the entire ecmo course. anticoagulation was provided with unfractionated heparin following a standardized protocol [ ] . the primary outcome was the dose of heparin required to maintain the ratio of activated partial thromboplastin time between . and . secondary outcomes were the adequacy of anticoagulation measured with anti-factor xa and the incidence of hemorrhagic and thrombotic complications and amount of blood products fig. b) . conclusions: this retrospective analysis was not able to show a survival benefit for additive pp to ecmo support in general. early initiation of pp could be an important factor for improving survival in this setting and should be considered in a randomized controlled trial for further evaluation. cause-specific mortality during extracorporeal membrane oxygenation, a single center review of medical records m panigada, d tubiolo, p properzi, g grasselli, a pesenti fondazione irccs ca´granda ospedale maggiore policlinico, intensive care unit, milano, italy critical care , (suppl ):p introduction: mortality during extracorporeal membrane oxygenation (ecmo) settles around % and the occurrence of bleeding during ecmo is associated with a high mortality rate. however, cause-specific mortality is rarely reported, probably due to the difficulty of its classification. the purpose of the study was to evaluate the agreement between two expert icu physician in the classification of the cause of death of patients supported with ecmo for either respiratory or cardiac support. methods: two intensive care unit (icu) expert staff physicians independently reviewed the entire medical records of all ecmo patients who died before icu discharge from january to september at fondazione irccs ca' granda, milan. they were asked to choose the cause of patient's death among six categories. in case of disagreement, a third expert adjudicated the case. the two reviewers were also asked whether, in their opinion, bleeding during the last hours contributed to death. elso definition of major bleeding [ ] during the last hours was also recorded for each patient. results: two-hundred and two patients were supported with ecmo of whom ( . %) died. most of these patients (n= , . %) died during ecmo. interrater agreement for cause-specific mortality between the two expert physicians was substantial (k . , se . , p< . ) of the discordant cases were categorized as refractory respiratory failure and as multiorgan failure and septic shock respectively. the distribution of cause-specific mortality is shown in figure . major bleeding (elso) was present in ( . %) patients, only in ( . %) of them bleeding contributed to death according to the reviewers. patients treated with early pp while ecmo showed a superior survival to patients treated with late pp or without pp while ecmo. optimal cut off value for duration of ecmo initiation to first pp was calculated using roc-analysis (auc = . ) and the youden-index. highest sensitivity and specificity for beneficial survival were achieved for a beginning of pp in < . days. (log rank= . ). pp: prone positioning p non-invasive mechanical ventilation in veno-venous extracorporeal membrane oxygenation j rilinger, v zotzmann, x bemtgen, pm biever, d duerschmied, c bode, dl staudacher, t wengenmayer heart center freiburg university, department of cardiology and angiology i, freiburg, germany critical care , (suppl ):p introduction: veno-venous extracorporeal membrane oxygenation (ecmo) support can be combined with a variety of different non-invasive ways to deliver oxygen to the patient's lung. several positive effects might be linked to this so called "awake ecmo". so far there is little evidence about indications and outcome of this approach. we report retrospective registry data on all ards patients treated with ecmo support at a university hospital between / and / . in a systematic review of medical records, we distinguished between patients with invasive mechanical ventilation (imv) from the initiation of ecmo therapy (imv group) and patients that received any kind of non-invasive oxygen supply (non-imv group). a total of patients could be analysed. ( . %) patients received non-imv ecmo support. patients receiving non-imv ecmo therapy showed severe underlying pulmonary disease and immunosuppression (fig. ) . these patients had higher rates of lung fibrosis, long-term oxygen therapy, pulmonary hypertension, renal insufficiency and immunosuppression (p< . ). of patients ( %) required imv during the hospital stay in average . ± . [ . - . ] days after ecmo initiation. reasons were hypoxia despite of ecmo, insufficient ecmo-flow, insufficient protective reflexes or patient agitation. patients with initially non-imv ecmo support showed a numerical but not significant lower icu and hospital survival ( . % vs. . %, p= . ). non-imv ecmo support was applied in patients with severe underlying pulmonary disease and/or immunosuppression. in a high proportion of patients the ventilation regime had to be switched from non-invasive to invasive. survival in this very selected cohort was low. in this retrospective analysis no evident benefit for a noninvasive ventilation strategy could be found. the high proportion of patients who switched from non-imv to imv therapy underlines the need for rigorous patient selection. intra-hospital transportation on extracorporeal membrane oxygenation (ecmo) -a single centre experience in ireland. z siddique, s o´brien, e carton, i conrick-martin mater misericordiae university hospital, department of critical care medicine, dublin, ireland critical care , (suppl ):p the objective of this study is to evaluate intra-hospital transportation of patients on extracorporeal membrane oxygenation (ecmo). it is a retrospective analysis of prospectively collected database, performed as part of ongoing quality improvement initiatives. the setting of this study is an -bed, combined surgical and medical adult intensive care unit (icu) located in a -bed hospital that serves as the national referral centre for cardiothoracic surgery, heart & lung transplantation and ecmo in ireland. we reviewed months of data (from to ) regarding patients admitted to our critical care unit who required intra-hospital transfer for diagnostic and/or therapeutic interventions. we also compared the data to available local guidelines. results: patients were transported on ecmo on a total of occasions; the most common indication being ct brain (table ) . ecmo cannulation sites were peripheral in patients, patients were centrally cannulated. median time from start of the transfer until the patient was returned to icu was minutes (range: - ). the ecmo console was placed on a dedicated ecmo trolley apart from two occasions where it was placed on the patient's bed. number of staff required for transport was between to ; with an icu consultant as team leader. ecmo specialist nurses were always present on the transport team. transfers were during normal working hours with happening on a weekend. a total of complications occurred during the transports, of underlying pulmonary disease or status of immunosuppression in ecmo patients without invasive mechanical ventilation which was significant and were not. the significant complication encountered was ventricular tachycardia in a v-a ecmo patient which required electrical defibrillation. no adverse events related to transport were seen following return to icu. in this single-centre study, we have demonstrated safe intra-hospital transport of ecmo patients. the use of local guidelines, appropriate personnel and performance during normal working hours is recommended. a novel approach for flow simulation in ecmo rotary blood pumps a supady , c benk , j cornelis , c bode , d duerschmied heart center freiburg university, cardiology and angiogiology i, freiburg, germany; heart center freiburg university, department of cardiovascular surgery, freiburg, germany; fifty technology gmbh, freiburg, germany critical care , (suppl ):p introduction: extracorporeal membrane oxygenation (ecmo) is used increasingly in critically ill patients suffering from acute respiratory failure, cardiogenic shock or cardiac arrest. however, this therapy can have deleterious side effects such as bleeding or clotting complications and hemolysis. these complications are particularly caused by physical stress acting upon the blood components while passing through the ecmo system, especially within the rotary pump. we here present a novel approach to simulate blood flows through rotary blood pumps used in current ecmo systems in order to better understand the genesis of these complications. geometries of the xenios dp (xenios ag, heilbronn, germany) rotary pump were reconstructed by ct-scans and manual measurements using computer-aided design (cad). the computational fluid dynamics (cfd) simulation was performed using the software preon-lab (fifty technology gmbh, freiburg, germany), which implements a mesh-free lagrangian method requiring minimal preprocessing of the cad data. the geometries are introduced to the simulation model as tessellated surfaces. five operating points have been specified by the rotation of the centrifugal fan and the corresponding inflow and outflow of blood. the blood is approximatively modelled as a newtonian fluid with a density of kg/m . preonlab allows detailed assessment of the blood flow while passing through the rotary pump including analysis of local flow rates, pressure gradients and shear stress acting upon the blood. dead zones in the fluid flow can be detected which gives reference points for optimizations of the pump design. for the first time, we demonstrate a novel approach for flow simulation in an ecmo rotary pump ( figure ). this approach may help better understand hemodynamics within the extracorporeal system to define optimal operating points or re-design components aiming to limit hemolysis, coagulation disorders and bleeding in seriously ill patients. one-year experience of bedside percutaneous va-ecmo decannulation in a territory ecmo center in hong kong km fong, sy au, pw leung, kc shek, hj yuen, sk yung, hl wu, so so, wy ng, kh leung queen elizabeth hospital, intensive care unit, hong kong critical care , (suppl ):p when veno-arterial extra-corporeal membrane oxygenation (va-ecmo) support can be terminated, arteriotomy wounds of the patients of are traditionally closed by open repair in the operation theaters. lots of manpower are involved and timeslots in operating theaters are scarce. transport of the critically-ill is risky. successful va-ecmo decannulation using percutaneous device called proglide has been reported and our group had adopted and modified this approach [ ] . methods: this is a retrospective study analyzing the one-year experience of bedside va-ecmo decannulation. our institution is a -bed tertiary ecmo referral center in hong kong. our first bedside decannulation was performed in november , and since then, this practice had replaced the traditional open repair, unless contraindicated. data from november to october were analyzed. in the study period, patients received va-ecmo. survived to decannulation and received bedside percutaneous decannulation. their median age was ( - ). the default arterial catheter size was fr, with fr in cases and fr in one. five ( %) failed percutaneous closure and they were subsequently surgically repaired without extra corporeal life support (ecls) continues to be associated with high mortality rates. our ability to predict outcome prior to initiation ecls remains limited. here we take a single cell rnaseq approach in an effort to identify novel immune cell types that are associated with-and may contribute to-survival on ecls. whole genome transcriptomic profiles were generated from~ , peripheral blood monocytes obtained from patients at the time of cannulation for veno-arterial ecls (va-ecls). within each subpopulation, differential gene expression analysis was performed to identify new markers associated with survival. findings were validated in a additional cohorts by flow cytometry. surviving patients had significantly higher proportions of cd + nkt cells (cd + /cd + /cd -/cd + ) that were cd + (p = . , fdr < . ) ( figure ). to validate this observation, we performed fc analysis of a second cohort of patients. for each patient, we quantified the proportion of cd + nkt cells that were cd + . using the median proportion as the cutoff, we again found that a high proportion of cd + cells among cd + nkt cells was predictive of hour survival (p= . ). we noted that while high levels of cd + cells among the cd + nkt cells was protective in this cohort of va-ecls patients, this relationship did not hold for patients with sepsis. as only a few the va-ecls patients were septic, we analyzed a third cohort of septic ecls patients. we observed that high levels of cd + cells among the cd + nkt populations was not protective in this population. the proportion of cd + nkt cells that are positive for cd is predictive of survival among patients undergoing va-ecls for noninfection related indications. introduction: the use of calcium sensitizers has grown enormously in the last decade, probably due to their interesting pharmacodynamic properties. levosimendan (ls) is frequently administered in patients under mechanical circulatory support. we performed a retrospective evaluation of patients treated with ls prior to weaning from mechanical support. this evaluation was combined with a review of the literature. a query of our icu patient data management system revealed patients receiving ls prior to or during vad/ecls support. outcome data were obtained from the patients medical records. of our patients, % was successfully weaned off ecls. fourteen patients ( %) died before being discharged of whom while on ecls support. of the weaned patients, died afterwards. of the converted patients needed subsequent veno-venous ecls support for right ventricular support after the implantation. survival to discharge ratio for the whole group was %. more detailed demographic results can be found in table . a pubmed search using the terms "(ecmo or ecls) and ls and weaning" resulted in publications which dealt specifically with weaning of ecls support. several weaning approaches are available, however poor outcome has remains a problem. some recent studies show a possible beneficial effect of ls infusion prior to weaning from ecls. however most of these studies are retrospective or observational at best. because ls is primarily reserved for the most severe cases, outcome interpretation is difficult. overall weaning success ranges from %- % and variation is very dependant of inclusion criteria. the calcium sensitizer ls can be used when weaning off patients from ecls, certainly given its low incidence of complications. future, large randomized trials are however needed in order to confirm this strategy. cardiogenic shock is well described in newly diagnosed pheochromocytoma, and crisis may be precipitated by hemorrhage into tumour. v-a ecmo represents a rescue therapy in a subset of these patients refractory to medical management, facilitating cardiac recovery and subsequent definitive surgery. consent to publish: written informed consent for publication was obtained from the patients. during a spontaneous breathing trial respiratory mechanics can worsen, and respiratory muscle effort can increase, leading to respiratory muscle fatigue, pump failure, hypercapnia and an unsuccessful weaning from mechanical ventilation. this case report discusses the possibility of applying extracorporeal co removal (ecco r) to reduce respiratory muscle effort in a liver transplant recipient who already failed three weaning attempts from mechanical ventilation. the ecco r membrane lung was integrated into a conventional renal replacement therapy circuit and blood flow was increased from to ml/min. measurements of respiratory mechanics (including esophageal pressure, as shown in fig. ) were used to assess the reduction of respiratory effort before and during the application of ecco r. was delivered through a fr-double-lumen-cannula; ml/min blood-flow with lt oxygen sweep-gas-flow and aptt . - baseline were maintained (iv-heparin). in all cases respiratory and metabolic parameters improved without complications ( figure ). ecco r-crrt facilitated extubation ( out imv pts). in out of pts at risk of niv failure, it avoided imv. treatment mean duration was ± hours, mean lenght of icu stay was ± days. all patients survived to the treatment, nevertheless patients died due to irreversible multiple mof. in our aecopd series prismalung®-prismaflex® facilitated weaning from imv and avoided intubation in patients at risk of niv failure without complications. these positive results may be related to minimal invasiveness of the low-flow device used and may constitute the rationale for a larger randomized controlled trial. consent: written informed consent for data publication has been obtained. extracorporeal the primary outcome findings from the supernova trial [ ] demonstrated that the use of extracorporeal carbon dioxide reamoval (ecco r) allows a reduction in tidal volume (tv) to ultraprotective levels (≈ ml/kg predicted body weight or pbw) during mechanical ventilation in ards patients without significant increases in the arterial partial pressure of carbon dioxide (paco ). unfortunately, it was not feasible to directly measure ecco r rates during the trial. we used a mathematical model of whole-body oxygen (o ) and carbon dioxide (co ) transport and biochemistry [ ] to calculate ecco r rates that permit a fit to the data reported for hemolung (alung technologies) and ila (novalung)/cardiohelp (getinge) devices in the supernova trial [ ] . the mathematical model was calibrated under baseline conditions where patients were mechanically ventilated at a tv of ml/kg pbw in the absence of an ecco r device; the o consumption rate, co production rate and pulmonary shunt fraction were adjusted to match the measured baseline arterial partial pressure of o and paco . assuming all baseline parameters were fixed, tv was then reduced to . ml/kg pbw and the mathematical model predicted the ecco r rate to the change in the paco level. model predictions for the devices are shown in table . these predictions suggest that ecco r rates for ila/cardiohelp devices were approximately twice those for hemolung devices during the supernova trial. these results may be useful to evaluate the expected performance of novel ecco r devices. efficiency and safety of a system crrt plus ecco r to allow ultraprotective ventilation protocol in patients with acute renal failure f maldarelli despite renal function replacement techniques (crrt), a patient who develops acute renal failure(aki) in intensive care unit (icu) has a mortality rate of - %. this risk is partly due to the adverse effect of aki on other organs than the kidney. respiratory complications are frequently associated with the development of aki. new machines combining crrt with a carbon dioxide removal membrane (ecco r) allows the setting up of an ultra-protective ventilation ( ml/kg of predicted boby weight (pbw)) to reduce any lung damage from mechanical ventilation (mv). the reduction in tidal volume (vt) is associated with a decrease in lung damage partly triggered by aki. we evaluated the efficacy of a combined system crrt+ecco r to reduce the vt to ultraprotective values in patients with acute respiratory failure and aki. ards is a syndrome with high morbidity and mortality. an emerging treatment option is ecco r, but the benefit its remains unclear. we assess different degrees of ecco r and varying dead space (ds) on ventilator settings in order to minimize mechanical power. we calculated mechanical power as ( ) power=rr*{Δ〖vt〗^ *[ / *el+rr*( +i:e)/( *i:e)*r]+ Δvt*peep} (el: system elastance, r: airway resistance, peep: positive end expiratory pressure, i:e: inspiratory to expiratory ratio). we calculated the combination of respiratory rate (rr) and tidal volume (vt) ("optimal rr" and *optimal vt*) leading to minimal applied power for a stable carbon dioxide elimination of ml/min (vco ) for two scenarios: ) variation of physiological ds from to % of vt at a fixed rate of eccor . ) variation of ecco r of either , , or ml/min at a fixed physiological ds of %. the alveolar ventilation (va) necessary to eliminate the vco was calculated as ( ) va= (-vco *σ_co *r*t*( +k_c ))/(vco /q-p_vco *σ_co *r*t*(( +k_c ))/ ) σco : co solubility in blood, r: gas constant, t: temperature. pvco : venous partial pressure, kc: function of ph ( . for a ph of . ), q: blood flow [ l/min]). increasing ds from to % increases the minimal mechanical power from . to . j/min, primarily caused by an increase of optimal vt ( - ml). optimal rr was only slightly increased ( . - . /min, figure panel a). for varying ecco r removal, necessary ventilation ranges from . to . l/min. this predicts a minimal power between . and . j/min with an unchanged optimal vt ( - ml) and an increasing optimal rr ( . to . /min ( figure panel b)). in order to minimize mechanical power, increasing shunt or co production should be met with increases in rr while increases in ds should be met with increases in vt. our results indicate that during ecco r, mechanical power and thus risk for lung injury can be minimized with higher vt compared to conservative ventilation strategies. validity of empirical estimates of physiological dead space in acute respiratory distress syndrome jd dianti, eg goligher, as slutsky university of toronto, interdepartmental division of critical care medicine, toronto, canada critical care , (suppl ):p increased physiological dead space fraction (v d /v t ) is a hallmark of the acute respiratory distress syndrome (ards) and has been shown to predict ards mortality. v d /v t is also important in estimating the reduction in tidal volume (v t ) and driving pressure (Δp) with extracorporeal co removal (ecco r). v d /v t can be measured with volumetric capnography but empirical formulae using the patient's age, weight, height, gender and paco have been proposed to estimate v d /v t based on estimates of co production (v co ). the accuracy of this approach in critically ill patients, however, is not clear. secondary analysis of a previously published trial [ ] in which v d /v t and v co were measured in ards patients. estimated dead space fraction (v d,est /v t ) was calculated using standard formulae. agreement between methods was evaluated by bland-altman analysis. the predicted change in Δp with ecco r was evaluated using both measured and estimated alveolar dead space fraction (v dalv /v t ). results: vd,est/vt was higher than measured vd/vt, with a low correlation between the (r = . ). vco was underestimated by the predicted approach (table ) , accounting for % of the error in estimating vd/vt. the expected reduction in Δp with ecco r using vdalv/ vt was in reasonable agreement with the expected reduction using introduction: acute respiratory distress syndrome (ards) is a common condition in critically ill patient. however neuromuscular blockers (nmb) result controvertial in early treatment of ards [ ] . we ought to search systematically and realize a meta-analysis on the matter. an electronic search of randomized clinical trials in adult patient treated with early neuromuscular blockers compared without neuromuscular blockers in ards. the primary objective of the analysis was the mortality at to days. secondary endpoints included mechanical ventilation free days, icu acquired weakness and barotrauma. the search obtained studies for the analysis [ ] [ ] [ ] [ ] [ ] [ ] (figure ). the early use of neuromuscular blockers in ards showed no increase in mortality, but the results should be taken with caution. there was no differences in mechanical ventilation free days. barotrauma is less with the use of nmb. ultrasound is fairly sensitive in the detection of lung infiltrates in patients with hematologic malignancies. in patients with pneumonia requiring intensive care (icu) admission, we hypothesise that abnormal right ventricular (rv) function is associated with an increased -day mortality. rv dysfunction in critically ill patients has a well-known association with adverse outcomes [ ] . however, its impact on mortality in patients with pneumonia has not been directly studied. patients admitted to the queen elizabeth hospital birmingham icu between april and july with a diagnosis of pneumonia who had a formal cardiologist tte were included. abnormal rv function was defined by either depressed function, dilated size or moderate to severe risk of pulmonary hypertension (phtn). abnormal lv function was defined by an lv ejection fraction £ % or grade ii or more diastolic dysfunction. patients with a clinical suspicion of pulmonary embolism were excluded. the primary outcome was -day mortality. continuous data is presented as median (iqr). categorical data is presented as % and analysed using a chi-squared test. results: patients were admitted to icu with pneumonia, of which ( %) had a tte. patients were % male, had a median age of ( - ) and -day mortality of %. abnormal rv function was present in % (n= ), with % depressed, % dilated and % with moderate to severe risk of phtn. rv dysfunction was associated with an increased -day mortality compared to normal rv patients ( % vs. %, p< . ). lv function was abnormal in % (n= ) and was not associated with a higher -day mortality compared to normal lv patients ( % vs %, p = . ). rv dysfunction was associated with a higher -day mortality than lv dysfunction ( % vs %, p = . ). conclusions: this is one of the first studies to demonstrate that abnormal rv function is associated with an increased mortality in icu patients with pneumonia. interestingly, abnormal lv function was not associated with an increased mortality. rakuno gakuen university, anesthesiology, hokkaido, japan critical care , (suppl ):p we previously reported a simple correction method of estimating pleural pressure (ppl) by using central venous pressure (cvp) and that it can be used to estimate ppl and transpulmonary pressure in pediatric patients with respiratory failure. however, it remains unknown that this method can be applied to patients with various levels of chest wall elastance and/or intravascular volume. the objective of this study is to investigate whether our method is accurate in various conditions of chest wall elastance and intravascular volume. the study was approved by the animal care and use committee of rakuno gakuen university. ten anesthetized and paralyzed pigs ( . ± . kg) were mechanically ventilated and subjected to lung injury by saline lung lavage. each pig was subjected to different intravascular volume and different intraabdominal pressures; in each condition, the accuracy of our method was tested. specifically, airway flow, airway pressure (paw), esophageal pressure (pes), and cvp were recorded in each condition, then changes in pes (Δpes) and Δppl calculated using a corrected Δcvp (cΔcvp-derived Δppl) were compared. cΔcvp-derived Δppl was calculated as κ × Δcvp, where κ was the ratio of the Δpaw to Δcvp during the occlusion test. means and standard deviations of the two variables that reflect Δppl (Δpes and cΔcvp-derived Δppl) in all pigs with all conditions were . ± . and . ± . cmh o. the bland-altman analysis for the agreement between Δpes and Δcvp showed a bias of - . the activity and functionality of the diaphragm are difficult to measure in patients ventilated in intensive care. ultrasound can be a useful tool for monitoring diaphragm muscle activity during different ventilation modes. few data currently exist on diaphragm muscle activity in critically ventilated patients [ ] . our goal is to evaluate the respiratory muscular work of the diaphragm with different settings of the respirator by means of an ultrasound scan. the ultrasound assessments of the diaphragm were performed with a mhz linear probe at the apposition zone. we measured the thickening of the diaphragm with the respiratory acts, through the thickening fraction (thickening fraction, tf), defined as:tf = (tdimax -tdimin / tdi min)% tdimax: diaphragm thickness at the end of inspiration (maximum thickness) tdimin: diaphragm thickness at the end of expiration (minimum thickness). ventilatory support was divided into classes: -spontaneous breathing (sb) or continous positive airway pressure (cpap); -pressure support ventilation (psv) with low pressure support ( - cmh o); -psv with high pressure support (> cmh o); -controlled mechanical ventilation (cmv). a total of assessments were performed in patients. the evaluations were all possible at the right hemidiaphragm, while on the left they were not possible in % of the cases. the median tf (iq range) of the ventilation classes was respectively: % ( - %) in sb / cpap; % ( - %) in low-psv; % ( - %) in high psv; and % ( - %) in cmv. the kruskal-wallis test confirms a significant difference between the groups (p < . ). the ultrasound of the diaphragm can be a valid tool for monitoring respiratory muscle activity during mechanical ventilation. introduction: extubation failure is defined as reintubation after hours of extubation in mechanically ventilated critically ill patients. it is associated with morbidity and mortality. the aim of our study was to assess reintubation rates in a busy district general hospital and evaluate the impact of high flow nasal oxygen therapy (hfno) on reintubation rates. we performed a retrospective observational study looking at patients admitted to our bedded level critical care unit ( patients a year) for a period of years between st november and st october . we included patients over years of age who were mechanically ventilated and length of stay was greater than hours. exclusions were age < years, tracheostomy and patients requiring ventilation for < hours. data was collected from ward watcher, a sicsag database and electronic patient records. our study failed to show any impact of hfno on reducing extubation failure. further work is needed to develop a standardized approach to weaning and to consider routine application of noninvasive ventilation to reduce reintubation rates [ ] . fig. (abstract p ) . the bland-altman analysis for the agreement between Δpes and cΔcvp-derived Δppl in various conditions. low: low intravascular volume, normal: normal intravascular volume, high: high intravascular volume, abd-: without an abdominal compression band, abd+: with an abdominal compression band oral endotracheal intubation is common to critically ill patients in intensive care unit. oral care for an intubated patient is important to maintain the moisture of oral mucosa. also, the securement method of oral endotracheal tube developed from cloth tape to commercial tube holder. training powerpoint and video for microteaching was prepared to train up icu nurses to perform the new practice. demonstration and re-demonstration was arranged to assess skills of every nurse. afterwards, each nurse answered a quiz to evaluate the understanding of oetth and its special techniques in application. questionnaire was designed to collect the feedback from all nurses too. the result showed there was nurses ( %) out of nurses achieved full marks in the post-quiz which demonstrated their full understanding of the use of oral ett holder and its nursing care. about the feedback from nurse, % of nurses claimed that they were confident in using the new oetth in clinical setting after training. % of nurses agreed in time-saving of nursing care routine with the use of an oetth. however, only % of nurses agreed that the oetth is effective in prevention of oral mucosa injuries and another % of nursing staff disagreed on its function in improving the patient's oral care. in conclusion, some of the nurses did not agree the prevention of oral mucosa injuries by the new securement method with oetth while some nurses welcomed the new oetth as more easy and effective in oral care to intubated patients. execution of percutaneous dilatational tracheostomy using the standard laryngeal mask airway for ventilation: a prospective survey study g gagliardi , v gagliardi , c chiani , g laccania , f michielan aulss -veneto, anesthesia and intensive care, adria, italy; aulss -veneto, university of padua, adria, italy; aulss -veneto, anaesthesia and intensive care, adria, italy; aulss -veneto, anaesthesia and intensive care, padua, italy critical care , (suppl ):p we fulfilled a survey study dealing with bronchoscope-guided percutaneous dilatational tracheostomies (pdt), using the classic laryngeal mask airway (lma) for the airway management [ ] . the aim was to verify the safety and the effectiveness of the aforementioned procedure methods: we performed an observational prospective survey study enrolling patients hospitalized in the intensive care unit. before performing the tracheostomy, the endotracheal tube has been replaced by the laryngeal mask airway. arterial blood gases, ventilation pressures and tidal volumes have been monitored, registered and compared. the median peak inspiratory pressure has been detected stable in all patients. furthermore, during the ventilation with the laryngeal mask, the tidal inspiratory and expiratory volume difference observed between before and after the bronchoscope positioning, has shown a statistically significant variation. finally, in all cases etco , spo . , pao , and blood ph values persisted within the normal range. the standard lma provides for a reliable airway management and allows an effective ventilation while performing the pdt. once positioned in the supraglottic zone, the lma does not need to be moved throughout all the pdt performance, avoiding risks of displacement, glottic harm and airway device damage, and permitting an easy handling of the bronchoscope, which gives an appropriated visualization of the trachea and a more efficient aspiration. in consequence to the large internal diameter of the lma tube, ppeak has continued to be stable in all patients, providing for minor resistance and inspiratory work. eventually, no late complications, such as tracheal stenosis and infections, have occurred. tracheostomies are the most common surgical procedure performed on critically ill patients. randomized control trials comparing tracheostomy timing in intensive care patients have been equivocal. in order to perform non-urgent tracheostomy in our icu, consent is required from the patient or a formal guardian appointed ad hoc by the courts. since tracheostomies are practically the only elective surgery performed in the critically ill, icu requested guardianship almost always indicates a clinical decision to perform tracheostomy. as appointing a guardian and arranging a tracheostomy takes about a week, the decision to appoint a guardian offers a unique "intention to treat" opportunity to evaluate outcomes in patients for whom tracheostomy is planned. we performed a retrospective analysis over years on patients for whom guardianship was sought excluding those requiring urgent tracheostomy and those with a do-not-resuscitate order. patients were divided according to outcome (tracheostomy, extubation or death prior to tracheostomy) and compared. guardianship was sought for ventilated patients. a decision to withhold tracheostomy was made for patients, who were excluded, leaving patients for analysis. tracheostomy was performed for / ( %) patients, / ( %) were extubated and / ( %) died while waiting for tracheostomy (from nonairway related reasons). tracheostomy was performed on mean ventilation day ± . comparing extubated patients to those who had tracheostomy (table) shows similar demographics, but significantly lower mortality and hospital length of stay. a significant proportion of patients initially planned for tracheostomy were successfully extubated. despite demographic similarities, mortality in this group was significantly lower than for patients undergoing tracheostomy. for a selected subgroup of possibly difficult to characterize patients, delaying tracheostomy may be beneficial. figure ). ptis were analysed by speciality and by outcome. complications occurred in cases (incidence . %). there were cases of subcutaenous emphysema, pneumothorax (occuring d post procedure) and case each of stoma and suture site infection. there was unplanned cannula change within days of insertion. % of cases had cuff inflated on discharge from icu. handover of care was suboptimal; follow up care plans were documented in % of cases. a supervising consultant was present for all ptis. there was a trend of increased insertion by consultant and increased reliance on theatre, with corresponding decrease in the number inserted by trainees. pti in our training icu appears safe with low incidence of complications and good senior support for tracheostomy insertion. emphasis must continue on training junior intensivists in pti. transition of care beyond icu requires further work where currently there is suboptimal handover of care and safety netting for non-icu colleagues. supplemental oxygen administration is ubiquitous in the critical care environment, yet evidence is mounting for the deleterious effects of hyperoxia [ ] . concerns over the adverse effects from hypoxaemia often exceed those of hyperoxaemia in developing world settings, and inconsistent availability of blood gas monitoring may limit judicious oxygen titration. the aim of this project was to audit oxygen delivery practice and introduce qi measures to avoid excess oxygen delivery in a tertiary icu in lusaka, zambia. a prospective snapshot of ventilatory parameters were recorded for critically ill patients over a -week period, including positive end expiratory pressure (peep), fio , and time-course spo . systematic education was provided through group and one to one tutorials to empower nursing and medical staff to titrate oxygen safely and appropriately. repeat data collection was then performed over weeks. initially / patients ( %) were over-oxygenated, as defined by fio > . and spo consistently > %. / patients with an fio of > . had peep ≤ cm ( %). no patient had a pao recorded in the past hours. education was provided as well as implementation of unit protocols above all patient beds documenting a stepwise approach to titration peep and fio . post intervention fewer patients were over-oxygenated: / ( %) had fio > . and spo consistently > %, and / with an fio > . ( %) had a peep ≤ cm. in addition, / ( . %) had a pao recorded within hours. this qi project has shown that nurse engagement and systematic education to titrate fio and peep can be achieved in a resource poor setting and may decrease the incidence of hyperoxia in critically ill patients. availability of blood gas monitoring and knowledge of interpretation was a major barrier to oxygen titration tracheal intubation (ti) in adult burn patients might be unnecessary in to % of cases [ , ] . in pediatric burn patients, there is little data on both the rate of ti and the rate of early extubation [ ] . it has been common practice for a child with a facial burn and/or a suspected airway injury to be intubated early due to the risk of losing airway patency. however this risk should be mitigated against the potential risks of ti and mechanical ventilation in children. therefore the aim of this study was to describe the airway status of child burn victims taken in charge of in our pediatric burn intensive care unit. focused on patients arriving with ti, we investigated the rate of early extubation. in addition we compared non intubated patients with those with prolonged ti. this retrospective study described a cohort of patients hospitalized between and . data was retrospectively recorded from the patient's paper clinical chart. the mean age of our patients was . ± . years [mean±sd] with an average burn area of ± %. % had scald burns and % had facial burns. % of the children were admitted in the burn icu with ti. for % of them, tracheal tube was removed within the first hours after admission. the probability of prolonged ti increased independently with the burned skin area (bsa) (p < . ), the presence of facial burns (p = . ), and in case of flame burns (p = . ) ( figure ). among patients with more than % bsa, % were intubated more than h. among patients with less than % bsa, . % were intubated more than h. according to our retrospective data, it seems appropriate to intubate children with % and more bsa, while for patient with less than % bsa, it might be relevant to seek guidance from physician of the nearest burn center. under % bsa, ti seems rarely required. an analysis of the predictive applicability of initial blood gas parameters for the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury c pirrone , m chotalia , t mangham , r mullhi , k england , t introduction: we hypothesise that initial blood gas parameters have a good predictive applicability in detecting the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury. to the best of our knowledge, this has not been directly studied in the literature. patients with suspected inhalation injury admitted to the icu at queen elizabeth hospital, birmingham between april and may were included. the initial blood gas parameters analysed were pao (kpa), paco (kpa), ph, carbon monoxide level (cohb; %) and pao /fio (pf) ratio. receiver operator characteristics (roc) for these parameters were plotted against the need for intubation for more than hours and the presence of inhalation injury as detected by bronchoscopy and laryngoscopy. area under the curve (auc) for each parameter was calculated. results: patients were admitted with suspected inhalation injury to the icu. % were intubated for more than hours. of patients who were intubated, % had inhalation injury as indicated by bronchoscopy or laryngoscopy. table outlines the auc for initial blood gas parameters in detecting the need for intubation for more than hours and the presence of inhalation injury. ph was the parameter with the most prominent auc, with reverse correlation indicating fair accuracy. no clear inflection point was identified, although all patients with ph < . required intubation and had inhalation injury. paco had a fair predictive applicability in detecting the need for intubation. pf ratio, pao and cohb had poor accuracy. conclusions: initial blood gas parameters had a broadly poor predictive applicability for the need for intubation and the presence of inhalation injury in patients with suspected inhalation injury. severe acidosis (ph < . ) was the most useful blood gas parameter. clinicians should be cautious in using blood gas parameters alone to inform intubation decisions. lung cancer surgery is associated with a high rate of pulmonary complications including ards and mandates lung protective ventilation strategies [ , ] . such strategies include non-intubated video assisted thoracic surgery (nivats) with spontaneous breathing [ ] . currently neither data on respirator settings nor on gas exchange have been reported for applying the latter. this data constitutes a prerequisite for meaningful evaluating the respiratory consequences of non-intubated spontaneous breathing during lung cancer surgery. the aim of this case series was for the first time providing such data from lung cancer surgery including pneumonectomy. during a month period patients without contraindications [ ] scheduled for video assisted thoracic surgery (vats) for non-anatomical and anatomical lung resection including one pneumonectomy (px) were offered non-intubated spontaneous breathing. all patients gave informed written consent to the procedure as well as for analysis and publication of data. anaesthetic management included target controlled infusion of propofol and remifentanil, laryngeal mask airway, and pressure support ventilation. we present early data that early trials of cuff deflation within hours of tracheostomy insertion can be achieved using a standardized protocol. its impact on length of stay, duration of ventilation and patient-centered outcomes needs to be investigated in larger multi-centre trials. preventing underinflation of the endotracheal tube cuff with a portable elastomeric device. a randomized controlled study je dauvergne , al geffray , k asehnoune , b rozec , k lakhal hopital laënnec -chu de nantes, service d´anesthésie-réanimation, nantes, france; hotel-dieu -chu de nantes, service d´anesthésieréanimation, nantes, france critical care , (suppl ):p the management of the endotracheal tube cuff pressure (p cuff ) is routine practice for critical care nursing staff. underinflation could lead to ventilator-associated pneumonia [ ] whereas overinflation exposes to tracheal damage [ ] . multi-daily check and adjustment is recommended to ensure that p cuff lies between and cmh o [ ] . to automate this task some devices exist but may be inconvenient, bulky and/or ineffective. their use is not supported by guidelines. a portable elastomeric device could be appealing for p cuff automated regulation. this prospective randomized controlled study tested whether the tracoe smart cuff manager tm reduced the rate of patients undergoing ≥ episode of underinflation (p cuff < cmh o), as compared with routine manual p cuff adjustment. monocentric, randomized controlled study. patients with acute brain injury and receiving mechanical ventilation were prospectively allocated to one of the two arms: manual reading and adjustment of p cuff at least every h (routine care) or adjunction of the smart cuff manager tm (intervention). this study was approuved by an institutional review board. among randomized patients (routine care in , smart cuff manager tm in ), measurements were performed in h. with routine care, a higher rate of patients experienced at least one episode of underinflation ( . vs. . %;p< . ). episodes of underinflation episodes ( % vs. %;p< . ) and manual adjustments ( % vs. %;p< . ) were more frequent with routine care. for overinflation, there was no between-arms difference (p> . ). the adjunction of continuous p cuff control with the tracoe smart cuff manager tm reduced the incidence of p cuff underinflation as compared with manual intermittent adjustments. overinflation was not promoted by this device. direct laryngoscopy as a technique for tracheal intubation is a potentially lifesaving procedure that healthcare professionals in a variety of fields are taught. however, this skill is challenging to acquire and difficult to maintain. poorly performed intubation technique can lead to potentially serious complications [ ] . the intersurgical iview video laryngoscope is a new intubation tool which may have advantages over direct laryngoscopes, such as the macintosh, in the hands of novice personnel. a prospective randomized counterbalanced trial of medical students, who did not have previous airway management experience, was conducted. each student received brief didactic teaching,following this, participants were directly supervised performing laryngoscopy and intubation using the macintosh and iview devices in an alternating pattern. students were permitted up to three attempts to successfully intubate under four conditions, three laryngoscopy conditions using alaerdal intubation trainer and one using a laerdal simman manikin. there was no significant difference in the success rate of intubation or time to intubation between the two devices. the iview outperformed the macintosh in time to intubation in the normal airway in the final scenario, once students gained experience with both devices. no significant difference was found in the number of optimisation manoeuvres, or intubation attempts between groups. areas where the iview outperformed the macintosh included severity of dental trauma and participants' perception regarding ease of use ofthe device. the iview may prove to be a useful teaching tool for novice personnel who are acquiring the skills of tracheal intubation. patients with a primary pulmonary pathology were more likely to respond to aprv. this association has not been described before and warrants further multi-centre exploration in a larger patient group. introduction: airway suctioning is common during mechanical ventilation, using either an open endotraqueal suctioning or closed endotracheal suctioning (ces). closed circuits were developed to prevent arterial desaturation and atelectasis associated to ventilator disconnection. however, ces may cause substantial loss of lung volume. the purpose of this study was to investigate the effects of a compensation method to prevent the loss in aeration during ces. the suctioning technique was performed for seconds, negative pressures limited at mmhg. closed suction catheters with fr (halyard health, georgia, eua) were used. electrical impedance tomography (eit) monitoring and arterial blood gas were collected. a nihonkoden mechanical ventilator (nkv , california, eua) was applied, having a newly developed algorithm for suctioning which overcomes any pressure loss during suctioning (inlinesuction-app). when activated, the app delivers pcv ventilation, adding cmh o of end-expiratory pressure above peep, and delivering driving pressures of cmh o. results: pigs ( ± . kg) with injured lungs and mechanically ventilated. we tested the aspiration procedures using low peep= cmh o, or high peep=± . cmh o with v t o), whereas maintenance of compliance was observed when the app was on (from . ± . ml/cmh o to . ± . ml/cmh o. blood gas in a representative animal showed a drop in pao when app was off (from , to mmhg after min, and to mmhg after min) ( figure ). with app on the pao changed from (pre-suction), to ( min), to mmhg ( min). the new nksoftware, delivering pcv ventilation during suctioning, could prevent atelectasis and functional loss associated to the procedure. tyrosine kinase inhibitor: an effective tool against lung cancer involvement responsible for acute respiratory failure in icu y tandjaoui-lambiotte patients with advanced-stage non-small-cell lung cancer have high mortality rates in the intensive care unit (icu). in the last two decades, targeted therapies have changed the prognostic of patients with lung cancer outside the icu. the fast efficacy of targeted therapies led some intensivists to use them as rescue therapy for icu patients. we performed a national multicentric retrospective study with the participation of the grrroh (groupe de recherche en réanimation respiratoire en onco-hématologie). all patients with non-small-cell lung cancer admitted to the icu for acute respiratory failure between and were included in the study if a tyrosine kinase inhibitor was initiated during icu stay. cases were identified using hospital-pharmacies records. the primary outcome was overall survival days after icu admission. results: thirty patients (age: +/- years old) admitted to a total of icus throughout france were included. seventeen patients ( %) were nonsmoker. adenocarcinoma was the most frequent histological type (n= , %). most patients had metastatic cancer (n= , %). epithelial growth factor receptor mutation was the most common oncologic driver identified (n= , %). during the icu stay, ( %) patients required invasive mechanical ventilation, ( %) catecholamine infusion, ( %) renal replacement therapy and one ( %) extracorporeal membrane oxygenation. eighteen patients ( %) were discharged alive from icu and ( %) were still alive after days (see figure) . moreover, patients ( %) were alive one year after icu discharge. despite a small sample size this study showed that, in the context of lung cancer involvement responsible for acute respiratory failure, the use of tyrosine kinase inhibitor should not be refrained in patients with severe condition in icu. the burned patient is one of the most complex patients whith a very high mortality. those patients with inhalation injury have a worst prognosis, typically associated with respiratory complications. the aim of our study is to evaluate the mortality of burn patientes with inalation injury in a critical burn unit. a prospective, observational and descriptive study was conducted over a period of years. inhalation injury was defined with these criteria (≥ ): history of injury in an enclosed space, facial burns with singed nasal hair, carbonaceus sputum and stridor. if they were intubated it was diagnosed by bronchoscopy. demographic data, tbsa, absi, baux score, apache ii, sofa, mechanical ventilation (mv), complications, length of stay, hospital course and mortality data were collected. results: burns patients were admitted. % ( patients) had inhalation injury. mortality among patients with inhalation injury was , % ( patients). most patients were men and those who died were older and with higher severity scores (fig. ) . we found no significant differences between groups in the need for mv ( % vs. %) or in the percentage of tracheostomy performed ( . vs. . ). however, patients who died had more respiratory complications like ards, and also shock, renal failure and need of renal replancement therapies although infectious complications were similar in both groups. there was no statistically significant difference in volume used during initial resuscitation in the different groups. patients with inhalation injury who died had higher severity scores at the begining. although there were no differences in the need for mv patients who died had more respiratory complications as well as shock, renal failure and need of rrt, but no infectious complications.the volume used during inicial resuscitation, that was always related to the prognosis, was similar in both groups. further studies are needed to see if this greater initial severity corresponds to the degree of inhalation. aerogen, medical affairs, galway, ireland; aerogen, science, galway, ireland critical care , (suppl ):p patients with acute exacerbations such as asthma are prescribed aerosol therapy from presentation in the emergency department to progression through to the intensive care unit. however, the variability in dose delivery to the lung across the possible patient interventions is not well characterized. here, we assess the predicted lung dose of a bronchodilator in a simulated spontaneously breathing adult patient via both facemask and nasal cannula, and via tracheostomy during mechanical ventilation. a standard dose of . mg in . ml salbutamol was aerosolized using the aerogen solo nebulizer (aerogen, ireland). for facemask testing, the nebulizer was used in combination with the aerogen ultra with lpm supplemental oxygen flow. for nasal cannula testing, the nebulizer was used in combination with the airvo system (fisher and paykel, nz) system at both and lpm gas flow rate. tracheostomy-mediated ventilation was assessed in combination with a hme, with the nebulizer placed between the hme and the tracheostomy tube. international standard iso adult breath settings (vt ml, bpm , i:e : ) were used across all tests, and generated using a breathing simulator (asl , ingmar medical, usa) or mechanical ventilator (servo-u, maquet, sweden). the dose delivered to the lung was assessed using a capture filter at the level of the trachea, with drug mass determined using uv spectrophotometry at nm and interpolation on a standard curve. the results of testing are illustrated in figure . the bronchodilator dose delivered to the simulated patient was seen to be relatively consistent between progressive interventions, except during high flow therapy, with the more clinically relevant lpm gas flow rate having a profound effect on the dose. these results may go some way towards explaining how different patient interventions can affect aerosol dose. the the mechanical ventilation (mv) have been identified as an independent factor indicating a worse prognosis for lung cancer patients [ ] . this study was conducted in order to assess the results of noninvasive mechanical ventilation (niv) and/or invasive mechanical ventilation (imv) modalities in lung cancer patients admitted to the icu with acute respiratory failure (arf). in this study, lung cancer patients with respiratory failure who were admitted to the icu between january and december were evaluated retrospectively. results: patients were included in the study. the mortality rate was . %. patients had niv. imv was applied to patients. in the first hours, of the patients who were initially treated with niv were administered imv. the duration of hospital stay, diagnosis of pneumonia and mortality rate were found to be significantly lower in patients treated with niv alone (p≤ . , p= . , p= . ), but glaskow coma score (gcs) was significantly higher in this group (p≤ . ). the mortality rate was similar between the patients who were initially treated with imv and those who were treated with imv in the first hours. charlson comorbidity index (cci) and mv duration were significantly higher in patients who died (p= . , p= . ), but gcs was significantly lower in this group (p= . ). in the linear regression model for the likelihood of mortality, ccl≥ and unsuccessful niv increased the mortality rate by . ( . - . ) and . times ( - . ) respectively (p= . , p= . ). niv has been an effective modality for respiratory support in most lung cancer patients presenting with arf. however, failed niv seems to be a factor for increased mortality. therefore, the choice of respiratory support modality to be applied in this patient group should be decided by considering the gcs, cci and etiology of arf. the interaction between ventilator settings and the occurrence of acute kidney injury is not fully elucidated. this study aimed at investigating the effect of stepwise increase in peep level on the risk of acute kidney injury as evaluated with the renal resistivity index (rri).the primary outcome is to investigate whether increased levels of peep could lead to increase rri and whether rri could predict the occurrence of aki. methods: patients mechanically ventilated for at least hours and without aki at admission were included in the study. rri was calculated at icu admission. posterolateral approach was used for kidney ultrasound. the peak systolic velocity (v max ) and the minimal diastolic velocity (v min ) were determined by pulse wave doppler, and the rri was calculated as (v max -v min )/v max . the exam was performed modifying the peep levels: , and cm h o in random order for minutes. occurrence of aki was defined within days according to kdigo criteria. sixty-four patients were enrolled in the study and incidence of aki was / ( %). demographical and clinical characteristics are reported in table . increase in peep showed a significant increase in rri from peep to peep (p< . ) and from peep to peep (p= . ) ( figure ). the area under the roc curve of rri to predict aki was . at peep , . at peep and . at peep (all p< . ). the youden index analysis showed an rri> . as the best cut off for aki with a sensibility of % and a specificity of %. patients with rri> . were / ( %), / ( %) and / ( %) at peep ,peep and peep respectively. patients ventilated with a peep value associated with rri> . had higher incidence of aki ( / vs / , p< . ). the application of peep can increase intrarenal vascular resistance,which is associated occurrence of aki; peep level should therefore be balanced taking into account the rri. the rri seems able to predict occurrence of aki in mechanically ventilated patients. alveolar and respiratory mechanics modifications produced by different concentrations of oxygen in healthy rats subjected to mechanical ventilation with protective ventilatory strategy d dominguez garcia , r hernandez bisshopp , jl martin barrasa , d viera camacho , a rodriguez gil , j arias marzan , s garcia hernandez high oxygen can damage tissues [ ] . in this study, we analyze the histological and pulmonary mechanics modifications that can occur when identifying different inspiratory oxygen fractions (fio ) in lungs of healthy rats during protective mechanical ventilation. we use sprague-dawley rat. groups were designed, each with animals, the tidal volume ( ml/kg), peep ( cmh o) and respiratory rate ( rpm) were kept constant, changing the fio between the groups. four groups were established: fio . , . , . and . after hours, the lungs were removed for histological study and obtaining the wet/dry index. the histological modifications studied were: alveolar septa (as), alveolar hemorrhages (ah), intraalvelolar fibrin (if) and inflammatory infiltrates (ii). each parameter was rated from to [ ] . peak pressure (pp) and pulmonary compliance were monitored every minutes. different statistical tests will be used to analyze the data. results: references to the damage produced in the as, ah, if, ii and the global histological pattern were identified in the groups with the highest fio and there was more damage (p < . ) ( figure ). the wet/dry index rose significantly as the oxygen concentration increased (p = . ). in the groups to which a fio of . and was administered, the pp selected specific values with respect to the baseline intake from the first minutes, an aspect that was not appreciated in the other groups (p < . ). regarding pulmonary compliance, it will be seen that, in the fio . and groups, it decreased from the first minutes, finding differences with respect to the other groups (p < . ). conclusions: mechanical ventilation applied for hours in healthy animals produces disorders that are more pronounced as oxygen concentration increase. fio greater than or equal to . should be avoided without clinical justification. introduction: patients requiring prolonged acute mechanical ventilation (pamv, defined as + days on mv) are sicker and incur disproportionate morbidity and costs relative to patients on short-term mv (stmv, < days of mv). we quantified specific clinical outcomes among patients requiring pamv vs. stmv in a contemporary database. we conducted a multicenter retrospective cohort study within~ hospitals in the premier database, - . using icd- -cm and icd- codes we identified pamv and stmv patients, and compared their baseline characteristics and hospital events. because of the large sample size, we omitted hypothesis testing. a total of , patients met the enrollment criteria, of whom , ( . %) received pamv. at baseline, patients on pamv were similar to stmv with regard to age (years: . ± . pamv vs. . ± . stmv), gender (males: . % pamv vs. . % stmv), and race (white: . % pamv vs. . % stmv). pamv group had a higher comorbidity burden than stmv (mean charlson score . + . vs. . + . ). the prevalence of each of the indicators of acute illness severityvasopressors ( . % vs. . %), dialysis ( . % vs. . %), severe sepsis ( . % vs. . %), and septic shock ( . % vs. . %)was higher in pamv than stmv, as were hospital mortality and combined mortality or discharge to hospice (figure ), extubation failure ( . % vs. . %), tracheostomy ( . % vs. . %), development of c. difficile ( . % vs. . %), and incidence density of ventilator-associated pneumonia ( . / , patient-days vs. . / , patient-days). conclusions: over / of all hospitalized patients on mv require it for days or longer. pamv patients exhibit a higher burden of both chronic and acute illness than those on stmv. commensurately, all clinical outcomes examined are substantially worse in association with pamv than stmv. identifying the readiness of patients recovering from critical illness for liberation from invasive mechanical ventilation (imv) is not always straightforward [ ] . the scottish intensive care society (sics) trainee audit conducted a scotland-wide study to understand current practices relating to liberation from imv. data were prospectively collected on patient demographics, indication for intubation, spontaneous breathing trial (sbt) practices, physiological markers, icu outcome and icu los. all patients > years ventilated with imv for > hrs from the st nov. - th nov. were eligible for inclusion. exclusion criteria included extubation for end-of-life, death whilst intubated and presence of tracheostomy. logistic regression was performed to detect factors associated with extubation failure (ef). results were analysed via excel and stata v. . . patient benefit and privacy panel approval was granted. total population of patients were included: ( %) male and median apache score (iqr - ). ef at first attempt occurred on occasions ( . %), median icu los of days (iqr - ), mortality rate . %. the cohort successfully extubated first time had a median icu length of stay of days (iqr - ) and mortality rate of . %. methods of sbt and extubation outcomes detailed in table . no sbt prior to extubation had higher odds of ef (or . , ci . - . , p= . ); patient ventilation for < days had a three times higher odds of ef (or . , ci . - . , p= . ). these were independently associated with ef on multivariate analysis conclusions: we found a reintubation rate of . % in scottish icus. type of sbt most commonly used is divergent from the methods advocated in the literature. the lack of sbt and early extubation attempt was associated with failure, which in turn was associated with longer icu los and higher mortality. in patients undergoing prolonged invasive ventilation we hypothesise that abnormal right ventricular (rv) and left ventricular (lv) function are associated with increased -day mortality. whether changes in lv or rv function could aid in the prognostication of these patients has not been directly studied. patients admitted to the queen elizabeth hospital birmingham icu between april and july who were intubated and ventilated for more than days and had a formal transthoracic echocardiogram (tte) whilst in icu were included. abnormal rv function was defined by the presence of depressed function, dilated size or moderate to severe risk of pulmonary hypertension. abnormal lv function was defined by the presence of lv depression (lv ejection fraction £ % or grade ii or more diastolic dysfunction) or a hyperdynamic lv (formally mentioned in tte report). patients who had a neurological cause for prolonged ventilation were excluded. the primary outcome was -day mortality. categorical data is presented as % and analysed using a chi-squared test. continuous data is presented as median (iqr). results: patients required prolonged ventilation, of which ( %) had a tte. patients were aged ( - ), were % male and had a % -day mortality. the median ventilator days were ( - ) and % required a tracheostomy. abnormal rv function was present in % (n= ) and was associated with an increased -day mortality compared to normal rv function ( % vs. %, rr . [ . - . ], p< . ). lv function was abnormal in % (n= ) and was associated with an increased -day mortality compared to normal lv function ( % vs %, rr . [ . - . ], p < . ). abnormal rv function had a trend towards an increased mortality compared to abnormal lv function ( % vs %, rr . [ . - . ], p = . ). in this study, abnormal rv and lv function were present in a quarter of patients undergoing prolonged ventilation and were associated with an increased mortality. introduction: tidal volume delivered by mechanical ventilation (mv) in sedated patients is distributed preferentially to ventral alveoli, causing overdistention and associated collapse in dorsal alveoli, driving volutrauma, atelectrauma and ventilator-induced lung injury [ ] . temporary transvenous diaphragm neurostimulation (ttdn) stimulates diaphragm contraction [ ] . when used in synchrony with mv, ttdn encourages increased dorsal ventilation due to the change in pressure gradients with diaphragm contraction, mimicking a more normal physiological pattern. this may improve gas exchange and reduce injury. a pilot study was conducted using kg pigs undergoing mv in a mock icu. deeply sedated subjects were provided lung-protective volume-control ventilation at ml/kg. ttdn diaphragm contractions were delivered in synchrony with inspiration on every second breath, reducing the ventilator pressure-time-product by - % during mv+ttdn breaths. tidal volume distribution was recorded in each condition using electrical impedance tomography, and compared to never-ventilated, spontaneously breathing subjects (nv). results: dorsal ventilation changed from % during mv breaths to % during mv+ttdn breaths, compared to % in the nv group (p= . ). ventral ventilation changed from % during mv breaths to % during mv+ttdn breaths, compared to % in the nv group (p= . , figure ). conclusions: ttdn diaphragm contraction used as an adjunct to mv yields a more physiological pattern of volume distribution. this translates into less overdistension in the ventral areas and less atelectrauma in the dorsal areas and reduces ventilator-induced lung injury. this technology introduction: by measuring the pes and its derivatives, we can measure the relationship that exist between the diaphragmatic excursion and the oscillation of the esophageal pressure curve: pswing (ps) so we infer that, just as with the pes, the variations of it might be related to a weaning failure [ , ] . however, no nominal value exists in the bibliography to predict the test result. patients who meet with the inclusion criteria start the weaning process through a test of minutes of spontaneous ventilation, t-tube (tt). and also the respiratory rate (rr) and the tidal volume (tv). from this analysis, an average ps (aps) is determined for each moment of the test (aps , initial and aps , final.).a quotient was obtained in relation to these variables using the value previously obtained (quotient dtv/dps x . a total of patients were included (n= ).regarding the evolution during tt, (n= ) ( %) were successful, while (n= ) ( . %) failed when analyzing a rate that relates the variables tv and ps, a quotient was obtained in relation to these variables using the value previously obtained (quotient dtv/dps) for patients who were successful and who failed, (dtv/dps)/ successful patients presented a value of . while those of the failure group presented a value of . , (or , - p= . ) ( table ) . when presenting the relationship between tv and ps through the quotient (dvt/dps)/ , it is observed a tendency to have a higher quotient among patients who failed versus those who did not fail. the process of weaning from mechanical ventilation imposes an additional workload on the cardiovascular system, which may result in impaired myocardial function, increase in left ventricular filling pressure and respiratory distress. among surgical patients, those undergoing heart surgery are particularly susceptible to cardiac dysfunction induced by weaning because of inadequate cardiovascular reserve. the aim of our study was to depict the pathophysiological changes assessed by echocardiography during the steps of weaning and to identify possible predictors of weaning failure (wf). we enrolled consecutive patients undergoing isolated coronary artery bypass grafting in our institution. data were obtained by intraoperative transesophageal echocardiography before sternotomy (t ) and by transthoracic echocardiography at the beginning of weaning (t ) and at the time of extubation (t ). wf was defined as deferral of planned extubation or respiratory failure needing reintubation or non-invasive mechanical ventilation within hours. results: wf occurred in patients ( . %) and involved manifestations of respiratory distress in ( . %). we found a significant association between left ventricle outflow tract-velocity time integral (lvot-vti) and ventricular-arterial coupling measured at t and wf, with lvot-vti emerging as the best predictor of wf with an area under roc curve of . ( figure ); an optimal cutoff value of cm provided % sensitivity and % specificity. significant increase in e/e' measured at t ( . vs . , p . ) suggested a cardiac etiology of respiratory distress in patients who failed the weaning trial. our study showed that serial assessment of hemodynamic parameters by means of echocardiography is feasible in cardiac surgical patients and can provide insight into pathophysiological changes during weaning. although these preliminary data need to be confirmed in a larger population sample, lvot-vti emerged as a promising predictor of subsequent wf. compliance with guidelines for respiratory therapy in preclinical emergency medicine g jansen, n kappelhoff, s rehberg protestand hospital of the bethel foundation, anaesthesiology, intensive care and emergency medicine, bielefeld, germany critical care , (suppl ):p introduction: current guidelines on pre-hospital emergency ventilation are based on the guidelines for lung protective ventilation in the intensive care unit. the present survey was designed to determine the accordance of actual pre-hospital emergency ventilation by german emergency physicians (gep) with these recommendations. recommendations include a respiratory rate (rr) between - /min, a tidal volume (vt) between - ml/kg, a maximum pressure (pmax) < mbar and a positive end-expiratory pressure (peep) of mbar. an anonymous web-based questionnaire encompassing questions was sent to gep from september to december of . gep were asked to specify their level of education, their preferred ventilation settings and the usually chosen parameters employed to guide mechanical ventilation. statistical analysis was performed using the ch²-test with a significance level ≤ . . % of the questionnaires were completed ( / ). % of the participants were trainees (tr), % consultants (co). as target parameters for guidance of ventilation, % of the tr and % of the co use capnometry. the vt controlled % of the tr and % of the co on the basis of body weight. % of the tr and % of the co reported to control oxygenation using spo . table shows our analysis of the given answers. there were no statistically significant differences between the groups. deviations from the guidelines of pre-hospital emergency ventilation settings are common and mainly concern the use of a guidelinecompliant peep. in addition, recommended target parameters for guidance of ventilation were not applied in a significant proportion of gep. prospective observational study including ltx recipients admitted to our icu from february to january , who underwent a spontaneous breathing trial (sbt) using a t-piece for minutes. clinical variables and arterial blood gas samples were recorded before starting sbt and after minutes on the t-piece. diaphragmatic excursion (de) and thickening fraction (dtf) were also assessed using ultrasound(us) after minutes on the tpiece. us-dd was defined as de< mm or dtf< . of at least one hemidiaphragm. patients who successfully completed a sbt, defined according to clinical criteria,were extubated. extubation failure was defined as the need for reintubation within h. results are expressed as medians (iqr) or frequencies (%). ltx recipients were admitted to the icu, of whom underwent an sbt. were male, and the median age was y. main indications for ltx were interstitial lung disease ( . %), copd and cystic fibrosis. were bilateral ltx, and and were left and right unilateral ltx respectively. patients were extubated after sbt and required reintubation within h. presented us-dd, though there were no differences between patients who succeeded and those needing reintubation. in contrast, patients who succeeded showed higher pao /fio after minutes on the t-piece (table ) . similarly, higher reductions in deltapao /fio after minutes on the t-piece were observed in patients who failed. oxygenation after sbt performed using a t-piece may predict extubation failure in ltx recipients with successful sbt. us-dd was not associated with the need of reintubation. descriptive study about the relationship between self-extubation episodes and patient-ventilator interaction s nogales , introduction: to evaluate the relationship between self-extubation and patientventilator interaction, among other physiological variables, in order to predict and to prevent these events. self-extubation (se) are quality indicators in patients under invasive mechanical ventilations (imv) and are related with mortality [ ] . planned secondary analysis of a prospective data base of clinical and physiologic signals of patients receiving imv. we included se episodes ( - ) with continuous record of ventilator and monitor signals (bclink bettercare®). we analysed demographic data, physiological parameters (peripheral oxygen saturation spo , heart rate hr, respiratory rate rr and media arterial pressure map) and patientventilator interaction (asynchrony index ai, ineffective efforts during expiration iee and double cycling dc). we studied a period of hours prior to the se episode. we used the wilcoxon non-parametric test and for a proper analysis a linear mixed effects model. we included episodes of se, mean age ± years, %men, apache ii at admission ± , , ± , days under imv until the episode, reintubation rate . %, icu stay , ± , days, icu mortality %. at the time of the se, % were under sedation, % with physical restraint. the % were in weaning. we observed a trend to increase in spo , rr, hr, map and asynchronies in the -hour period prior to se episode. we compared these variables from this period with a -hour period before and we observed a statistically the data presented in this study show that our results are in accordance with the literature with favorable mortality and early postoperative complication rates and support that this procedure is an excellent alternative for surgery in the elderly patients. it is reported that patients with pulmonary hypertension (ph; systolic pulmonary arterial pressure (spap)≥ mmhg)) have frequent cardiac complications after transcatheter aortic valve implantation (tavi). ph often gets worse in some patients despite the normal cardiac function after tavi. no studies have ever examined prognosis after tavi in patients with or without worsening of ph. therefore, we retrospectively examined the frequency of mid-to long-term heart failure and cardiac death in patients with and without deterioration of ph after tavi. among patients who underwent tavi at our hospital between february and march , we analysed patients with ph (spap≥ mmhg) before surgery. spap was measured in transthoracic echocardiography before and within week after tavi. patients were divided into two groups according to whether spap worsened/ did not change or improved after tavi. we examined the frequency of admission due to heart failure or cardiac death (death caused by heart failure, angina, or myocardial infarction) during the period of years after tavi. ph worsened or did not change after tavi in patients, while it improved in patients. the left ventricular ejection fraction measured within week after tavi showed no difference between the two groups ( . ± . % vs . ± . %, p= . ). the worsened/ no change group was higher in frequency of admission due to heart failure (logrank; p< . ) and cardiac death (logrank; p< . ). despite successful treatment for as by tavi, the frequency of heart failure and cardiac death was higher in patients who did not show improvement of ph after tavi, even in the absence of cardiac function decrease. vigorous intervention for ph worsening after tavi may be helpful to improve prognosis. the there are several different anti platelet drugs that can be used to treat acute cardiac events. currently there are no effective markers that can assess how these drugs modify coagulation profile and quality. a new functional biomarker that measures fractal dimension (df ) and clot formation time (tgp) has been developed [ ] . df quantifies clot microstructure whereas tgp is a real-time measure of clotting time. we aimed to validate df and tgp in st elevation myocardial infarction (stemi) and assess the effect of two p y inhibitors which have different pharmacological mechanisms: clopidogrel and ticagrelor. we prospectively recruited stemi patients in the emergency setting. venous blood samples were collected hours after admission, following treatment with either ticagrelor or clopidogrel, in accordance with the local guidelines at the time. the blood samples were tested using the df and tgp biomarker, platelet aggregometry, clot contraction and standard markers of coagulation. results: patients received clopidogrel and received ticagrelor. the df for clopidogrel was higher than ticagrelor ( . ± . vs . ± . , p= . which corresponds to a decrease in clot mass of % figure ) and the tgp was reduced ( ± sec vs ± sec, p= . a % reduction in time). the results of the study suggest that clopidogrel is less powerful in its effects on clotting characteristics compared to ticagrelor. blood from patients receiving clopidogrel formed quicker and denser clots. this would suggest the risk of secondary events or stent occlusion is lower in those patients on ticagrelor, highlighting that df and tgp may be important in identifying patients at risk of future thrombotic events, the study is ongoing and will investigate the long term outcome in these patients. introduction: new onset atrial fibrillation (noaf) during critical illness frequently resolves prior to discharge. however long-term risks of noaf (i.e. heart failure, ischemic stroke and death)remains high [ ] . previous studies noted that nearly half of noaf cases did not have diagnosis recorded [ ] . addressing this may reduce post critical illness mortality by increasing af surveillance post intensive care (icu) discharge. retrospective data was collected from an electronic health record for icu admissions over a month period from a biomarker is defined as a measurable indicator of some biological state or condition. combined with a good clinical evaluation, they can enable an early and safe diagnostic, thus a faster management for the patient. cardiac biomarker testing is not indicated in routine in the emergency department (ed) because of low utility and high possibility of false-positive results. however, current rates of testing are unknown. the aim of our study was to evaluate the importance of measuring cardiac biomarkers especially troponins, d-dimer, and btype natriuretic peptide in our daily practice, and to identify the latest recommendations for a better use of these biomarkers in the diagnostic and therapeutic approaches. we conducted a prospective observational study, over a months periods performed in the ed of the university hospital center ibn rochd, casablanca, morocco, including all patients admitted during our study period and having a blood test for at least one biological marker. the dataset was analyzed by spss statistics . . a total of patients was enrolled. troponins were tested in . % patients (high sensitive in . % and troponin i tni in . %), ddimer in . %, bnp % and nt pro bnp in . % of cases. the diagnostic impact was significant in . % of cases for troponins, . % of cases for d-dimer and . % for bnp. the therapeutic impact was considered important in . % cases for troponins, . % for ddimer and . % for bnp. cardiac biomarkers have an important role in the ed, not only do they confirm the diagnosis (including the role of troponins in acs) but also eliminate others (with a strong negative predictive value of d-dimer for thromboembolic disease) and prove the cardiopulmonary origin of acute dyspnea (the significant place of bnp in confirming the diagnosis of acute heart failure). a multicenter study on the comparison of inter-rater reliability of a new and the original heart score among emergency physicians from three italian emergency departments the heart (based on history,ecg,age,risk factors,troponin) score is a valid tool to stratify the acs in chest pain. but some reports suggest that its reliability could be low for heterogeneity in the assignment due to the subjective interpretation of the history. we used the chest pain score for the "history". in this study we compare the reliability of the new heartcps and original heart. this is a multicenter retrospective study conducted in italian ed between july and october using clinical scenarios. ten physicians were included after a course on heart and heartcps score. we used scenarios which included clinical and demographic data. each participant independently assigned scores to the scenarios using the heart and heartcps. we tested the interrater agreement using the kappa-statistic (k), the confidence intervals are bias corrected ; we used stata/se . statistical software . a p-value of < . defines statistical significance. the overall inter-rater reliability was good for heart and heartcps: kappa = . (ci %; . - . )and , (ci %; . - . ); with good agreement among all the class of risk for heartcps but moderate in the medium class for heart . we found significant differences of inter-rater reliability among the senior and junior physicians who used the heartcps:k= . (ci %; . - . )and . (ci %; . - . ). heartcps score increased its history inter-rater reliability specially among the junior physicians from k= . (ci %; . - . ) to k= . (ci %; . - . ).the junior physicians seem to be more reliable than senior with the heartcps:k= . ( . - . ) vs k= . (ci %; . - . ). the heartcps showed inter-rater reliability better than original heart among the medium class of risk and the junior group. it could be proposed to young doctors to stratify the acs risk of chest pain. limit: we used scenarios rather than real patients. a hybrid approach as treatment for coronary artery disease: endo-cabg or pci first, does it matter? introduction: the aim of this study is to discuss the short-term results of a hybrid approach combining minimally invasive endoscopic cabg (endo-cabg) with a percutaneous coronary intervention (pci). to bypass the disadvantages and potential complications of conventional cabg via median sternotomy, we developed the endocabg technique to treat patients with single-and multi-vessel coronary artery disease (cad). this procedure is performed with three -mm thoracic ports and a mini-thoracotomy utility port ( cm) through the intercostal space. this technique can be combined with pci: the hybrid approach. the sequence of the procedures (endocabg followed by pci or vice versa) may result in different outcomes. from / to / data from consecutive patients scheduled for a hybrid technique at jessa, belgium, were prospectively entered into a customized database. this database was retrospectively reviewed. subgroup analysis was performed to compare outcomes of patients who first received endocabg with patients who first received pci. a p-value < . is considered significant, a p-value < . is considered as a trend toward significance. four patients underwent revision surgery and patients died within the first days. in patients the left anterior descendens artery (lad) was grafted with the left internal mammary artery (lima), the right coronary artery (rca) was the most stented vessel using pci. patients first treated with pci received more units of fresh frozen plasma after endocabg compared to those who were first treated with endocabg (p= . ). there was also a trend toward significant more transfusion of packed cells in this small subgroup (p= . ). the hybrid approach is a feasible technique as a treatment option for patients with multi-vessel cad. if cabg follows the pci, patients are more likely to receive transfusion. a possible explanation could be the need for dual antiplatelet therapy prior to surgery in this group, but this needs further investigation. prognostic difference between troponin elevation meeting the mi criteria and troponin elevation due to myocardial injury in septic troponin t (ctnt) elevation in critically ill patients is common and is associated with poor outcome. using common assays, - % of patients in the icu will have elevated troponin level. our aim was to determine whether there is any prognostic difference between troponin elevation meeting the mi criteria (rise and fall more than % together with echo and ecg new abnormalities) and troponin elevation due to myocardial injury in septic patients. we enrolled patients with sepsis and mean sofa score , respectively in which ctnt level was measured more than once and analyzed there ecg and echo findings. patients were classified into three groups:definite mi (rise and fall ctnt ≥ % and contemporaneous changes on ecg and/or echo),possible mi (rise and fall ctnt ≥ % and no other findings),myocardial injury (ctnt rise less than %) results: data from patients were analyzed ( % female; mean age . (sd . )). a total of patients had at least one elevated ctnt more than . mkg/l. in ( %) of patients ctnt level rised more than % from the first elevated measurement. ( %) of patients met mi criteria considering new ecg and echo findings. the overall mortality rate in all patients was . %.the mortality rate didn't differ significantly in three groups: in the definite mi group . %, in the suspected mi group %, in the non mi ctnt elevation group , %, p= , . coronary angiography was performed in ( %) of patients from the definite mi group,pci was performed in ( %) of patients. the mortality rate in the invasive group was not significantly lower comparing to the nonivasive group % vs , %, p= , . bleeding complications were significantly more frequent in the definite mi group % vs % and % respectively conclusions: ctnt level elevation is associated with poor outcome regardless coronary or non coronary injury. myocardial revascularization may be beneficial in patients with sepsis and definite mi, but it is also associated with increased bleeding risk. diagnostic interest of "marburg heart score" in patient consulting the emergencies department for acute chest pain chest pain is a common reason for emergency department visits, although this primarily refers to acute coronary syndrome (acs), this symptom may be frequently related to other non-ischemic etiologies. the aim was to validate the marburg heart score as a tool to exclude coronary artery disease in emergency department patients with nontraumatic acute chest pain. methods: a prospective, observational, descriptive and analytic cohort study conducted in the emergency department, from february st to march st, , collecting patients consulting for nontraumatic acute chest pain, the "marburg heart" score was calculated for all these patients. telephone contact was made after weeks to look for an ischemic cardiovascular event. we included patients. the mean age was +/- years, the sex ratio was . . the majority of the patients ( . %) consulted directly to the emergency department, . % were referred by a primary care physician. the median time to consultation after the onset of chest pain was hours. high blood pressure was the most common risk factor ( . %), followed by smoking ( %), diabetes ( . %) and dyslipidemia ( . %). thirty-five patients ( . %) had already coronary heart disease, ecg was pathological in . % of patients, patients had an acs with st segment elevation. at six weeks, . % of the patients had an acute coronary event. according to the patients' answers on the questions of the marburg heart score. the area under the roc curve of this score was . with a negative predictive value of . %; the "marburg heart score" is a simple, valid and reproducible clinical score with a discriminatory power to rule out the diagnosis of coronary artery disease from the first contact with the patient presenting for chest pain in emergencies. the abdominal aortic aneurysm (aaa) surgery is a complex procedure in elderly patients with high cardiovascular risk. anesthesiological techniques should play special attention to the volume status during cross-clamping as well as to the blood loss. goal directed fluid therapies (gdt) in aaa surgery in elderly patients decrease the perioperative morbidity and mortality [ ] . aim of this study is to investigate administration of fluid-based on either a gdt approach or a control method (fluid administered based on static preload parameters and traditional hemodynamic) in all phases of aaa surgery and especially in the phase of clamping and de-clamping. a total of patients asa iii, randomly scheduled for elective, open aaa surgery were included in this clinical trial. they were randomly assigned to two groups i -gdt with targeting stroke volume variation (svv) and ii -control group where fluids were administered at the discretion of the attending anaesthesiologist. in both these groups hemodynamic parameters, central venous pressure (cvp), temperature, blood loss and diuresis were registered during the operation and hours postoperatively. each group was assessed for postoperative complications. gdt group received less fluids and had a higher cardiac index (ci) ( . ± . vs. . ± . l/minute per m , p < . ) and stroke volume index ( . ± . vs. . ± . ml/m , p < . ) than the control group. there were significantly fewer complications in the intervention than control group ( vs. , p = . ). gdt fluid administration enables less use of fluids, improved hemodynamic and fewer postoperative complications in elderly patients undergoing aaa surgery. ultrasonography is a valid diagnostic tool, used to measure changes of muscle mass. the aim of this study was to investigate the clinical value of ultrasound-assessed muscle mass, in patients undergoing cardiothoracic surgery that present muscle weakness postoperatively. for this study, consecutive patients were enrolled, following their admission in the cardiac surgery intensive care unit (icu) within hours of cardiac surgery. ultrasound scans, for the assessment of quadriceps muscle thickness, were performed every hours for days. muscle strength was also evaluated in parallel, using the medical research council (mrc) scale. of the patients enrolled, ultrasound scans and muscle strength assessment were performed in patients. the muscle thickness of rectus femoris (rf), was slightly decreased by . % ([ %ci: - . ; . ], n= ; p= . ) and the combined muscle thickness of the vastus intermedius (vi) and rf decreased by . % ([ % ci: - . ; . ], n= ; p= . ). patients whose combined vi and rf muscle thickness was below the recorded median values ( . cm) on day (n= ), stayed longer in the icu ( ± vs ± hours, p = . ). patients with mrc score ≤ on day (n= ), required prolonged mechanical ventilation support compared to patients with mrc score ≥ (n= ), ( ± vs ± hours, p = . ). the use of muscle ultrasound seems to be a valuable tool in assessing skeletal muscle mass in critically ill patients after cardiothoracic surgery. moreover, the results of this pilot study showed that muscle wasting of patients after cardiothoracic surgery is of clinical importance, affecting their stay in icu. prediction of cardiac risk after major abdominal surgery s musaeva, i tarovatov, a vorona, i zabolotskikh, n doinov kuban state medical university, anesthesiology and intensive care, krasnodar, russia critical care , (suppl ):p the aim is to assess the incidence of cardiovascular incidents in major abdominal surgery [ ] using the revised lee index. a study was conducted of elderly patients who underwent major abdominal surgery in the krasnodar regional clinical hospital no. under combined anesthesia. in the preoperative period, the risk of cardiovascular incidents was assessed using the revised lee index and the functional status was assessed by met. depending on the lee index, groups were identified: group (n = ) -low risk (index value - ), group (n = ) -intermediate risk (index value - ); group (n = ) -high risk (index value> ). we estimated the incidence of critical incidents in groups: hypo-, hypertension, arrhythmias, and bradycardia. in the general population, cardiac risk was . ± . points; functional status - . ± met. the greatest number of critical incidents was recorded in patients with high risk ( . %), the smallest -in patients with low risk ( . %), in patients with intermediate risk - . % (n < , between groups according to chi-square criterion). in the structure of critical incidents, hypotension was most often encounteredin ( %) patients, while some patients revealed several incidents from the circulatory system (n = ). overall, the lee scale showed good prognostic ability (auroc = . ) in predicting hemodynamic incidents. the revised lee index is a useful tool to help assess the risk of cardiovascular incidents and determine patient management tactics in the perioperative period. postoperative cognitive dysfunction (pocd) remains an unresolved problem due to lack of consensus on its etiology and pathogenesis. some believe that pocd is the result of the direct toxic effect of general anesthetics on the nervous system. others claim that surgical trauma activates proinflammatory factors that induce neuroinflammation. wistar rats were allocated into groups: -minor surgery (n= ), major surgery group (n= ). after days of handling and habituation rats undergone surgery under isoflurane general anesthesia ( vol.%). group rats underwent laparotomy with gentle gut massage followed by wound closure. rats in group undergone left side nephrectomy. starting from the th postoperative day spatial memory in rats was studied in morris water maze which is a cylinder metal pool with a diameter of . and a height of . m filled with water (temp. ± o c) up to half. it has a platform with a diameter of cm and a height of cm below the water level. testing was preceded by a training stage, which included sessions daily for days. thus, rats developed spatial memory to the location of the platform. on the th day of the study test stage was conducted to assess spatial memory: rats were launched from points into maze without platform and data were recorded for seconds at each session. time spent on the target quadrant (ttq) and the number of target area crossings (tac) were registered. a second test was conducted days after the first test to evaluate long-term spatial memory. the duration of surgery and anesthesia did not differ significantly between groups. there was a significant difference between groups in average ttq and tac in test (table ). in test minor surgery group showed better results but they were less significant. major surgery is associated with a more pronounced deterioration of spatial memory in rats in early postoperative period compared to minor surgery. cardiac inflammatory markers in icu patients with myocardiac ischemia after non cardiac surgery (a pilot study) p manthou , g lioliousis , p vasileiou , g fildissis national kapodistrian university of athens, athens, greece; national kapodistrian university of athens, general thoracic hospital´´sotiria´´, athens, greece; national kapodistrian university of athens, university of athens, athens, greece critical care , (suppl ):p patients with known coronary artery disease have higher perioperative risk for myocardial ischemia [ , ] . mortality is frequent following cardiac ischemia in the intensive care unit (icu) after non-cardiac surgery. the first group includes patients admitted to the intensive care unit for post-operative follow-up without myocardiac ischemia in the first hours. the second group includes patients with myocardiac ischemia postoperatively and needs intensive care monitoring. cardiac risk assessment was made with the lee index,hemorrhagic risk assessment with the has-bled bleeding score and thrombotic risk assessment with cha ds -vasc score. postoperatively, pathological test values such as bnp, troponin, crp, calcitonin were estimated. the sequential organ failure assessment (sofa) systeme was used to assess sepsis. the nursing activity score (nas) scale was used to measure the workload of various nursing activities in the icu. according to the pilot study, the sample consists of patients. . % had myocardial ischemia. the lee index was significantly higher in patients with myocardial ischemia. the duration of hospitalization, the high dose of vasoconstrictive drugs, the length of stay in the icu, the duration of mechanical stay and the nursing workload were higher in patients with myocardial ischemia. ck-mb and troponin levels differed significantly between the two groups. creatinine, bilirubin and bnp during the hours were significantly higher. patients with myocardial ischemia had significantly higher mortality. cardiac risk assessment, has-bled score and cha ds -vasc score in combination with cardiac enzymes such as troponin could predict myocardiac ischemia in severely ill icu patients. introduction: according to the literature an airway complication followed thyroid gland surgery are: difficult trachea intubation, tracheomalacia, postextubation stridor and bleeding [ , ] . most common cause of death was problem with respiration and airway obstruction [ ] . subsequent hypoxia could require emergency airway and even tracheostomy [ ] . aim of our study was to determine the most common of airway complications and their association with type of surgery in our region. the retrospective cohort study included pts., ( women, men) was performed in odessa regional hospital, oncology centre odessa. there were three types of patients: with euthyroid goiter - ( %), polynodos goiter - ( %) and thyroid cancer - ( %) ( table ) . airway complications were diagnosed after trachea extubation based on indirect laryngoscope, presence of stridor, desaturation. the pearson's criteria was calculated. the ratio of airway complications after thyroid surgery was . % ( pts). the main reasons of airway complications in thyroid surgery included: laryngeal edema - pts ( . %); recurrent laryngeal nerve injury - pts ( . %) and postoperative bleeding pts ( . %). thyroid gland cancer and polynodosal goiter associated with laryngeal edema and recurrent laryngeal nerve injury (pearsen criteria were . -moderate and . consequentially). it's may require more attention from the anesthetists after extubation and readiness for an urgent airway. serum iron level and development of multiple organ dysfunction syndrome in patients in the perioperative period s tachyla mogilev regional hospital, department of anesthesiology and intensive care, mogilev, belarus critical care , (suppl ):p recently there has been attention of researchers to the problem of perioperative anemia. it was found that it increases the risk of death and postoperative complications. threatening complication is multiple organ dysfunction syndrome (mods). the objective was to determine the level of serum iron in the perioperative period in patients with endoprosthetics of large joints, and with the presence of mods in abdominal surgery. a prospective cohort study was conducted in patients, including men and women, age . ± . years. two groups were identified: st (control) -patients after endoprosthetics of large joints (n = ), nd (main) -patients in abdominal surgery with the presence of mods (n = ). the presence of mods was established based on the criteria for the sccm / accp conference. serum iron was monitored using an au analyzer (usa). the study identified several stages: st -before surgery, nd - st day after surgery, rd - rd day, th - th day, th - th day. when studying the indicators of serum iron, its significant decrease (p < . ) in the postoperative period was established. in the st group: st stage - . ( - . ) mmol / l, nd stage - . ( . - . ) mmol / l, rd stage - . ( - . ) μmol / l, stage - . ( . - . ) μmol / l, stage - . ( . - ) μmol / l. in the nd group: st stage - . ( - ) mmol / l, nd stage - . ( . - . ) mmol / l, rd stage - , ( . - . ) μmol / l, stage - . ( . - . ) μmol / l, stage - . ( . - ) μmol / l. moreover, in both groups, iron increased at the th stage against the nd stage (p < . ). when comparing the level of iron between the groups, significant differences were found (p < . ) at the nd, rd and th stages. in patients in the postoperative period, a decrease in serum iron is observed, the level of which rises by the th day, but does not reach the initial values. this decrease is more pronounced in patients with the presence of mods after abdominal surgery. kidney and pancreatic graft thrombosis happened in . % and . %, respectively, and bleeding in . %. forty-one ( . %) developed at least one infection during hospital stay. infection during icu was found in . % and main pathogens were gram negative bacilli sensible to beta-lactam. after icu, the incidence of multi-drug resistant pathogen was . %, predominantly gram negative bacilli. fungal infection was lower %. all-cause hospital mortality rate was . %. infectious complications are the main cause of morbidity and mortality following spk transplantation. the administration of broadspectrum prophylactic antibiotics are leading to the appearance of multi-drug resistant pathogens. knowing local microbiological flora may be helpful, allowing more adequate antibiotic prophylaxis. introduction: cardiopulmonary bypass (cpb) is associated with thrombotic complications. occurrence of thrombosis after cpb is % which takes the third place between cpb-associated complications. our study determined preoperative predictors of thrombosis in children with congenital heart defects. patients with congenital heart diseases in age up to months days (median age - , months, youngest age - days after birth, oldest - months days), underwent cardiac surgery with cpb, were enrolled in this study. all patients were divided into two groups: st -without thrombosis, nd -with thrombosis. protein c, ddimer, von willebrand factor and plasminogen plasma levels were assessed directly before surgery. thrombotic cases were proven by performing doppler ultrasound or mri. thrombotic complications were diagnosed in children ( %). between all thrombotic complications ischemic strokes were diagnosed in % ( cases), arterial thrombosis in % ( cases), intracardiac thrombus in % ( cases) and mechanical mitral prosthetic valve thrombosis %( ). receiver operating characteristic (roc) curves are created for the listed indicators. area under the curve (auc) for protein c , (sensitivity(sn)- %, specificity(sp) - %), d-dimer is , (sn - %, sp %), for plasminogen activity - , (sn %, sp %) and for von willebrand factor level - , (sn %, sp %). an roc curve was created for all three indicators, the auc was . (sn - %, sp - %). these parameters can be recommended as predictors of thrombosis in children after cardiac surgery. cpb is related with a large number of life-threatening complications. in our work, preoperative predictors of thrombosis were identified. based on this data, it is possible to create thrombosis risk scale change the tactics of the anaesthetic approach, the prevention of thrombosis in the postoperative period. further studies are needed to identify other possible predictors of thrombosis. introduction: abdominal ischemia occurs in % of patients submitted to aortic aneurysm repair. its early diagnosis requires an elevated index of suspiction, particularly in more severe patients. we hypothesized that earlier increase and higher levels of c-reactive protein (crp) may help to predict intra-abdominal ischemia. we performed a retrospective study of patients admitted to the intensive care department (icd) after abdominal aorta aneurism surgery. we included all patients admitted during a two-year period, that survived for more than hours. primary outcome was splanchnic ischemia assessed by abdominal ct-scan. we also evaluated the presence of bacteremia, abdominal compartment syndrome and icd mortality. association between inflammatory parameters and ischemia was evaluated by multivariate logistic regression. introduction: crp (c-reactive protein) has been shown to be a useful biomarker in identifying complications after major abdominal surgery. gastrectomy is a high-risk surgical procedure that requires post-operative critical care support to monitor for complications which are predominantly infective in nature. the aims of this study were to determine whether there is a relationship between post-operative crp levels and patients who developed post-operative infective complications. a retrospective analysis was performed on patients undergoing elective gastrectomy for gastric cancer at a single centre between september and july . post-operative crp levels for each day following resection were analysed for all patients. roc curve analysis was used to determine which post-operative day (pod) gave the optimal cut-off. of patients included, the majority were male ( . %), mean age was . years and . % had node-negative disease. a total of patients ( . %) had an infective complication, which includes those who experienced an anastomotic leak. crp levels on post-operative day gave the greatest auc for the gastrectomy group ( . ). crp cut-off of mg/l was significantly associated with infective complications (or . , % ci . - . , p= < . ) and gave a sensitivity of % and specificity % (ppv %, npv %). more patients with a crp > on post-operative day experienced an infective complication ( % vs %, p = < . ) or a leak in particular ( % vs %, p = . ). a crp level of less than mg/l on pod may be useful to predict the development or exclude the likelihood of such infective complications in this group of patients prior to clinical signs (ppv %, npv %). this may prompt and facilitate decision-making regarding early investigation and intervention or prevent inappropriate early discharge from critical care, whilst providing more assurance in identifying those who could be stepped down to ward level care. vasoplegia is commonly observed after cardiopulmonary bypass surgery (cpb) and associated with high mortality. chronic use of reninangiotensin aldosterone system inhibitors (raasi) is associated with its incidence and ensuing need for vasopressor support after cpb. renin serves as marker of tissue perfusion [ ] . we examined the role of renin in the setting of raasi exposure and vasopressor needs in the peri-cpb period. prospective observational study of adult patients undergoing cpb, aged . ± . years ( men, women). blood was collected ) post induction, pre-cpb; ) min post cardioplegia, and ) immediately post bypass. vital signs and perioperative medications were recorded. as control, blood was collected from men and women aged . ± . , not diagnosed with lung disease and not prescribed any raasi. baseline plasma renin in cpb patients tended to be higher than in control subjects (mean= . pg/ml± . vs. . pg/ml ± . , respectively, p= . ). minutes into cpb, mean renin was increased from baseline ( . pg/ml± . , p= . ), and remained elevated immediately post cpb ( . pg/ml± . ). patients using raasi prior to cpb tended to have a larger increase in renin post cpb (delta= . pg/ ml± . ) vs. those not previously on raasi ( . pg/ml± . , p= . ). renin was elevated in patients requiring vasopressor support in the hours post cpb vs. those not requiring pressors ( . pg/ ml± . vs. . pg/ml± . p= . ). in those prescribed raasi and requiring pressors post cpb, there was a tendency toward greater renin increase than those not requiring pressors postoperatively ( . pg/ml± . vs. . pg/ml± . , p= . ). this study suggests a trend toward higher renin levels, particularly during cpb, in patients prescribed raasi, and a positive association between renin and postoperative vasopressor needs. we speculate that increased renin levels may predict postoperative vasoplegia. cardiac surgery is associated with perioperative blood loss and a high risk of allogenic blood transfusion. it has been recognized that high blood product transfusion requirement is associated with adverse clinical outcomes. guidelines on patient blood management therefor aim at reducing blood loss and blood transfusion requirements in cardiac surgery. as there remains controversy about the advantage of minimal invasive techniques on blood loss an transfusion requirements, we wanted to investigate if the average blood loss and transfusion requirement in minimal invasive endoscopic coronary artery bypass graft surgery (endo-cabg) differ from conventional technique. we assessed the influence of pre-operative anticoagulant medication for blood loss. estimated average blood loss after conventional cabg is ml (+/- ) and transfusion requirement , units packed red blood cells . we performed a retrospective cohort study of our cardiac surgical database. from / / to / / , we collected data from patients undergoing endo-cabg. we analyzed blood loss, transfusion as well as pre-operative use of anti-coagulants as a risk factor for blood loss. we found that mean total blood loss in endo-cabg does not differ from conventional cabg, nonetheless mean transfusion requirement was lower in our cohort. use of direct oral anticoagulant is aossciated with increased blood loss and transfusion requirements (table ) . total blood loss is not influenced by minimal invasive technique for cabg (endo-cabg). an explanation for the lower transfusion requirements is the use of a minimal extracorporeal circulation, which is known to reduce the risk of transfusion. another important factor is the implementation of a standardized transfusion-protocol based on available evidence. reducing transfusion requirements is an important component in improving patient outcome after cardiac surgery and is related to multiple factors in perioperative care of our patients. retinal microvascular damage associated with mean arterial pressure during cardiopulmonary bypass surgery v shipulin retinal perfusion corresponds to cerebral perfusion and it is very sensitive to hemodynamic disturbances [ , ] . we investigated the association between retinal microvascular damage and hemodynamic characteristics in patients undergoing coronary artery bypass grafting surgery (cabg) with cardiopulmonary bypass (cpb). methods: patients with coronary artery disease and systemic hypertension were examined. ophthalmoscopy and optical coherence tomography were performed before and - days after cabg. the hemodynamic parameters during cpb were analyzed. results: ( %) patients had changes in the retinal vessels and in the ganglionic fiber structure on - day after surgery: in % of patients the foci of ischemic retinal oedema appeared, in % the decrease of the thickness of ganglionic fiber were observed. these changes may be associated with intraoperative ischemia of the central retinal artery. in ( %) patients the mean arterial pressure (map) during cpb was increased up to mmhg. in ( %) of them the association between map and foci of ischemic retinal oedema were revealed. the ischemic retinal changes were observed significantly more often if the delta of map during cpb was over then mm hg compared with the patients where the delta of map was less than mm hg (p= . ). this is probably due to an intraoperative disorders of the myogenic mechanism of blood flow autoregulation in the retinal microvasculature in patients with coronary artery disease [ ] . the level of map up to mm hg during cpb is associated with retinal blood flow impairment and the foci of ischemic retinal oedema. delta of map more than mmhg was associated with the foci of ischemic retinal oedema and decreased ganglionic fiber thickness in % of cases. atrial fibrillation after cardiac surgery: implementation of a prevention care bundle on intensive care unit improves adherence to current perioperative guidelines and reduces incidence introduction: atrial fibrillation after cardiac surgery (afacs) is a very frequent complication affecting - % of all patients. it is associated with an increase in morbidity, mortality and hospital and intensive care unit (icu) length of stay. we aimed to implement an afacs prevention care bundle based on a recently published practice advisory [ ] , focusing on early postoperative (re)introduction of β-blockers. baseline afacs incidence and β-blocker administration practices in our centre were audited for all patients undergoing valve surgery or coronary artery bypass graft (cabg) during a weeks period. the afacs prevention care bundlean easy to follow graphical toolwas subsequently introduced to the cardiac icu by a multidisciplinary team and audited following a model of improvement approach. after exclusion of patients with preoperative af, differences between pre-and post-implementation groups were compared with chisquare and fisher's exact tests for categorical, and one-way anova for continuous variables, using spss. a total of patients were analysed. patient and surgery characteristics did not differ between groups. significantly more patients received postoperative β-blockers after bundle implementation ( . % pre-vs . % post-bundle, p= . ) with a higher proportion on day ( . % pre-vs % post-bundle, p< . , figure ). the incidence of afacs was significantly reduced from . % to . % (p= . ), with a particularly marked reduction in the age group - years and for isolated aortic valve and cabg surgery. there was no significant reduction in hospital length of stay for this cohort. introduction of an afacs prevention care bundle using a graphical tool improved adherence to current guidelines with regards to early β-blocker administration and significantly reduced afacs incidence. future care bundles should include preoperative interventions and might reduce hospital length of stay. in neonates with univentricular physiology, there is a delicate balance between pulmonary and systemic circulations, with a tendency towards generous pulmonary blood flow, and a risk of systemic underperfusion. preoperatively, the use of hypoxic gas mixture (hm) has been advocated as a therapy to increase pvr, with the aim of improving systemic oxygen delivery. it is a therapy which has been routinely initiated in our institution in the setting of signs of pulmonary overcirculation. we performed a retrospective analysis of all patients in our institution who underwent a norwood procedure and who received hm preoperatively. we compared peripheral saturations, arterial blood gas analysis, serum lactate, regional cerebral and renal saturations and invasive blood pressure, prior to, and then , and hours after hm was commenced. between and (inclusive), patients underwent the norwood procedure. patients received preoperative hm. average fio was % during administration of hm. average peripheral saturations were . % prior to hm, and dropped to . % at hours, and % at and hours after initiation (p < . ). there was no change in any of the measured markers of systemic oxygen delivery, including regional cerebral and renal saturations, lactate, urine output or blood pressure. there was an association between an extended period of hm (> hours) and the need for pulmonary vasodilator therapy post norwood procedure. hypoxic gas mixture in patients with parallel systemic and pulmonary cicrculations causes desaturation and hypoxia. it does not lead to an increase in systemic perfusion and thus an improvement in systemic oxygen delivery. its ongoing use in this fragile population should be considered. introduction: analgesia in the critical patient, and especially in the neurocritical patient, is a basic goal in all therapeutic practices. patients in the icu are frequently administered prolonged and/or high doses of opioids. multiple serious complications due to the use of infusion of opioids at large doses has been described. to reduce high doses of intravenous opioids, multimodal forms of analgesia can be used. prospective observational study of the use of tapentadol enteral and buprenorphine in transdermal patches, at low doses, for the control of pain and its effect on reducing the use of fentanyl infusion in high doses on patients admitted to neuro icu of indisa clinic during consecutive years ( - ). enteral tapentadol (through ng tube) mg/ hours, was considered in patients who required intravenous fentanyl in continuous administration. buprenorphine was also added at low doses ( ug/hr) in a weekly transdermal patch, in cases of neurosurgical spine patients, fractures and long-term neuropathic pain. pain was controlled on behavioral pain scale (bps) and visual analogical scale (vas) scores, according to the conditions of each patient. their hemodynamic, gastrointestinal complications and the appearance of delirium episodes according to cam-icu scale were recorded. results: patients received tapentadol. of them also received transdermal buprenorphine. all managed to maintain adequate level of analgesia, not requiring fentanyl at doses greater than . ug / kg / hr. distribution by diagnoses: neurotrauma patients, guillain barre , spine surgery , hsa , hice , malignant ischemic acv . complications: gastric retention patients ( %), hypotension ( %), acute hypoactive delirium ( . %), acute hyperactive delirium ( %). no drug interactions were found. the introduction of enteral tapentadol and buprenorphine patches in neurocritical patients was safe and resulted in a decrease in the use of endovenous opioids and its adverse effects. we hypothesized that changing the pain management for our post cardiac surgical patients to an assessment-driven, protocol-based approach using fast acting and easily titratable agents will significantly improve patient satisfaction by reducing pain intensity in the first h after surgery as suggested by society of critical care [ ] guideline. we prospectively assessed and ( . vs . ) consecutive patients before and after introducing our pain management protocol. the nursing and medical team received rigorous training on the guideline as well as the correct assessment using appropriate pain scores measured at least hourly (numeric pain score, ≥ is timing of beta-blocker (re)initiation versus incidence of afacs before and after prevention care bundle implementation, per post-operative day and for postoperative days - (insets) moderate to severe or critical care observation tool, > is moderate to severe). we introduced a multimodal approach with a combination of fast acting iv, long acting oral opiates, regular paracetamol and rescue iv boluses for difficult to control situations and we created a prescription bundle on our electronic prescribing record. among other variables we assessed hours spent in moderate to severe pain in the first h after surgery and compared to the data collected before the guideline was introduced. we analysed patients from and from . baseline characteristics were similar between the two groups. in only . % of the patients spent less than hours and . % spend more than hours in moderate to severe pain. the data showed significant improvement in that . % of patients spent less than hours and only % patients who spent more than hours in moderate or severe pain. (p < . , chi square) ( figure ). only % of the patient needed rescue medications. % of time was the protocol inadequate necessitating other approach. introducing an assessment driven, stepwise, protocolized pain management significantly improved patient satisfaction by reducing pain intensity in the first h on our cardiothoracic intensive care unit. introduction: proximal femur fractures are most common fractures in the elderly and associated with significant mortality and morbidity, with high economic and social impact. perioperative pain management influence outcomes and mortality after surgery with early mobilization being possible [ , ] . the goal of the study was to compare the efficacy and safety of the compartment psoas block for perioperative analgesia in elderly patients with proximal femur fractures. the randomized controlled study was held in medical center "into-sana" (odesa, ukraine) from january till july . patients with proximal femur fractures and older than years were included in the study. they were randomly allocated to groupscompartment psoas block group (bupivacaine analgesia was started as soon as possible before surgery and prolonged during and after surgery with additional ischiadicus block before surgery) and general (inhalational) anesthesia with systemic analgesia perioperatively. results: patients were included in this study. perioperative compartment psoas block was associated better pain control, decreased opioid consumption, better sleep quality, earlier mobilization after surgery, decreased incidence of opioid-associated vomiting/nausea and myocardial injury. there were no difference in the incidence of hospital acquired pneumonia and delirium. perioperative compartment psoas block is effective and safe for perioperative analgesia in elderly patients with proximal femur fractures, and is associated with better pain control and decreased complications incidence. parenteral olanzapine is frequently used in combination with parenteral benzodiazepines for hospitalized patients with severe agitation. the fda issued a warning for increased risk of excessive sedation and cardiorespiratory depression with this combination based on post-marketing case reports with overall limited quality of evidence [ ] . the purpose of this study is to evaluate the safety and efficacy of concomitant parenteral olanzapine and benzodiazepine for agitation. this retrospective chart review evaluated agitated patients who received concomitant parenteral olanzapine and benzodiazepine within minutes from / / to / / . the primary end points were rate of respiratory depression requiring mechanical ventilation and hypotension requiring vasopressors. the secondary end points were percentage of patients requiring additional sedatives for agitation during the same time frame, cumulative dose of olanzapine and benzodiazepine (midazolam equivalent) received, and rate of cardiac arrest and death. a total of patients were included with notable baseline characteristics: median age of years old, % with a history of substance abuse, and % with a history of psychiatric illness. for the primary outcomes, . % of patients required mechanical ventilation and % required vasopressors. additionally, . % patients received additional sedating agents to control agitation. refer to table for more details. no cardiac arrests or deaths were observed. concomitant use of parenteral olanzapine and benzodiazepine within minutes for the treatment of agitation appears to have a small risk of respiratory depression without significant hypotension. hip fracture is very common in the elderly,it causes moderate to severe pain often undertreated. ficb is a simple safe method, easy to learn and use. the aim of our study is to assess the efficacy and safety of preoperative ficb compared with intravenous analgesia for elderly patients with femoral fracture and hip surgery in terms of opioid consumption and perioperative morbidity methods: after informed consent obtained, patients - yo asa i-iii with hip fracture were randomized to receive either an us guided ficb( ml of ropivacaine , %) or a sham injection with normal saline ' before surgery. both groups were operated under general anesthesia. postoperative analgesia was done according to vas: vas - mm, paracetamol g iv at h, vas - mm, ketoprofen mg iv at h, vas> , morphine , mg/ kgbw iv. the primary outcome was the comparison of vas score at rest over the first 'following the procedure, at the end of the surgery and at h intervals for h. the secondary outcome were the incidence of the cardiovascular events, of the ponv and of the confusion episodes, the amount of morphine consumption for h results: at baseline, ficb group (a) had a lower mean pain score than the sham injection group (b). the same difference was observed over h of follow-up (p< . ). there was a significant difference between the two groups in total cumulative iv morphine consumption at h and in the incidence of ponv and confusion episodes ( figure ). ficb provides effective analgesia for elderly patients suffering from hip fractures, with lower morbidity and lower opioid consumption compared with intravenous analgesia. pain assessment in chronic disorders of consciousness patients with ani monitoring e kondratyeva, m aybazova, n dryagina almazov national medical reseach centre, minimally conscious research group, st petersburg, russia critical care , (suppl ):p pain and suffering controversies in doc to be debated by the scientific, legal and medical ethics communities. methods: ani (anti nociception index) monitor was used to assess pain in patients with chronic disordersof consciousness (doc) age range to years - in vegetative state/ unresponsive wakefulness syndrome (vs/uws) and minimal consciousness state (mcs). average age: in mcs group , ± , and , ± , in vs/uws group. neurological status was assessed using crs-r scale. the average score on the crs-r scale was ± . in vs/uws and . ± . in mcs. pressure on the nail phalanx was used as a pain impulse. ani and nociception coma scale was evaluated before the application of pain stimulus, immediately after and past minutes. prolactin level was measured before the pain stimulus application and minutes after. ani less than indicates pain, - hypoalgesia, severe pain. the mean value of the ani in mcs patients: before the pain stimulus . ± . , after the pain stimulus application ± . and minutes later . ± . . prolactin level in mcs patients before pain . ± . ng/ml; after pain . ± . ng/ml (p> . ). prolactin in vs/uws patients before pain . ± . ng /ml, after pain . ± . ng / ml (p> . ). conclusions: ani monitor revealed that vs/uws and mcs patients react equally to the pain impulse. prolactin dynamics showed poor statistical mean and can not be consider as a marker of nociception in this group of patients. it is possible that the level of pain impulse was insufficient neuroendocrine response activation or the increase of prolactin level occurs in the long term (more than minutes). in all patients the total hip arthroplasty tha is one of the most common major surgical procedures associated with significant postoperative pain that can adversely affect patient recovery and could increase morbidity. effective perioperative pain management allows an accelerated rehabilitation and improve the functional status of these patients. multimodal analgesia mma combines analgesics with different mechanism of action which by synergistic and additive effects enhance postoperative pain management and reduce complications. the aim of our study is to assess if perioperative association of very low dose of ketamine, a potent nmda antagonist and dexamethasone, by antiemetic and antiinflammatory properties could decrease opioid consumption and postoperative morbidity of patients with tha. after informed consent, patients scheduled for primary hip joint replacement surgery aged - yo asa i-iii were prospective randomized in two groups. both groups were operated under general anesthesia fentanyl/sevoflurane. supplementary, patients in group a received mg iv dexamethasone and mg at h and ketamine mg iv bolus at induction and mg/h iv during surgery. postoperative analgesia was done according to vas, - mm paracetamol g iv at h, - mm ketoprofen mg iv at h, vas> mm morhine , mg/kgbw iv. we recorded perioperative opioid consumption, the number of intraoperative cardiac events, vas score at the end of surgery and at h, the incidence of ponv and persistance of chronic pain at months. we obtain a significant less pain score at the end of surgery p< . in group a, no significant difference at h, a significant less chronic pain at months, a fewer npvo and cardiovascular events in group a, p< . ( figure ). a multimodal approach with very low doses of ketamine and dexamethasone could be efficent in the treatment of pain for elderly patients with hip arthroplasty, decreasing postoperative side-effects and reducing chronic pain persistance. introduction: treatment in an intensive care unit (icu) often necessitates uncomfortable and painful procedures for patients. chronic pain is becoming increasingly recognized as a long term problem for patients following an icu admission [ ] . throughout their admission patients are often exposed to high levels of opioids, however there is limited information available regarding analgesic prescribing in the post-icu period. this study sought to examine the analgesic usage of icu survivors pre and post icu admission. methods: patients enrolled in a post-intensive care programme between september and june . intensive care syndrome: promoting independence and return to employment (ins:pire), is a -week multicentre, multidisciplinary rehabilitation programme for icu survivors and their caregivers. patients' level of analgesia was recorded pre-admission and upon attending ins:pire, their level of prescribed analgesia was categorized using the word health organisation (who) analgesic ladder [ ] . results: . % of patients (n= ) were prescribed regular analgesia preadmission; this increased to . % (n= ) post-admission, representing a significant absolute increase of . % ( % ci: . % - . %, p< . ) in the proportion of patients who were prescribed regular analgesia pre and post icu. in addition, pre-admission, . % (n= ) of patients were prescribed a regular opioid (step and of the who ladder) compared to . % (n= ) post-admission, representing an absolute increase of . % ( % ci: . % - . %, p< . ). this study found a significant increase in analgesic usage including opioids in icu survivors. follow-up of this patient group is essential to review analgesic prescribing and to ensure a long term plan for pain management is in place. introduction: pain, agitation, and delirium (pad) are commonly encountered b patients in the intensive care unit (icu). delirium is associated with adverse outcomes, including increased mortality and morbidity. clinical guidelines suggest that routine assessment, treatment and prevention of pad is essential to improving patient outcomes. despite the well-established improvements on patient outcomes, adherence to clinical guidelines is poor in community hospitals. the aim of this quality improvement project is to evaluate the impact of a multifaceted and multidisciplinary intervention on pad management in a canadian community icu. a pad advisory committee was formed and involved in the development and implementation of the intervention. the -week intervention targeted nurses (educational modules, visual reminders), family members (interviews, educational pamphlet, educational video), physicians (multidisciplinary round script), and the multidisciplinary team (poster). an uncontrolled, before-and-after study methodology was used. adherence to pad guidelines in the assessment of pad by nurses was measured weeks pre-intervention and weeks post-intervention. data on patient-days (pd) and pd were available for analysis during the pre-and post-intervention, respectively. the intervention significantly improved the proportion of pd with assessment of pain and agitation at least times per -hour shift from . % to . % and from . % to . %, respectively ( figure ). proportion of pd with delirium assessment at least once per -hour shift did not significantly improve. a multifaceted and multidisciplinary pad intervention is feasible and can improve adherence to pad assessment guidelines in community icus. quality improvement methods that involve front-line staff can be an effective way to engage staff with pad. oversedation introduction: sedation is a significant part of medical treatment in icu patients. a too deep sedation is associated with a longer time of mechanical ventilation, lung injury, infections, neuromuscular disease and delirium, which can lead to a longer duration of icu hospitalization, as well as an increase of morbility and mortality. many patients spend a considerable amount of time in a non-optimal sedation level. a continuous monitoring system of the sedation level is therefore necessary to improve clinical evaluation. our goal was to evaluate the incidence of non-optimal sedation (under and over sedation) comparing the parameters expressed from ngsedline with clinical evaluations and to correlate oversedation and the incidence of delirium. we have studied a cohort of patients admitted to the icu of spedali civili of brescia university hospital requiring continuous sedation for more than hours. in addition to standard monitoring, the patients have been studied using next generation sedline (masimo). sedation depth was evaluated through rass scale and the presence of delirium was evaluated with cam-icu scale. we collected data from adult patients. our data showed high incidence of oversedation. of our patients had a sr> and had a psi level< . a logistic regression analysis was performed and it showed statistically significant association between incidence of delirium and the age of the patients (p . ). the association between delirium incidence and suppression rate time was at the limits of statistics significance (p . ) and was statistically significant for non neurocritical patients (p . ). our study didn't show an association between delirium and the total time of sedation. non-optimal sedation is an unsolved problem in icu, affecting lot of patients, with a major incidence of over-sedation compared to under-sedation. our study shows an association between sr levels and the incidence of delirium. predictors of delirium after myocardial infarction, insights from a retrospective registry m jäckel, v zotzmann, t wengenmayer, d dürschmied, c von zur mühlen, p stachon, c bode, dl staudacher heart center freiburg university, department of cardiology and angiology i, freiburg, germany critical care , (suppl ):p delirium is a common complication on intensive care units. data on incidence and especially on predictors of delirium in patients after acute myocardial infarction (mi) are rare. by analyzing all patients after acute mi, we aim to identify incidence and potential risk factors for delirium. in this retrospective study, all patients hospitalized for acute mi treated with coronary angiography in an university hospital in were included and analyzed. incidence of delirium within the first days of care attributed to the mi and was defined by a nudesc score ≥ , which is taken as part of daily care three times a day by especially trained nurses. this research is authorized by ethics committee file number / . results: patients with acute mi (age . ± . years, stemi, mortality . %) were analyzed. delirium occurred in ( . %) patients and was associated with a longer hospital stay ( ± . d vs . ± . d, p< . ). patients with delirium were significantly older than patients without ( . ± . vs. . ± . years, p< . ) and had more often preexisting neurological diseases ( . % vs. . %, p< . ) and dementia ( . % vs. . %, p< , ). multivariate logistic regression analysis suggested that odds ratio for delirium was higher in patients after resuscitation or . ( % ci . - . ), preexisting dementia or . (ci . - ) and in patients with alcohol abuse or (ci . - ). while maximum lactate was also connected to delirium or . (ci . - . ), infarct size or type had no effect on the incidence of delirium. in patients with mi, delirium is frequent. incidence is associated with clinical instability and preexisting neurological diseases rather than infarct size. incidence and risk factors of delirium in surgical intensive care unit ma ali, b saleem aga khan university, anaesthesia, karachi, pakistan critical care , (suppl ):p introduction: delirium in the critically ill patients is common and distressing. the incidence of delirium in the icu ranges from % to %. although delirium is highly common among intensive care patients, it is mostly underreported. to date, there have been limited data available related to prevalence of delirium in surgical patients. in a study published in , the risk was observed % in surgical and trauma patients [ ] . the purpose of this study was to find out the incidence and associated risk factors of delirium in surgical icu (sicu) of a tertiary care hospital. we conducted prospective observational study in patients with age more than years and who were admitted to the surgical icu for more than hours in aga khan university hospital from january to december . patients who had preexisting cognitive dysfunction or admitted to icu for less than hours were excluded. delirium was assessed by intensive care delirium screening checklist icdsc. incidence of delirium was computed and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors. delirium was observed in of patients with an incidence rate of . %. multivariable analysis showed that copd, pain > and . ] were also the strongest independent predictors of delirium while analgesics exposures was not statistically significant to predict delirium in multivariable analysis. delirium is significant risk factor of poor outcome in surgical intensive care unit. . there was an independent association between pain, sedation, copd, hypernatremia and fever in developing delirium delirium is an acute mental syndrome which may cause negative consequences if it is misdiagnosed [ , ] . the aim of this study was to determine the incidence of delirium in different intensive care units and reveal the risk factors. the study was performed with patients hospitalized in intensive care units of anesthesia, neurology and general surgery departments. written informed consent was obstained from patients or relatives. delirium screening test was performed twice daily with camicu (confusion assessment method for the icu). patients who met the study criterias, were evaluated for the possible risk factors of delirium and the data was recorded daily. patients were reevaluated after the treatment. the incidence of delirium was . %. delirium was found to increase with the length of stay (p < . ). the mean age of the patients with delirium was . . this was higher than the patients without delirium ( . ) (p< . ). visual impairment (p< . ), hearing impairment (p= . ), educational status (p= . ), hypertension (p= . ), mechanical ventilation (p = . ), oxygen demand (p= . ), midazolam infusion (p= . ), propofol infusion (p= . ), infection (p < . ), sofa (p = . ), apache ii (p < . ), nasogastric catheter (p= . ), aspiration (p < . ), number of aspirations (p< . ), enteral nutrition (p< . ), albumin (p= . ), steroid (p= . ), hypercarbia (p= . ) hypoxia (p= . ), sleep disturbance (p< . ) were found risk factors for delirium. oral nutrition (p< . ) and mobilization (p= . ) were found to prevent delirium development. various factors are important in the development of delirium. these risk factors should be considered in reducing the incidence of delirium in intensive care units. ). an unplanned and brutal stop of alcohol consumption, as it can occur during icu admission, may lead to an alcohol withdrawal syndrome (aws). the most severe clinical manifestation of aws is described as delirium tremens (dt). there are no current guidelines available for aws treatment in icu. the study's aim was to describe the clinician's practices for dt treatment and the outcome of dt in icu patients. observational retrospective cohort study in two icus of a universityaffiliated, community hospital in france. patient diagnosed for dt during their icu stay, as defined by dsm-v classification, were enrolled in the study. results: patients with dt were included between and . benzodiazepines was administered to % of the patients in order to prevent an aws. as associated measures, vitamin therapy was administered to % of the patients and % had an increased fluid intake (mean . l+/- . ). concerning the curative approach of aws, the treatment's heterogeneity was notable. there was a high frequency of treatment's association ( % of the patients), every patient had benzodiazepines and the use of second line treatments such as neuroleptic, alpha- agonist, propofol was variable ( figure ). complications of dt were the following: need for mechanical ventilation due to unmanageable agitation or acute respiratory distress ( % of the patients) self inflicted injuries such as pulling out of central lines, tubes, surgical drain ( %) falls ( %). seizures ( %). delirium tremens is a severe complication of an untreated aws, which can lead to serious adverse events in icu. the current lack of evidence concerning the management of aws in icu probably explains the heterogeneity of treatments. given the potential severity of aws in icu, further evidences are required to optimize care of aws in icu patients. the incidence and related risk factor of delirium in surgical stepdown unit s yoon , s yang , g cho , h park , k park , j ok , y jung asan medical center, nursing department, seoul, south korea; asan medical center, seoul, south korea critical care , (suppl ):p step down units (sdus) provide an intermediate level of care between the icu and the general medical-surgical wards. the critically ill patients who are in recovery after long-term intensive care or who require monitoring after acute abdominal surgery are admitted to sdus. delirium in critically ill patient is common and leads to poor clinical outcomes. it is, however, preventable if its risk factors are identified and modified accordingly. to determine risk factors associated with delirium in critically ill patients to admitted surgical sdu at asan medical center. this is retrospective study conducted on critically ill patients who were admitted to the sdu from september to april and able to express themselves verbally. delirium status was determined using the short-cam tool. data were analyzed by spss . software, using t-test, fisher's exact test and logistic regression. the incidence of delirium was . %( of patients) and hypoactive delirium( case, . %) was the most commonly assessed, followed by hyperactive delirium( case, . %), mixed type( case, . %). risk factors associated with developing delirium identified from univariate analysis were age(p= . ), admission via icu (p= . ), tracheostomy (p= . ), chronic heart failure (chf) (p= . ), invasive hemodynamic monitoring (p= . ), heart rate (p= . ). after adjusted in multivariate analysis; factors those remained statistically significant were old age (rr we identified risk factors consistently associated with incidence of delirium following admitted to surgical sdu. these factors help to focus on patients at risk of developing delirium, and to develop preventive interventions that are suitable for those patients. patients with sepsis frequently develop delirium during their intensive care unit (icu) stay, which is associated with increased morbidity and mortality. the prediction model for delirium in icu patients (pre-deliric model) was developed to facilitate the effective preventive strategy of delirium [ ] . however, the pre-deliric model has not yet been validated enough outside europe and australia. the aim of this study is to examine the external validity of the pre-deliric model to predict delirium using japanese cohort. this study is a post hoc subanalysis using the dataset from previous study in nine japanese icus, which have evaluated the sedative strategy with and without dexmedetomidine in adult mechanically ventilated patients with sepsis [ ] . these patients were assessed daily throughout icu stay using confusion assessment method-icu. we excluded patients who were delirious at the first day of icu, were under sustained coma throughout icu stay and stayed icu less than h. we evaluated the predictive ability of the pre-deliric model to measure the area under the operating characteristic curve. calibration was assessed graphically. of the patients enrolled in the original study, we analyzed patients in this study. the mean age was . ± . years and patients ( %) were male. delirium occurred at least once during their icu stay in patients ( %). to predict delirium, the area under the receiver operating characteristics curve of the pre-deliric model was . ( . to . ). graphically, the prediction model was not well-calibrated ( figure ). to predict delirium in japanese icus, we could not show the well discrimination and calibration of the pre-deliric model in mechanically ventilated patients with sepsis. introduction: delirium is a serious and common complication and in some cases it treatment is difficult. aim of the study was an evaluation of the prevalence, structure of delirium and efficacy of dexmedetomidine and haloperidol sedation in geriatric patients after femur fracture. after local ethic committee approval case-records of geriatric patients with femur fracture in the period from to in the institute of traumatology and orthopedics in astana were analyzed. patients was divided for groups: in dpatients with delirium treated by i/v dexmedetomidine ( . - . mkg/kg per hour), in g group patients with delirium treated by i/v galoperidol ( . - . mkg/kg). delirium was assessed by rass at day of permission and every day at a.m. the prevalence, structure of delirium and efficacy of sedation were analysed. results: by anthropometric and gender characteristics of the group did not differ. the average age in the d-group with delirium was . ± . years old, which was comparable to the g-group - . ± . years old (p = . ). all study participants had similar comorbidities. delirium in all patients debuted at . ± . days, with an average duration of . ± . days. the effect of dexmedetomidine was better and expressed in % decrease in the duration of delirium in compare to haloperidol (p < . ). dexmedetomidine provided a more controlled and safe sedation compared with haloperidol. the average consumption of narcotic analgesics in the subgroup with dexmedetomidine was two times less than in the subgroup with haloperidol. thus, the average consumption of trimeperidine hydrochloride in patients of group d was . mg versus . mg in group g (p = . ). in gerontological patients with femur fracture treatment delirium by dexmedetomidine was more effective in compare with haloperidol. when using dexmedetomidine, the consumption of narcotic analgesics in postoperative period was % less than with haloperidol. live music therapy in intensive care unit mc soccorsi , c tiberi , g melegari , j maccieri , f pellegrini , e guerra intensive care units (icu) are not comfortable for patients, relatives or next of kin. in the last years many news approaches were described to implement the humanization of medical treatments. the positive effect of music therapy in icu is well described, especially reducing delirium risk [ ] . the aim of this paper is describing the effect in patients and their family of a music live performance in icu. after ethical committee approval (procedure aou / , italy) for three months (november -january ) patients in icu were treated twice a week with live music therapy performed by coral vecchi-tonelli of modena, italy (fig. ). data were collected all awake and conscious patients. vitals parameters, gcs, raas and cam icu were collected before, during and after the treatment, at every performance. after the treatment a feedback questionnaire were given to patients and to next of kin. results: subjects were enrolled in the research with mean age of . years old, delirium rate before the treatment was . % later . %, raas does not show any difference. over % of patients were satisfied, and relatives felt less anxiety. we recorded also a satisfaction also in relatives not enrolled. the study does not demonstrate a delirium risk reduction for the small sample and the length treatment, anyway it was recorded a low delirium rate. the safety and the potential effect of music therapy are well known, surely the research underlines the feeling of patients and their next of kin: icu is the most stressful setting for admitted patients and its humanization is a current topic for medical literature. live performances could be an entertainment moment and probably create a moment of an interaction among patients, their family and medical and nurse: icu become more human. the high level of satisfaction push us to continue this experience. introduction: patients undergoing medical procedures benefit from distraction techniques to reduce the need for drugs alleviating pain and anxiety. this study investigates if medical hypnosis or virtual reality glasses (vrglasses) as adjuvant method reduces the need for additional drugs. in a prospective, randomized, interventional trial, patients undergoing procedures were stratified in four age groups, and randomly assigned into three arms by means of a closed envelope system. all patients received standard care for pain before the procedure; the control group received further drugs for pain and stress as indicated by the visual analog scale (vas; threshold / ) and comfortscore (threshold / ), two index groups received either medical hypnosis or vr glasses as a plus before and during the procedure. vas and comfort were scored continuously and analysed with the kruskal-wallis test. patients, parents and healthcare providers scored their satisfaction at the end. of included patients to years old, % were female. regardless of age, pain and comfort scores were similar before and at the start of the procedure (vas . - . ; comfort - . ), but as of one minute after starting the procedure, both vas and comfort reduced significantly more in both index groups compared to the control (p< . ), remaining far below the threshold for both pain and stress ( figure ). there was no advantage of one index group over the other (p= . ). there were no adverse effects. patients in the vr group were more satisfied than in the standard group (p= . ) or in the hypnosis group (p= . ). there was no significant difference in satisfaction of parents or healthcare providers. from the very start of the intervention, the application of either medical hypnosis or vr glasses significantly reduces pain and anxiety in patients undergoing medical procedures. more studies are needed but both are promising safe adjuvant tools to standard pharmacological treatment. music to reduce pain and distress due to emergency care: a randomized clinical trial ne nouira, i boussaid, d chtourou, s sfaxi, w bahria, d hamdi, m boussen, m ben cheikh mongi slim academic hospital, emergency department, tunis, tunisia critical care , (suppl ):p recent clinical studies have confirmed the benefits of music therapy in managing pain and improving quality of care in the emergency department. the aim wasto evaluate the impact of receptive music therapy on pain and anxiety induced by emergency care methods: a randomized controlled study in patients consulting the emergency department. two groups: the music therapy group; patients needed venous sampling, peripheral venous catheter or arterial catheter. will bless ten minutes music therapy by headphones and a second control group of patients with the same care without music therapy. consent was requested from all participants. the level of pain caused by the act of care was assessed by visual analogic scale. heart rate, blood pressure and the mood of the patient were assessed before and after emergency care. we assessed patient satisfaction, adverse events. patients admitted to the emergency room, patients with communication difficulties and non-consenting patients were not included results: two hundred and forty patients were included randomized in both groups, with music therapy and without music therapy, the results showed comparable characteristics between the two groups: demographic data, pathological history, and initial clinical presentation. after the session of music therapy a difference was noted in the evaluation of the mean vas who was in the group with music of . ± . versus . ± . in the control group p< . ci % [- . ; - . ], and the mean of diastolic blood pressure which was , mmhg in the first group against . mmhg for the control group p = . ci % [- . ; - . ]. as for the mood, the patients were more smiling after the act of care in the group music therapy. all patients were satisfied with their experience and % recommend this therapy to their relatives . music therapy may reduce pain and anxiety in patients during emergency care. the music therapy is the intervention of music and/or its elements to achieve individual goals within a therapeutic.the music has proved to have positive physiological and psychological effects on patients [ ] . patients admitted to the intensive care unit (icu) experience anxiety and stress even when sedated, negatively influencing recovery [ ] . methods: two groups are established, a music therapy group (mg) and a control group (cg). the first one undergoes music therapy interventions, it consists of -minutes sessions of live music. patients of the gc will receive the usual treatment established by the service protocol for weaning management and the data are collected during the same time interval. data collection includes mean arterial pressure (map), heart rate (hr), respiratory rate (rr), oxygen saturation (sao ) and temperature (t). a total of patients were recruited, of which patients had to be excluded for meeting any of the exclusion criteria (n= ). of which (n= ) were randomized in the gm and the rest to the gc (n= ) ic %. regarding delirium in gm ( . %) presented a positive cam-icu, while in the cg were ( . %) (p= . ). when analyzing the variables in the cg and gm, it was observed that there were no differences with respect to hr, rr and map variable ( figure ). according to the results, we can say that music therapy as a nonpharmacological strategy for management of anxiety and delirium in patients of critical care units, might be an useful tool for the management of patients in weaning of mechanical ventilation introduction: coagulopathy and basopenia are common features of anaphylaxis, but the role of coagulopathy in anaphylaxis remains uncertain. the aim of this study is to evaluate the association between coagulopathy and clinical severity or basopenia in patients with anaphylaxis. we conducted a single-center, retrospective study of patients with anaphylaxis about their coagulopathy. levels of fibrin degradation products (fdp) and d-dimer were analyzed with the cause of anaphylaxis, clinical symptoms, medications and outcomes. we also studied the levels of intracellular histamine as a biomarker of basophil degranulation in the peripheral blood in relation to fdp and ddimer. in total, sixty-nine patients were enrolled to the study, and the levels of intracellular histamine were analyzed in patients. the symptoms included respiratory failure (n= ), shock (n= ), abdominal impairment (n= ), and consciousness disturbance (n= ). thirty-two patients needed continuous intravenous vasopressors for refractory shock. the increase of fdp was significantly associated with consciousness disturbance (p= . ) and refractory shock (p< . ). the increase of d-dimer was also significantly associated with refractory shock (p= . ). there was no correlation between the levels of intracellular histamine and either of fdp or d-dimer (p= . and p= . , respectively). the increase of fdp and d-dimer were associated with severe symptoms of anaphylaxis, while they were not correlated with intracellular histamine. these results suggest that anaphylaxis is closely associated with coagulopathy in a mechanism which is different from basophile degranulation in anaphylaxis. cardiac manifestations of h n infection in a greek icu population e nanou , p vasiliou , e tsigou , v psallida , e boutzouka , v zidianakis , g fildissis agioi anargiroi hospital, attiki, greece; agioi anargiroi hospital, icu, attiki, greece critical care , (suppl ):p introduction: cardiovascular involvement in influenza infection occurs through direct effects on the myocardium or through exacerbation of pre-existing cardiovascular disease [ ] . the aim was to study cardiac manifestations in all pts admitted to the icu with severe influenza's attack. clinical, laboratory, electrocardiographic, echocardiographic and hemodynamic data were retrospectively recorded in all pts admitted to the icu due to influenza infection (winter -spring ). diagnosis was established by pcr on bronchial aspirates the next days after admission. myocardial injury was defined by troponin levels > pg/ml ( fold uln). left ventricular systolic dysfunction was defined as ef < % and was characterized as either global or regional. hemodynamic monitoring by fig. (abstract p ) . comparison between mg and cg transpulmonary thermodilution method (picco) was recorded in pts with shock (norepinephrine > . μg/kg/min). values are expressed as mean±sd or as median (ir). results: nine pts ( males) with a mean age . ± . years, apache ii ± . and sofa score . ± . were assessed. icu admission was due to ards ( ) and copd exacerbation ( ) . icu los was . ± . days and mortality rate was %. no history of vaccination or coronary heart disease was referred. results are shown in table . levosimendan was administered in pts with severe cardiogenic shock. in all survivors, shock and indices of myocardial dysfunction subsided till discharge. coronary angiography was performed in pt showing no abnormalities. mortality was attributed to septic shock and multi-organ failure. myocardial involvement, though common in influenza pts admitted to the icu, didn't contribute to a dismal prognosis. the cardioprotective effects of levosimendan could be related to the modulation of oxidative balance. we aimed to examine the effects of levosimendan in patients with cardiogenic shock or with ejection fraction (ef) lower than % on cardiac systo-diastolic function and plasma oxidants/antioxidants (glutathione, gsh; thiobarbituric acid reactive substances, tbars). in patients undergone coronary artery bypass grafting or angioplasty, cardiovascular parameters were measured at t (before the beginning of levosimendan, . mcg/kg/min), t ( h after the achievement of the therapeutic dosage of levosimendan), t (at the end of levosimendan infusion), t (at h after the end of levosimendan infusion), t (at the end of cardiogenic shock). the same time-course was followed for plasma gsh and tbars measurements. we found an improvement in cardiac output, cardiac index and systolic arterial blood pressure. ef increased from mean % to %. a reduction of central venous pressure and wedge pressure was also observed. moreover, indices of diastolic function were improved by levosimendan administration (e/e' from to ; e/a from > to < ) at early t . it is to note that an improvement of gsh and tbars was observed early after levosimendan administration (t ), as well ( figure ). the results obtained have shown that levosimendan administration can regulate oxidant/antioxidant balance as an early effect in low cardiac output patients. the modulation of oxidative condition could be speculated to play a role in exerting the cardio-protection exerted by levosimendan in those patients. table . early administration of vasopressors and their use in the emergency department was associated with survival in septic shock. this seemed to be independent of median map recorded in the ed. we excluded all the traumatic or post-myocardial infarction forms. out of patients, the tuberculous etiology was identified in cases ( , %), mean age was years, , % were men. patients reported a tb contact in their environment, had a medical history of pulmonary tb. after pericardiocentesis, the liquid was citrine yellow in cases and hematic in patients, no patient underwent surgical drainage in our serie. mycobacterium tuberculosis was found in the expectorations in cases and ada was positive in patients. hiv serology was negative in all our patients. a months anti bacillary therapy with isoniazid, rifampin, pyrazinamide, and ethambutol was initiated in all our patients with a good evolution in cases, deaths, chronic constrictive pericarditis, small pericardial effusion and lost to follow-up. althought cardiac tamponade is rarely caused by tuberculosis, this condition remains common in endemic countries such as morocco and affect younger population, hence the importance of a better knowledge of its prevalence and and multidisciplinary management and more importantly the treatment of the underlying cause using combined antibacillary medication that has shown satisfying results. . the main perceived limiting factor is the absence of a standardized didactic program, followed by mentor's availability in residents' perception and by mentor's experience in consultants' one. pocus teaching is present although not optimal and not homogenous in italian acc residency schools. standardisation of residents' ultrasound curriculum is suggested to improve ultrasound teaching. the study included a convenience sample of critically ill patients with supradiaphragmatic cvcs and a cxr for confirmation. us is used for direct confirmation of the guidewire in the internal jugular (ijv) or subclavian (scv) vein and visualizing the guidewire in the right atrium. to evaluate for pneumothorax, "sliding sign" of the pleura was noted on us of the anterior chest. results: patients have been included, % of the catheters have been placed in the scv and % in the ijv. it was possible to confirm the position of the cvc tip for . % ( correct, incorrect cxr) of (figure ). overall, it was not possible to identify the guide in the right atrium cases ( false negatives, of them due to the presence of defibrillator leads). regarding the case where an incorrect position was seen on cxr it was also detected on ultrasound: us of the inserted vein and a negative tte confirmation. in all cases it was possible to exclude a pneumothorax by us. these results show that bedside ultrasound might be a feasible technique to confirm the cvc positioning. it is important to note that the level of the operator's expertise is significant when assessing the feasibility of this method. we only had a limited sample size and the occurrence of only one misplaced catheter. these preliminary results need to be confirmed on a larger scale. central venous catheter (cvc) misplacement occurs more frequently after cannulation of the right subclavian vein compared to the other sites for central venous access. misplacement can be avoided with ultrasound guidance by using the right supraclavicular fossa view to confirm correct guidewire j-tip position in the lower part of the superior vena cava. however, retraction of the guidewire prior to the cvc insertion may dislocate the j-tip from its desired position, thereby increasing the risk of cvc misplacement. the aim of this study was to determine the minimal guidewire length needed to maintain correct guidewire j-tip position throughout an us-guided infraclavicular cvc placement in the right subclavian vein. methods: adult intensive care patients with a computed tomography scan of the chest were retrospectively and consecutively included in the study. the distance from the most plausible distal puncture site of the right subclavian/axillary vein to the junction of the right and left brachiocephalic veins (= vessel length) was measured using multiplanar reconstructions. in addition, measurements of the equipment provided in commonly used - cm cvc kits were performed. the minimal guidewire length was calculated for each cvc kit. the guidewires were up to mm too short to maintain correct j-tip position throughout the cvc insertion procedure in seven of nine commercial cvc kits. four of these are shown in table . when us guidance is used to confirm a correct guidewire j-tip position, retraction of the guidewire prior to the cvc insertion must be avoided to ensure correct cvc-tip positioning. this study shows that most of the commonly used - cm cvc kits contain guidewires that are too short for cvc placement in the right subclavian vein. the reliability of lung b-lines to assess fluid status in patients with long period of supine introduction: ultrasound-guided cannulation is usually done using either longitudinal or transverse approach. the oblique approach utilizes advantages of both these approaches allowing visualization of the entire course of needle including tip and lateral discrimination of artery from vein [ ] . the reported incidence of the complete overlap of femoral vein by the femoral artery is - percent [ , ] . we describe the use of the oblique approach for successful cannulation of such a femoral vein which is not possible by usual approaches (figure ). endothelial cells play a pivotal role in the atherogenic process. endothelial cell dysfunction (ed) is the main risk factor for cardiovascular diseases such as hypertension, coronary heart disease (chd) and peripheral occlusive disease (pod). these diseases significantly increase the risk for perioperative complications. therefore, identifying patients with ed is important and should influence our prospective perioperative strategy. however, sensitive tools to diagnose ed are still missing and do not belong to our standard of care. aim of this study was the validation of a new non-invasive method to detect ed and a correlation with a set of established an new endothelial biomarkers. the cohort includes preoperative patients without anamnestic relevant cardiovascular disease and patients with known peripheral occlusive disease (pod). we used non-invasive endopat® technology from itamar-medical to measure ed by changes in vascular tone before and after occlusion of the brachial artery and calculate a reactive hyperemia index (rhi). in addition, we measured established markers and alternative biomarkers potentially indicate vascular diseases such as substrates and products from the no-metabolism l-arginin, asymmetric/symmetric dimethylarginine (adma/sdma), von-willebrand factor (vwf) and sphingosine- -phosphate (s p). rhi was able to identify patients with pod. rhi was significant lower in patients with clinical signs and symptoms of pod (p< . ). among other markers adma was significant higher in pod patients compared to controls and correlates with rhi. the pad technology is a helpful non-invasive functional test to measure ed and seems able in identify patients with vascular disease. in future, a combination of anamnesis, new diagnostic tools and biomarkers may further increase our sensitivity in identifying risk-patients. single-lumen fr and triple-lumen fr peripherally inserted central catheters (piccs) for cardiac output assessment by transpulmonary thermodilution s d´arrigo achieving effective critical care in low-and middle-income countries is a global health goal [ ] , which includes the provision of effective point of care ultrasound [ ] . we sought to establish zambia's first focused critical care echocardiography training programme in a bedded icu at university teaching hospital, lusaka. the programme was accredited by the uk intensive care society fice programme, with teaching adapted for local disease patterns such as tuberculous pericardial effusions. parasternal, apical and subcostal windows were used to assess ventricular dysfunction, hypovolaemia, pleural effusion, alveolar interstitial syndrome and pneumothorax. zambian doctors working with critically ill patients received an intensive one-day course, followed by mentored scanning at the bedside. teaching was delivered by visiting fellows from the uk who are accredited in echocardiography and experienced ultrasound educators. patients with abnormal mean ci or hr suffer from increased hospital mortality. abnormality of mean svi was not associated with mortality. these data support accurate measurement of ci as a hemodynamic target and the normal range defined for ci. since ci also carries the hr information, ci seems to be the more important target than svi. our data cannot necessarily be interpolated to less invasive and less precise measurements of ci. an evaluative study of the novelty device with the function of auto-aspirating and pressure indicator for safety central venous catheterization ly lin, wf luo, cy tsao national taiwan university hospital, taipei, taiwan critical care , (suppl ):p previous studies have shown that . % of cvc attempts resulted in arterial punctures that were not recognized by blood color. to overcome the problem, our team has developed a concept of pressure detecting syringe that can indicate the artery puncture [ ] . based on previous research, different springs, the actuator of the design, have been evaluated to optimize the proposed device and reduce the risk of cvc procedure. tested devices -the inner-spring is set between the pressure indicator and plunger (fig. a ). three springs are tested. test condition -blood samples were simulated by glucose solution with absolute viscosities of and mpa-s. different blood pressures were applied to simulate the artery and vein (fig. b) . the response time (rt) is defined as the time required to show the indicating signal (is) which is the movement of the piston from the position in fig. b : a - to a - . the rt is strongly influenced by spring (fig. b) but every design can show the is when pressure is higher than mmhg, the assumed minimum artery pressure. the rt of s , the strongest spring design, is about s in the mmhg-pressure and high viscosity condition. during our tests we found the user can realize the is before the position be fully changed from fig. ib : a - to a - . thus, we believe the s rt, the worst case, is still acceptable. we also found the weak spring force may lead to difficulty to empty the syringe because the spring must to overcome the blood pressure and the friction between the piston and barrel. as a result, it was difficult for s to absolutely empty the syringe even if the blood pressure is only mmhg. the spring will be compressed as fig. b : a - and fail to push the piston when pushing the plunger forwardly, which is not acceptable in clinical use. the results indicate the feasibility of using the device to facilitate cvc and we believe the s or s are more suitable for the future application. introduction: models using standard statistical features of hemodynamic vital sign waveforms (vs) enable rapid detection of covert hemorrhage at a predetermined bleed rate [ ] . by featurizing interactions between vs we can train powerful hemorrhage detectors robust to unknown bleed rates. waveforms (arterial, central venous, pulmonary arterial pressures; peripheral and mixed venous oxygen saturation; photoplethysmograph; ecg) of healthy pigs were monitored min prior and during a controlled hemorrhage at ml/min (n= ) and ml/min (n= ). two sets of vs features were extracted: statistical features [ ] and maximal pairwise cross correlations between pairs of vs within a s lag over various time window sizes ( s, s, s, s); and normalized with pre-bleed data of each given animal. for each feature set, a tree-based (ert) model [ ] was trained and tested in a one-animal-out setting to mitigate overfitting on the ml/min cohort, and another trained on the ml/min and tested on the ml/min cohort. we evaluated models with activity monitoring operating characteristics curves [ ] that measure false alert rate as a function of time to detect bleeding. models using cross-correlations show no significant deterioration of performance when applied to detect bleeding at different rates than trained for, while standard models require s longer on average to detect hemorrhage at % false alert rate in the previously unknown setting ( figure ). correlations between vs data encode physiologic responses to hemorrhage in a way independent of the actual bleed rates. this enables training effective hemorrhage detectors using only limited experimental data, and using them in practice to detect bleeding that occurs at rates other than used in training. we validated a dataset of data lines containing hemodynamic variables and treatment options. we selected nine hemodynamic variables as inputs. furthermore, data were collected regarding underlying conditions: heart failure, septic shock, renal failure or respiratory failure or a combination. we applied datastories regression on the dataset (turnhout, belgium, www.datastories.com). six different interventions were analyzed as kpi: administration or removal of fluids, increasing or decreasing inotropes and increasing or decreasing vasopressors. finally, we elaborated and challenged predictive models to generate a decision algorithm to predict each kpi. we first looked at how each hemodynamic parameter impacts the prediction of each kpi individually and performed a standard correlation analysis as well as a more involved analysis of the mutual information content between each kpi and all other hemodynamic parameters individually. confusion matrix and variable importance was obtained for each kpi. the baseline hemodynamic parameters were: gedvi ± ml/m , evwli . ± . ml/kg pbw, svv . ± %, mbp . ± . mmhg, hr . ± . bpm, ci . ± . l/min.m . the results of the regression analysis identified the different variables of importance for each of the different interventions ( fig a) . based on these results the hemodynamic variables (hr, mbp, gedvi, elwi, ci, svv) were used to develop the final hemoguide prediction model ( fig b) . the hemoguide app can be used to advise physicians with respect to basic therapeutic decisions at the bedside or as an educational tool for students. with the collection of new data, the accuracy of the system may grow over time. the next step of the project is to develop a more-sophisticated suite: the icu cockpit. feedback function contributes to accurate measurement of capillary refill time r kawaguchi , ta nakada , m shinozaki , t nakaguchi , h haneishi , s oda chiba university, department of emergency and critical care medicine, chiba, japan; chiba university, chiba, japan critical care , (suppl ):p capillary refill time (crt) is well known as an indicator of peripheral perfusion. however, it has been reported to have an intra-observer variance, partly because of manual compression and naked-eye measurement of the nailbed color change. we hypothesized that a we developed a novel portable crt measurement device with an oled display that feedbacks weather the strength of the nailbed compression is enough and counts the time. we settled the target strength and time as n and seconds according to the study we reported before [ ] . examiners measured crt with and without the feedback function. the pressing strength and time during the measurement were evaluated. there was a significant difference among the pressing strength and time between the crt measurement using the device with and without the feedback function (strength: p< . ; time: p< . ). furthermore, intra-examiner variance was significantly reduced with the feedback function (strength: p< . ; time: p< . ). in all measurements without the feedback function, % was outside the optimal strength while the measurements with the feedback function % achieved the targeted range. without the feedback function, % could not reach the optimal time, while % with the feedback function did. in total, % of the measurements could not achieve the optimal pressing strength and time. the feedback function for crt measurements, guiding examiners to an optimal pressing strength and time, fulfilled the required measurement conditions and reduced intra-examiner variance. our novel portable device would assist an accurate crt measurement regardless of personal work experience. introduction: the aim of the study was to detect the difference of conjunctival microcirculation between septic patients and healthy subjects and evaluate the course of conjunctival microcirculatory changes in survivors and non-survivors over a hours period of time. this single-centre prospective observational study was performed in mixed icu in a tertiary teaching hospital. we included patients with sepsis or septic shock within the first hours after icu admission. conjunctival imaging using idf videomicroscope as well as systemic hemodynamic measurements were performed at three time points: at baseline, hours and hours later. baseline conjunctival microcirculatory parameters were compared with healthy control. a total of patients were included in the final assessment and analysis. median apache ii and sofa scores were ( - ) and ( - ) respectively. ( %) were in septic shock, ( %) required mechanical ventilation. patients were discharged alive from the intensive care unit. we found significant reductions in all microcirculatory parameters in the conjunctiva when comparing septic and healthy subjects. we found a significant lower proportion of perfused vessels and microvascular flow index (mfi) of small vessels during all three time points in non-survivors compared with survivors. in nonsurvivors we observed no significant changes in conjunctival microcirculatory parameters over time. however, survivors had significantly improved mfi of small vessels at second and third time points compared to first time point. microcirculatory perfusion in conjunctiva was altered in septic patients. over hours evaluation survivors in comparison with nonsurvivors had better microcirculatory flow with incremental improvement of microvascular flow index. healthy pigs were centrally cannulated for veno-arterial ecmo and precision flow probes were placed on the pulmonary artery main trunk for reference. ml boluses of iced . % saline chloride solution were injected into the ecmo circuit and right atrium at different ecmo flow settings ( , , , l/min). rapid response thermistors of standard pa-catheters in the ecmo circuit and pulmonary artery recorded the temperature change. after calibration of the catheter constants for different injection volumes in the ecmo circuit, the distribution of injection volumes passing each circuit was assessed and enabled calculation of pulmonary blood flow. analysis of the exponential decay of the signals allowed assessment of right ventricular function. calculated blood flow correlated well with true blood flow (r = . , p < . , figure panel a, individual measurements organ congestion is susceptible to be a mediator of adverse outcomes in critically ill patients. point-of-care ultrasound (pocus) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. the aim of this study was to develop prototypes of congestion scores and to determine their respective ability to predict acute kidney injury (aki) after cardiac surgery. this is a post-hoc analysis of a prospective study in patients for which repeated daily measurements of hepatic, portal, intra-renal vein doppler and inferior vena cava (ivc) ultrasound were performed before surgery and during the first hours after cardiac surgery [ ] . five prototypes of venous excess ultrasound (vexus) scores combining multiple ultrasound markers were developed (figure ). the association between each score and aki was assessed using timedependant cox models as well as conventional performance measures of diagnostic testing. a total of ultrasound assessments were analyzed. we found that defining severe congestion as the presence of severe flow abnormalities in multiple doppler patterns with a dilated ivc (> cm), corresponding to grade of the vexus c score, showed the strongest association with the development of subsequent aki compared with other combinations of ultrasonographic features (hr: . there is an increasing awareness on the consequences of fluid administration in patients leading to the development of methods that evaluate the effects of fluids loading on the cardiocirculatory system. however, most of methods used in the clinical practice investigate the effects of fluids on the cardiac function, instead of investigating those on the determinants of venous return. besides volume of fluids, the determinants of fluid loading are the blood volume distribution and the availability of vascular bed. in this study we aimed to test non-invasively the effects of fluids administration on the venular compartment in the skeletal muscle. in addition to the mean systemic filling pressure (msfp), we calculated changes in the stressed and unstressed volumes (vs, vu) and the venular bed availability. we enrolled critically ill patients in our intensive care unit. we assessed volumes and pressures by the near infra-red spectroscopy on the forearm using graded venous occlusions in steps of mmhg from to mmhg. the msfp, vu and vs were measured as previously reported (microcirculation ; : - ). the vascular bed availability was measured by changes in the volume recruited from the occlusion maneuvers. all the measures were done at baseline and after a fluid load ranging from to ml. values were expressed as median and interquartile range. wilcoxon test was used to compare data and a p< . was considered as significant. introduction: hypotension is a common side effect of general anesthesia (ga) and is associated with organ hypoperfusion and poor perioperative outcome [ ] . post-induction hypotension (pih) is caused by the depressant cardiovascular effect of anesthetic drugs and could be amplified by hypovolemia. the aim of this study was to assess the ability of two echocardiographic fluid responsiveness markers to predict pih: the inferior vena cava collapsibility index (ivc-ci) and the velocity time integral change (Δvti) after passive leg raising. sixty patients > years of age and scheduled for elective surgery were included. ivc-ci and Δvti were measured before ga induction. anesthesia protocol, fluid infusion and vasopressor administration were standardized in all patients. pih was defined as a mean arterial pressure (map) < mmhg or a relative decline from pre-induction value of at least % within minutes of ga induction. receiver operating characteristic (roc) curve analysis was used. the optimal cutoff was selected to maximize the youden index (sensitivity + specificity − ). the measurement of ivc-ci and/or Δvti were unsuccessful in seven patients ( . %). pih occurred in patients (incidence %). the areas under the roc curves ( figure ) preload responsiveness might be detected by the changes of cardiac index (Δcimini) induced by a "mini-fluid challenge" (mini-fc) of ml or even by the changes (Δcimicro) in response to a "micro-fluid challenge" (micro-fc) of ml. however, the smaller the fluid challenge, the larger the "grey zone" of diagnostic uncertainty. we tested whether ( ) micro-and mini-fc monitored by calibrated pulse contour analysis detect preload responsiveness and ( ) adding ml when the result of a micro-fc is within the grey zone improves diagnostic accuracy. in patients with circulatory failure, we infused ml saline over s followed by ml over s. we measured Δcimicro and Δcimini by the pulse contour analysis (picco ). preload responsiveness was defined by an increase in ci (Δciplr) during a passive leg raising test ≥ %. diagnostic uncertainty was described by calculating the grey zone after bootstrapping. Δcimicro were larger in responders than in non-responders ( . for the micro-fc, the area under the receiver operating characteristic curve was . ± . (threshold %), while it was . ± . for the mini-fc (threshold %). for the micro-fc, the grey zone ranged from . % to . % and included ( %) patients. for the mini-fc, it ranged from . % to . % and included ( )% patients, among which were already in the grey zone of the micro-fc. when evaluated by pulse contour analysis, micro-and mini-fc reliably detect preload responsiveness but with a large diagnostic uncertainty. it seems that adding ml more fluid to a micro-fc when its result is within the grey zone does not improve the diagnostic accuracy. the study is ongoing. the starling-sv bioreactance device (cheetah medical) reliably detects passive leg raising (plr)-induced changes in cardiac index (Δci). we tested whether it can also track the small and short-time Δci induced by the end-expiratory occlusion (eexpo) test, and whether shortening the time over which it averages cardiac output ( s in the commercial version) improves the detection. in mechanically ventilated patients, during a -sec eexpo, we measured Δci (in absolute value and in percentage) through calibrated pulse contour analysis (ci pulse , picco device) and starling-sv. for the latter, we considered both ci starling- provided by the commercial version and ci starling- obtained by averaging the raw data over s. we calculated the correlation between Δci pulse and both Δci starling- and Δci starling- , and the area under the receiver operating characteristic curve (auroc) to detect preload responsiveness, defined by a plr test. when considering absolute values, the correlation coefficient r between Δci pulse and Δci starling- was . (p= . ), which was lower than the one between Δci pulse and Δci starling- (rr comparison). when considering percentage changes, no correlation was observed between Δci pulse and Δci starling- . conversely, the correlation coefficient between Δci pulse and Δci starling- was . (p= . ), but it was lower than the one obtained for absolute values (p= . for r comparison). eexpo-induced Δci starling- , both in absolute values and in percentage, detected preload responsiveness with aurocs of . (sensitivity %, specificity %) and . (sensitivity %, specificity %), respectively. shortening the averaging time of the bioreactance signal increases the reliability of the starling-sv device to detect eexpo-induced Δci. moreover, the accuracy of the method is increased when absolute rather than percentage changes of ci are considered. fluids are among the most prescribed drug in intensive care, particularly among patient with circulatory failure. yet, very little is known about their pharmacodynamic properties and this topic has been left largely unexplored. there is a lack of strong scientific evidence in current guidelines for fluid administration in shock. several factors may impact the hemodynamic efficacy of fluids among which the infusion rate. the aim of this study was to study the influence of fluids administration rate on their pharmacodynamics in particular by studying mean systemic pressure (p ms ). we conducted a prospective observational study in patients with circulatory failure to compare two volume expansion strategies. when a patient required a fluid bolus, ml of normal saline were administered and several hemodynamic parameters were recorded continuously: cardiac output (co), arterial pressure (ap), mean systemic pressure (p ms ). infusion rate was let to the discretion of the attending physician and a "slow" and a "fast" group were determined based on the median of the infusion time. fluids effect was measured by the area under the curve (auc), maximal effect (e max ) and time to maximal effect (t max ) for each hemodynamic variable. results: p ms auc was higher in the "fast" group compared to the "slow" group (p= . ). we observed a shorter t max and a higher e max for p ms in the "fast" group compared to the "slow" group (p= . and . respectively). regarding co, t max was also shorter in the "fast" group (p= . ). auc and e max were similar between the two groups. fluid effect dissipated within minutes following the end of fluid infusion for every patient in both groups. the decreasing slope from maximal effect was comparable in the groups, for p ms and co alike. the effect of a ml fluid bolus in septic shock patients vanished within one hour. a faster infusion rate increased maximal effect and shortened the delay to reach it. study is ongoing. fluid management in the control arm of sepsis trials aa anparasan, ac gordon, mk komorowski imperial college london, department of surgery and cancer, london, united kingdom critical care , (suppl ):p in the past, high-volume intravenous fluid resuscitation in severe sepsis and septic shock was common. more recently, concerns over the harmful effects of this practice have led some clinicians to adopt less liberal fluid strategies. we sought to analyse temporal trends in fluid administration in the control arms of recent adult sepsis trials and assess any correlation with patient severity and mortality. a literature search was conducted to identify relevant randomized controlled trials that reported fluid administration published post . we recorded outcomes: total amount of iv fluid administered in the control arms of these trials between hospital admission and hour and hour following trial enrolment, mortality rates at the latest reported time point and apache-ii score at admission. we computed the pearson correlation coefficient and linear regression between study dates and the outcomes. we identified relevant trials [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , which recruited a total of , patients in their control arms, from to . the temporal analysis revealed no obvious trend in the in the total volume of iv fluid given by hour following trial enrolment (correlation p= . ) ( figure ). however, the total volume of fluid given by hour decreased significantly over the period of interest (r=- . , p= . ). in parallel, we observed a decrease in mortality (r=- . , p= . ) but there was no evidence of decrease in illness severity over time (p= . ). we found that in published rcts over the last two decades, the amount of intravenous fluid given to patients with sepsis in the initial hours did not appear to change, however less intravenous fluid was given over the first three days. upcoming large rcts will test the safety and efficacy of restrictive fluid administration approaches in sepsis. clinical practice guidelines recommend prompt intravenous (iv) fluid resuscitation for pediatric sepsis, including an initial fluid bolus of ml/kg [ ] . however, recent evidence is conflicting as to the effectiveness, volume, and consequences of aggressive fluid resuscitation in septic children. therefore, we sought to determine the epidemiology of early iv fluid resuscitation in an integrated health system, specifically at community hospital emergency departments (ed). we studied a retrospective cohort of pediatric patients (ages > month to < years) with sepsis identified in electronic health record data at community eds in southwestern pennsylvania from to . sepsis was defined as ) suspected infection (combination of fluid culture collection and administration of antibiotics and ) organ dysfunction (pediatric sofa score ≥ ) within hours of suspected infection. fluid bolus therapy was defined as electronic documentation of administration of . % normal saline iv bolus within hour of the time of sepsis onset. results: among , patients with pediatric sepsis, ( %) received iv fluid bolus therapy within hour of time of sepsis onset. the volume of fluid administered ranged from ml/kg to ml/kg (figure , panel a), corresponding to a median volume of ml/kg (iqr - ml/kg). patients who received ≥ ml/kg of fluids (n = , %) were younger (mean age years, sd vs. years, sd ; p< . ), more often had blood cultures collected during evaluation ( % vs. %, p= . ), and were more often transferred to another facility ( % vs. %, p< . ) when compared to patients who received < ml/kg of fluids (n = , %). mean fluid bolus volume within hour of time of sepsis onset by hospital ranged from ml/kg to ml/kg (figure , panel b) . in a cohort of community emergency departments, % of septic children received intravenous fluid boluses within one hour, and of those, only one half received volumes concordant with guidelines. (figure ). a wide range of fluid balance exists in septic shock patients cared for in icu. trends of serum albumin in septic and non-septic critically ill introduction: the link between hypoalbuminaemia and poor outcomes in critical care is well established [ ] . limited data are available on serum albumin trends during critical illness [ ] . in this study we assessed trends in serum albumin for up to days in both septic and non-septic critically ill patients. we retrospectively examined the records of adult patients admitted to critical care at the royal liverpool university hospital between and . we then excluded patients who did not have albumin data available for the first days, leaving us with patients. patients ( . %) had sepsis, and of these patients had died by day . of the non-septic patients ( . %), patients had died by day . albumin levels were collected for days from admission to critical care, in addition to other demographic and biochemical data. statistical analysis was performed using repeated measures analysis. septic patients had lower serum albumin than non-septic patients throughout the day period (p< . ). we observed a decrease in albumin by day in all groups, with levels increasing over the subsequent days. there was no difference in daily serum albumin between non-septic patients who survived or died. this is the first study, to our knowledge, to compare albumin trends in septic and non-septic critically ill patients over days. further research is needed to elucidate the optimal recipients and timing of albumin therapy. introduction: burn injury is characterized by marked inflammation, capillary leakage, and profound hemodynamic alterations. early albumin resuscitation is avoided fearing a paradoxical fluid escape into the interstitium. on the other hand, administration of crystalloids in massive amounts causes tissue edema and fluid extravasation, which deteriorates tissue perfusion by increasing oxygen diffusion distance. albumin administration could reduce the amount required to maintain hemodynamic stability in this population. we investigated whether albumin improves tissue perfusion and microcirculation by reducing tissue edema. this is an observational study conducted in the burn unit of maasstad hospital, rotterdam. patients with burns higher than % of total body surface area (tbsa) were included in the study. sublingual microcirculation was measured at admission (t ), (t ), and (t ) hours after burn injury. total vessel density (tvd) and functional capillary density (fcd) were analyzed. fluid management was calculated according to the modified parkland formula. albumin ( %) infusion was started hours after the burn insult. a total of nine patients were recruited between january and december . patients were included in the study after . ± . hours of the insult with a mean tbsa of ± %. the amount of crystalloid infusion was ± ml and ± ml at t and t ,respectively. within the first h (t ) ± ml albumin was given. tvd decreased from . ± . at t to ± . at t (p< . ) (figure ) introduction: spontaneous bacterial peritonitis (sbp) accounts for ≥ % of the bacterial infections that occur in patients with cirrhosis, and sbp has a high mortality rate ( % to %). albumin infusion has been shown to improve the outcome of sbp. the aim of this study is to examine the impact of albumin infusion on hospital length of stay (los) for cirrhotic patients with sbp. we utilized a nationwide electronic health record data set (cerner health facts®) to extract real-world data on adult patients (≥ years old) with cirrhosis and sbp who received antibiotics and admitted between january , , and april , . international classification of diseases (icd- / ) codes were used to identify cirrhosis and sbp. we used laboratory data for calculation of the model for endstage liver disease sodium (meld-na) score and vital signs data for calculation of the quick sepsis related organ failure assessment (qsofa) score at baseline for each encounter. a generalized linear model was used to assess the relationship between albumin infusion and hospital los. results: there were , encounters that identified patients with sbp and cirrhosis, of which , survived hospitalization. albumin was infused within hours of admission ('early albumin') in % (n= ), after hours in % ('late albumin', n= ), and not administered in % ('no albumin', n= ). meld-na was higher at presentation in early albumin cases versus late-or no-albumin cases (mean . and . ). unadjusted los was lower in patients receiving early albumin ( . days versus . days). risk-adjusted analysis demonstrated that early albumin led to a . % reduction in los ( % ci . %- . %, p = < . ). in these real-world data, albumin infusion within hours of admission in patients with cirrhosis and sbp was associated with a shorter hospital stay despite more severe illness. early albumin may not only improve clinical outcomes but may also reduce the costs of hospitalization in cirrhotic patients with sbp. early albumin use in patients with septic shock is associated with a shorter hospital stay: real-world evidence in the united states introduction: septic shock is among the most common critical care illnesses and incidence is rising, with mortality in excess of %. septic shock predisposes patients to multiple organ failure. while albumin is effective in management of circulatory dysfunction in septic shock, its utilization in this population is understudied in the us. we evaluated the impact of albumin utilization on hospital length of stay (los) among septic shock patients. we used a nationwide electronic health record data set (cerner health facts®) to extract real-world data on adult patients (≥ years old) with severe sepsis or septic shock, admitted between january , , and april , , identified by international classification of disease (icd- / ) codes, and receipt of antibiotics and vasopressors. we calculated the charlson comorbidity index (cci) and the acute physiology score (aps) at baseline. a generalized linear model was used to examine the association between albumin and hospital los, especially accounting for the timing of albumin infusion. we identified , unique visits for septic shock patients that survived to discharge. albumin was infused within hours of admission ('early albumin') in %, after hours ('late albumin') in %, and not administered in %. both cci and aps were higher, at presentation, in early albumin cases than late-or no-albumin cases (mean: . and . , and . and . , respectively). unadjusted los was slightly lower in patients receiving early albumin ( . days versus . days). a risk-adjusted analysis demonstrated that early albumin was associated with . % shorter los ( % ci . %- . %, p = . ). albumin infusion within hours of admission was associated with a shorter length of hospital stay. early albumin infusion may lead to better outcomes and reduced costs in patients with septic shock. further research is being conducted to assess other potential benefits of early albumin administration in this patient population. every new septic event follows by hemodynamic instability may lead sequentially to decreased organ perfusion, multiple organ failure. acute renal failure is recognized clinical feature during sepsis (up to - % in all cases). furthermore, urine output close monitoring is a cornerstone diagnostic clinical tool in each septic critically ill patient. in present study, we analyzed the dynamic minute-to-minute changes in the urine flow rate (ufr) and also the changes in its minute-to-minute variability (ufrv) during new septic event in critically ill patients. demographic and clinical data were extracted from the of critically ill patients who were admitted to the icu and developed new septic event (followed by fever and leukocytosis) and analyzed. a foley catheter was inserted into the urinary bladder of each study patient. the catheter was then connected to electronic urinometer, a collecting and measurement system which employs an optical drop detector to measure urine flow. the urine flow rate variability (ufrv) is defined and calculated as the change in ufr from minute to minute. results: ufr and ufrv both decreased significantly immediate after new septic episode until beginning fluid resuscitation (ppvalues < . ) (figure ) . statistical analysis by the pearson method demonstrated a strong direct correlation between the decrease in ufr, ufrv and the decrease in the map (r= . , p= . ; r= . , p= . ) ( figure ), and heart rate (r= . ,p=< . ) since systemic pressure starts to drop. ufrv and ufr demonstrated good clinical response to fluid administration despite the fact that systemic blood pressure did not improve (figure ) . we consider that dynamic changes in ufrv and ufr could potentially serve as a more sensitive signals ofclinicaldeterioration during the new septic event in critically ill patients.we also suggest that those parameters mightbeable to identify the optimal end-point of fluid resuscitative measures in septic critically ill patients. diminished urinary output (uo) is largely used as marker of acute kidney injury (aki) in critically ill patients. we aimed to explore the role of urinary output on incidence and mortality of aki developed during icu admission. the study population consists of all patients admitted between and to one of the dutch icus included in the nice database with an icu length of stay of at least hours, having daily measurement of creatinine and uo. only patients without renal replacement therapy that have a serum creatinine lower than . mg/dl ( . μmol/l) or a uo above . ml/kg/h on the day of the index icu admission were considered at risk for aki. patients were followed during their icu stay and classified according to the highest kdigo criteria reached based on creatinine alone (model ) and creatinine plus uo (model ) using icu admission serum creatinine as baseline. in both models, patients were classified as: no aki, renal impairment at the first day of icu admission, aki stage , aki stage , and aki stage . we identified , patients ( % male, mean age years, median icu-los days). of those, . % of patients had renal impairment at the first day of icu admission. among the remaining patients, . % in model and . % in model were classified as having no aki, . % and . % as aki stage , . % and . % as aki stage , and . % and . % as aki stage , respectively. survival at -day markedly differed according to the aki classification model used (figure) . similarly, adjusted hrs for -day mortality differed among patients with and without aki compared to patients with renal impairment at the first day of icu admission ( figure ) . among patients admitted to the icu % had renal impairment at the first day of icu admission. our findings suggested that uo plays an important role both on aki incidence and mortality and should be carefully interpret in the clinical setting especially in aki stage classification. introduction: acute kidney injury (aki) mostly attributed to renal tubular damage, has a high morbidity and mortality outcome [ ] , so a sensitive tool to assess the degree of tubular affection is needed for early detection and management of this condition. we investigated the ability of furosemide stress test (fst) (one-time bolus dose of mg/kg or . mg/kg if on prior furosemide-intake) to predict progression to akin stage-iii in critically ill subjects with early aki. we studied subjects; consecutive patients in group i receiving fst and consecutive patients in group ii receiving standard medical management for aki; patients ( . %) and patients ( %) met the primary endpoint of progression to akin-iii in groups i and ii respectively. patients with progressive aki had significantly lower urine output following fst in the first hours (p< . ). the area under the roc curves for the total urine output over the first hours following fst to predict progression to akin-iii was . (p = . ). the ideal-cutoff for predicting aki progression during the first fig. (abstract p ) . thirty-day survival according to aki classification model and model . hazard ratios (hrs) for -day mortality adjusted by sex, age, type of admission, apache iv score, sofa score at day of admission (excluded renal sofa score) for patients with aki classified with model and model fig. (abstract p ) . clinical correlation between urine flow rate variability (ufrv) and ufr and mean arterial blood pressure over new septic event (black arrows) and and after initial fluid resuscitation (red arrows). note: the ufrv and ufr decreased progressively in parallel with the falling mean arterial blood pressure and, than, rose again after the administration of fluids hours was a urine volume of less than milliliters with a sensitivity of . % and specificity . % group receiving fst. on the other hand, statistically significant hypotension, hypo-(kalemia, phosphatemia and magnesemia) occurred in group i. the fst in patients with early aki could predict liability for progression of aki, however it should be performed under adequate monitoring. introduction: ischemia-reperfusion (ir) causes renal dysfunction and damage. ir induces renal tubular injury triggered by hypoxia and hyperoxia, mediated by oxidative stress and inflammation. furosemide inhibits na + -k + - clcotransporter in the thick ascending limb of the renal medulla to decrease na + reabsorption, reducing oxygen consumption. we investigated if furosemide could improve renal oxygenation, function and damage by reducing o consumption and oxidative stress after ir. methods: wistar albino rats were divided into groups, with in each group; sham-operated control (c), control + furosemide (c+f), ir and ir+f. after anaesthesia (bl), min supra-aortic occlusion was applied to ir and ir+f groups followed by min (t ) and hours of reperfusion (t ). furosemide μg/kg/h infusion was simultaneously administered to c+f and ir+f after ischemia. systemic hemodynamic, renal blood flow (rbf), renal vascular resistance (rvr), renal oxygen delivery (do ren ), renal oxygen consumption (vo ren ), creatinine clearance (ccr), sodium handling, urine output (uo), cortical (cμo ) and medullar (mμo ) microvascular oxygenation were measured. results: rbf was reduced in ir ( . ± ) and ir+f ( . ± ) at t (p< . ) but it was further reduced in ir+f ( . ± ) (p< . ) at t compared to c and c+f. rvr was increased in ir ( ± ) and ir+f ( ± ) at t compared to c. rvr was normalized in ir ( ± ) but not in ir+f ( ± ) at t compared to c (p< . ). cμo and mμo did not differ between groups after ir insults (figure ). tissue o was reduced at the medulla, but not at the cortex in ir+f group compared to ir. do ren and vo ren were reduced in ir ( ± and ± ml/ min) and ir+f ( ± and ± ) at t (p< . ). pc was higher in ir+f ( . ± . ) compared to ir . ± . (p< . ). vo / tna + was increased in ir+f compared to ir. no change in ccr and uo was observed. furosemide after ir causes further impairment of renal perfusion, energy utilization and renal oxygenation resulting in renal damage. acute renal failure induced by hypoxemia: incidence and correlation study a trifi , h fazzeni , a mehdi , c abdennebi , f daly , y touil , s abdellatif , s ben lakhal la rabta hopital, medical intensive care unit., tunis, tunisia; la rabta hopital, tunis, tunisia critical care , (suppl ):p introduction: acute renal failure (arr) is a common complication in icus and usually caused by hypoperfusion. arf induced by hypoxemia is a concept rarely reported in icu. its incidence and pathogenesis are not well understood. we aimed to study the relationship between hypoxemia and the occurrence of arf. retrospective cohort study including patients with hypoxemia whatever its etiology between january and august . patients with chronic renal failure were excluded. arf was defined and ranked according to the kdigo criteria . arterial blood gas, urea, creatinine and clearance were reordered on the first, third and seventh days of evolution. results: patients were included and groups were obtained: group of hypoxemic patients with arf (arf+, n= ): versus group of hypoxemic patients without arf (arf-, n= ). the incidence of hypoxemie-induced arf was therefore %. clinical characteristics were comparable in both groups with a mean age of ± and a sex ratio of . . the comparative study showed in arf+ group: a lower ph ( . . ], p = . ). the most significant correlation was showed with mdrd clearance at day and p/f ratio at day (rho = . , p = . ). multivariate analysis found that septic shock and non invasive ventilation in hypoxemic patients were the factors related to arf with respectively or= . , % ci= . - . , p= . and or= . , % ci= . - . , p= . . overall mortality was % (n= ) and arf was an independent factor of mortality: or= , and % ci= . - . , p = . . hypoxemia-induced arf is a common complication associated with excess mortality. our study suggests that renal function is correlated with the degree of hypoxemia and that this correlation is rather distinct hours from hypoxemia. in preclinical models of sepsis, we have previously demonstrated that activation of amp activated protein kinase (ampk) using metformin, improves survival and organ function. thus, ampk activation is a potential therapeutic target in sepsis, and we hypothesize that exposure to metformin during sepsis is associated with decreased aki and mortality methods: retrospective analysis of a -hospital cohort of adult icu patients with type diabetes mellitus (t dm) who presented sepsis. we investigated if exposure to metformin during the hospitalization was associated with reduced -day mortality and aki. we used : propensity score matching (psm), propensity score stratification (pss) and propensity score weighting (psw) based on the probability to be exposed to metformin using covariates. for psm an exact match for insulin, amputation, cardiovascular diseases, retinopathy, charlson index, egfr, hba c, and apache iii, were used. sepsis was defined using sepsis criteria, and aki as kdigo stage or . from , patients, we found diabetic adults exposed to metformin during hospitalization and , who were not. metformin exposure during hospitalization is associated with decreased -day mortality and aki in septic adult patients with t dm. these findings suggest that metformin may constitute a potential therapeutic strategy in sepsis, and the potential role of ampk activation as a protective mechanism. however, studies are needed to confirm this association and the specific mechanisms of action. introduction: acute kidney injury (aki) may occur up to % in the intensive care unit (icu). predicting aki recovery may allow for risk stratification of patients, patient and family counseling, and early post-discharge renal care planning. however, predicting aki recovery at an early stage remains a challenge. methods: this is a retrospective study of the epanic multicenter randomized controlled trial database [ ] , which was split into development (n= ) and validation (n= ) cohorts, and patients experiencing aki stage and/or renal replacement therapy (rrt) in the icu were included [ ] . aki recovery was defined as being alive, without any stage of aki, and without need of rrt at hospital discharge. a logistic regression model with backward feature elimination was developed. the model performance was assessed by discrimination, calibration, and net benefit analysis, and internally validated with ten-fold cross validation. only the results in the development cohort are reported. of the patients who developed aki , patients ( . %) recovered from aki. the multivariable model selected age, bilirubin, heart rate, mean arterial blood pressure, surgical diagnostic group on icu admission, mechanical hemodynamic support on icu admission, suspected sepsis on icu admission as aki recovery predictors. the model had a mean area under the receiver operating characteristic curve (auroc) of . (standard deviation (sd) . ), mean calibration slope of . (sd . ), and mean calibration-inthe-large of < . (sd . ) (figure ). at the classification threshold that maximized sensitivity and specificity, mean net benefit with respect to treat-none was . (sd . ) and mean net benefit with respect to treat-all was . (sd . ). by using the routinely collected clinical data, the developed prediction model can fairly identify patients with a higher chance of aki recovery at hospital discharge. introduction: acute kidney injury (aki) is a frequent complication in critically ill patients and is associated with increased morbidity and mortality. sepsis is one of the most common cause of aki. a prospective study was conducted over months (january -june , ).we included patients with septic shock at admission or at any time during hospitalization.the aki staging was based on kdigo criteria.patients were divided into two groups, a group with aki (aki+) and a group without aki (aki-).then we compared the baseline characteristics, laboratory and physiologic data. patients with aki (aki+) were subdivided according to their prognosis. were enrolled patients. the mean (sd) age was . (± ) years.sex ratio was . . fifty-two ( %) patients developed aki.sapsii and sofa score in admission were higher in patients with kidney injury [ vs points (p= . ), . vs points ;(p= . )] respectively.the serum lactate level was significantly higher in (aki +) group patients during the first day of septic shock [ . ± . mmol/l (aki+)vs . ± . mmol/l(aki-);(p= . ) ] and its clearance was lower [( ± . % (aki +)vs ± %(aki-);(p= . )]. a significant difference was observed in c reactive protein level [ ± mg/l (aki +) vs ± mg/l (aki-) ; (p= . )].among (aki+) patients, kadigo iii was observed in . % of cases.nineteen ( . %) patients received hemodialysis.a normal kidney function was recovered in . % of cases.aki+ patients had a higher occurrence in disseminated intravascular coagulation ( vs patients, p= . ),acute respiratory distress syndrome ( vs patients; p= . ) and cardiac dysfunction ( vs patient, p= . ).mortality was higher in aki group ( % vs %; p= . ). the development of septic aki was associated with poor outcomes and prognosis.a better understanding of sepsis induced aki pathway will enable us to develop targeted therapeutic protocols.newer tools,permitting aki early detection, may make these therapies more fruitful. this study aims to show that contrast procedures do not significantly increase the risk of renal injury and should not be deferred. traditionally ciaki is the most important cause of in-hospital renal failure after nephrotoxic drugs and shock. problem is also the non-uniform definition of ciaki proposed by three different initiatives (akin, esur and kdigo). akin, being the most rigorous, defines ciaki as an increase in serum creatinine > . mg/dl or > % of baseline within hours. a retrospective observational single-centre cohort study analyzed patients who underwent a contrast procedure with iomeron . the first group underwent a ct pulmonary angiography (ctpa), and the fig. (abstract p ). internally validated model performance: (top row) roc curve; (middle row) calibration curve; (bottom row) decision curve second a coronary angiography with pci. no patient was previously prepared (raas blockade removal, crystalloid administration etc). we studied demographics, history of ckd and comorbidities and their impact on the ciaki by the akin criteria. a total of patients were divided into two groups (ctpa and pci). ctpa group ( m, f) all had acute pe and the pci group ( m, f) were treated for acs. the mean age was and years respectively. ckd was more prevalent in the pci group ( pt vs. pt) possibly explained by the more advanced atherosclerotic disease. advanced chd (nyha iii/iv) was found in pt (pci) vs. pt (ctpa) while diabetes and shock were equally distributed ( pt and pt) in both groups. the mean amount of contrast was significantly higher in the pci group ( . ml vs. ml). the mean creatinine/egfr measured before and after contrast in the ctpa group was . the goal of this study was to determine whether changing the body mass (bm) with fat-free mass (ffm) in cockcroft-gault (cg) formula could provide a more accurate prediction of aki in obese patients undergoing cardiac surgery. in this retrospective study, we reviewed institutional data of patients who underwent elective cardiac surgery in a tertiary referral university hospital. baseline patient creatinine value was collected and gfr was estimated using the mdrd, ckd-epi and cg formulas. cg formula was further modified by replacing the bm with ffm derived from the bioelectrical impedance analysis. postoperative aki was defined by kdigo creatinine change definitions. accuracy of the egfr values to predict the aki was calculated with roc-auc analysis. all the calculations were performed in different categories of bmi. figure ). the egfr is a poor predictor of aki in obese patients undergoing cardiac surgery. the ffm modified cauckraft-gault formula yield more accuracy in this specific group. retroaki: a ten-year retrospective study of acute kidney injury in intensive and progressive care units introduction: acute kidney injury (aki) is a frequent condition in intensive care units (icu) and progressive care units (pcu), affecting % to % of the patients, depending on the studied population and aki definition. aki has been identified as an independent risk factor of icu mortality and development of chronic kidney desease. the objective of this study was to describe the incidence of each aki stages as defined by kdigo definition (with evaluation of urine output, serum creatinine and initiation of renal replacement therapy (rrt)), in a mixed medical and surgical population of patients hospitalized in icu and pcu over a -year period ( - ). we included all patients who stayed more than hours in icu or pcu of edouard herriot hospital from may to january . data used to classify the patients were the urine output over a sixhour period, serum creatinine and the need for rrt, according to kdigo classification results: , hospital stays were analyzed. median icu/pcu length of stay was days [iqr: . - . ]. among icu patients, % had at least one aki episode graded , or and % had at least one severe episode (stage or ). among pcu patients, % had at least one episode of aki and % a severe episode of aki. patients had an average of . episodes of aki per stay. table represents the incidence of maximal aki stage during one stay. we found that urine output was the more frequent criteria to make diagnosis of aki stage or whereas rrt was more frequent for aki stage . this retrospective study reports a more important aki incidence in our icu/pcu than in previous studies. the difference could be fig. (abstract p ) . when comparing auc in different categories of bmi, the mcg appeared to be the only statistically accurate formula in patients with bmi - . explained by the difficulty to collect urine output from conventional database. serum creatinine and the use of rrt are often the only two criteria used to define and classify aki. these results confirm the high incidence of aki in icu and pcu and the importance to make an early aki screening of patients for whom preventive nephroprotective actions are needed. introduction: icu-patients with acute kidney injury (aki) requiring renal replacement therapy (rrt) are at risk for infections [ , ] . in this study we evaluated the incidence of infection in icu patients with and without less severe aki. finally, impact on outcomes was explored. this is a retrospective study on the pdms (protection data management system) of the adult icus of a university hospital. aki was assessed on kdigo criteria (creatinine (scr) and urine output), during the first -d of icu stay. infection was validated in the pdms by a team of icu specialists. results: during a -year period, a total of subjects were enrolled. aki was diagnosed in . % of patients during icu stay. aki patients were older ( vs. y, p= . ), had higher saps ( vs. , p< . ), and had more urgent icu admission ( % vs. %, p< . ). more aki patients had mechanical ventilation ( % vs. %, p< . ) and vasopressors on d- ( % vs. %, p< . ). aki stage , , and was present in . %, . % and . % of patients. more aki patients had infection ( % vs. %, p< . ) and increasing aki stages were associated with higher infection rates (aki- : %; aki- : %, aki- : %, aki- : %, p< . ) (figure ). we observed - times higher mortality in aki patients with infection, and a stepwise increase of mortality with increasing aki stages. after correction for infection and other confounders we found that all aki stages were associated with in-hospital mortality (ors aki- : . , aki- : . , aki- : . , all p< . ). over half of aki patients experienced an episode of infection and increasing aki severity was associated with higher infection rate. aki patients with infection had marked higher mortality, suggesting that infection was an important driver of outcome. however, after adjustment, aki stages had strong association with hospital mortality. several new biomarkers have been introduced to improve early diagnosis of acute kidney injury (aki). "nephrocheck" (nc; astute medical, usa) is a bedside test calculating "akirisk" (product of urinary concentration of the cell cycle arrest-markers timp- and igfbp ). several studies suggest the usefulness of nc in selected populations. however, the value of early routine measurement of nc is unclear. methods: therefore, we compared the prediction of a combined endpoint (cep: death < days and/or requirement of renal replacement therapy rrt) by nc within h of icu admission (nc ) and h later (nc ) with admission values of serum-creatinine, bun, cystatin c, urinary ngal, apache ii and sofa (roc-analysis). as a secondary endpoint we investigated the additional value of pathological measurements of nc ≥ . critically ill patients showed increased relative uce in the first days of icu admission, which may be attributed to higher protein catabolism. increased relative uce was associated with arc and both had no effect on -day mortality. introduction: this study compared epidemiology, short-and long-term outcomes for patients with community-acquired (ca) and hospital-acquired (ha) acute kidney injury (aki). we retrospectively analyzed all episodes of aki over a period of . years ( - ) on the basis of routinely obtained serum creatinine measurements in , patients whose creatinine had been measured at least twice and who had been in the hospital for at least two days. we used the "kidney disease: improving global outcomes" (kdigo) criteria for aki and analyzed the first hospital admission. a total of were admitted in hospital and fulfilled the inclusion criteria. average observation period per patient was days. the incidence of ca-aki among included hospital admissions was . % compared with an incidence of . % of ha-aki, giving an overall aki incidence of . %. patients with ca-aki were younger than patients with ha-aki ( vs . y) and had significantly less comorbidities, including preexisting cardiac failure, ischemic heart disease, hypertension, diabetes. patients with ca-aki were more likely to have stage aki ( , vs , %, p< . ) and had significantly shorter lengths of hospital stay than patients with ha-aki ( vs d, p< . ). those with ca-aki had better survival than patients with ha-aki (figure ; p< the evidence base for management of fluid removal during renal replacement therapy (rrt) is limited. a recent international survey revealed the extent of practice variation worldwide [ ] . our aim was to summarise the responses from europe-based healthcare professionals who participated in the survey. the international self-administered, cross-sectional, internet-assisted, open survey was disseminated between january and january via website links and emails to members of different critical care societies. results: participants from european countries completed the survey of whom ( %) were intensivists and ( %) worked in university-based hospitals. persistent oliguria / anuria was the most common indication for fluid removal ( % responders). the parameters which guided fluid removal included hemodynamic status ( % responders), cumulative fluid balance since admission ( % responders), and -hour fluid balance ( % responders). % of participants reported using crrt with a median net ultrafiltration rate ml/hr (iqr - ml/hr) for hemodynamically unstable and a rate of ml/hr (iqr, - ml/hr) for hemodynamically stable patients. only % of practitioners checked net fluid balance hourly ( % nurses, % physicians). new hemodynamic instability, defined as new onset or worsening tachycardia, hypotension, or need to start or increase the dose of vasopressors was reported to occur in % fig. (abstract p ). long-term survival patients (iqr . - . ). different strategies to re-gain hemodynamic stability were used. (figure ) main barriers to fluid removal were patient intolerance ( % physicians, % nurses) and interruptions in fluid removal ( % physicians, % nurses). the majority of participants agreed that guidelines and protocols would be beneficial. the practice of fluid removal during rrt is very variable across european countries. nurses and doctors identified a need for evidencebased protocols and clear guidelines. introduction: kidney disease improving global outcomes (kdigo) guidelines suggest the use of anticoagulation in continuous renal replacement therapy (crrt) [ ] . the effectiveness of the anticoagulation is important because replacing the hemofilter and tube interrupts crrt and increases total therapy time. regional citrate anticoagulation (rca) and unfractionated heparin (ufh) are most commonly using methods for crrt anticoagulation [ ] . the aim of this study was to investigate the efficacy, safety and metabolic differences of the patients in icu who underwent crrt and anticoagulation method changed from ufh to rca for different reasons. after ethics committee approval ( - / ) patients who underwent crrt between - at bursa uludag university hospital icu have been investigated and patients who underwent crrt by both rca and ufh included in the study. we divided patients in two groups (rca, ufh), demographic data (sex, age), sofa score, creatinine, urea, mean filter life time (flt) and ultrafiltration flow (uf), platelets, electrolytes (na, k, ca, mg), lactate, nahco and ph of groups at beginning and ending of first rca and ufh hemodialysis collected. we used t-test and bootstraps statistic tests. in agreement with other studies [ , ] , flt and uf was statistically significant lower in ufh group (table ) . there was no statistically significant difference in efficiency (urea and creatinine decrease), ph, lactate, nahco level, platelets count and electrolytes between two groups. to our knowledge, there are no studies comparing these two anticoagulation methods in the same patients. small number of patients and retrospective evaluation are limitations of the study. our results suggest that the implementation of rca method is safe and effective as ufh method with longer flt and uf. regional citrate anticoagulation during crrt in liver failure mj jain, pk kumar g, dg govil, jk kn, sp patel, ms shafi, rh harne, dp pal, sm monanga medanta the medicity, critical care, gurugram, india critical care , (suppl ):p continuous renal replacement therapy (crrt) with regional citrate anti-coagulation (rca) is increasingly being used as a treatment modality in critically ill patients. there is limited experience of use of citrate anticoagulation patients with acute liver failure and acute on chronic liver failure who pose a tough challenge of being at a higher risk for bleeding. an institutional protocol was formulated for use of commercially available citrate solutions and the same was studied to assess filter life and safety of citrate in liver disease. the primary objective was to assess safety of citrate anticoagulation in liver disease. this study was a single centre, prospective, non-randomized, single arm, observational study. all adult patients, with acute liver failure and acute on chronic liver failure requiring crrt were included. blood ionized calcium levels of . to . mmol/l was targeted throughout the therapy and total to ionized calcium ratio of less than . was maintained. rca was stopped if the ratio was more than . for consecutive assessments. incidence of citrate accumulation and toxicity were assessed. average filter life was also assessed. metabolic parameters, electrolytes and strong ion gap were followed till hours after completion on crrt. a total of patients were included in the study. nineteen patients of acute on chronic liver failure and patients of acute liver failure underwent crrt with rca. baseline average serum bilirubin, lactate and inr were . mg/dl, . mmol/l and . respectively. the average filter life was hours minutes. citrate accumulation took place in (n= ) patients and rca had to be stopped for ( n= ) patients due to the same. none of the patients had evidence of citrate toxicity. citrate anticoagulation was well tolerated in patients with acute liver failure in patients with or without pre-existing chronic liver disease on crrt. introduction: the intention of this study is to highlight the levels of citrate load for the general population that increases the risk of citrate complications (insufficient trisodium citrate delivery; net citrate overload and citrate accumulation) [ ] . this was a prospective data collection between february and march in a fourteen bedded critical care unit. eleven consecutive episodes of crrt were collected (a new episode characterized if crrt was discontinued for hours and above). one episode was excluded due to short duration (less than hours). patients undergoing rca-crrt received either a fixed or ml/kg/h effluent dose protocol. median patient age was , male %. average time on crrt was . days ( - ). % of the patients had complications, although % were minor ( figure ). all of the patients with net citrate overload had citrate loads of . mmol/h or above. the main risk factors were found to be shock and liver impairment which occurred in % of cases of which % developed complications. a fixed dose effluent protocol to standardise practice can potentially lead to a higher risk of minor complications. in our experience this is likely due to a lack of appropriate monitoring for rca-crrt complications. despite this, our complication rate of citrate accumulation is in line with that reported in literature. citrate loads in our ml/kg/ hr protocol were . % higher than our ml/kg/hr protocol and strongly related to higher complication rate that worsened in patients with risk factors for poor citrate metabolism. introduction: there is no optimal timing of continuous renal replacement therapy (crrt) in acute kidney injury (aki); however, it is based on volume overload, azotemia, hyperkalemia and severe metabolic acidosis [ ] . an important reason for metabolic acidosis in aki is increased unmeasured anions (ua) [ ] . delta-ph-ua (Δph ua ) detects the degree of metabolic acidosis caused by ua and is calculated by using 'the partitioned ph model' [ ] . in this study, we investigated whether Δph ua was a predictor to start crrt in patients with aki. the study was designed as a multicentric, prospective, observational study in . patients who were ≥ years old and diagnosed with aki [ ] were included. the moment aki was diagnosed, arterial blood gas, albumin, magnesium, inorganic phosphorus, urea, creatinine and Δph ua values were recorded. all patients were divided into two groups as crrt(-) and crrt(+) which consists of patients performed crrt due to traditional criteria. fig. (abstract p ) . incidence of complications introduction: continuous renal replacement therapy (crrt) is labor intensive and requires advanced nursing knowledge and skills. however, % of registered nurses (rn) are less than -year post-registration experiences in our unit. also there is an increasing demand of crrt from crrt days in to crrt days in . the obstacles for crrt in our department, includes variation of regimen, complicated workflow and insufficient training of nurses. a continuous quality improvement project is carried out to standardize the regimen, enhance workflow and provide structured training to nurses in the intensive care unit, to enhance nursing competence. methods: introduction: sepsis and septic shock is a leading cause of mortality in the intensive care unit. we tried to evaluate a novel hemoperfusion cartridge through a retrospective evaluation of patient's data in our centre. we used it as an adjuvant therapy in our patients with sepsis and septic shock due to varied causes. the aim of this study was to evaluate the efficacy of therapeutic hemoperfusion cartridge (hc-foshan biosun medical ® ) in the management of patients with sepsis. we retrospectively analysed data of group (n= sepsis) and group (n= sepsis+hemoperfusison; sepsis treated with hemoperfusion cartridge) admitted between to . group had received hemoperfusion cartridge as adjuvant therapy along with standard of care. demographic data, procalcitonin [ ] and leukocyte levels before and after therapeutic cytokine removal and duration of hc were recorded. while the mean duration of cvvhdf was . hours, the duration of hemoperfusion cartridge (application was . ± . hours). among patients who survived patients were administered hemoperfusion cartridge within hours of icu admission. there was a significant reduction in scores like apache and sofa score post hemoperfusion cartridge therapy procalcitonin and leucocyte levels after therapeutic hemoperfusion cartridge were found significantly lower than the pretreatment values (respectively p= . , p= . ). retrospective analysis showed significant reduction of vasopressors, and improvement in map in group . therapeutic hemoperfusion cartridge with cytokine removal applied with cvvhdf in septic patients have positive contributions to provide survival advantage. removal of activated leukocytes and endotoxin from the blood is a complex therapeutic effect of the device for removing endotoxin. in the main group ( patients with abdominal septic shock) after surgery, the traditional treatment was supplemented with two sessions of endotoxin removal ( hours each with an interval of hours) using "alteco lps adsorber" (sweden). the control group consisted of patients with a similar diagnosis and only traditional treatment. results: % of white blood cells were adsorbed in lps adsorber. among them, granulocytes ( %) were maximally extracted, then cd + monocytes (cd + mo) ( %), hla-dr + mononuclear cells ( %), monocytes ( %). il- , il- , procalcitonin (pct) were not adsorbed. the -day mortality rate in the main group was % and was lower compared to the control group - %. during monitoring, in the main group hours after the first removal of endotoxin, a decrease in the initially increased amount of activated cd + mo by . times, as well as functionally mature defensin + granulocytes (def + gran) by . times was observed. il- , il- , and pct decreased by . ; . ; and . times, respectively. during this period, the control group showed an increase in cd + mo and def + gran, while il- , il- did not change, and pct increased . times. a day after the second removal of endotoxin and then days later, the main group of il- , il- , and pct continued to decline. in the control group, only il- decreased after days, the rest continued to grow. the cellular adsorption of endotoxin-bound cd + mo and mature def + gran is an important part of the mechanism of action of the endotoxin removal device. does the endotoxin adsorption of pmx column saturate in hours? preliminary study c yamashita in the euphrates trial, the polymyxin b-immobilized fiber column (pmx) hemoperfusion (hp) had no significant effect on -day mortality. endotoxin (lps) burden by endotoxin activity assay > . may exceed μg [ ] , so the dose and duration of pmx-hp could be insufficient to lower the lps burden. to confirm this issue, we experimented in a closed-circuit with h continuous lps addition, and pmx can adsorb > μg [ ] . further, lps concentration became constant within h in the single lps spike test for determining pmx-hp duration [ ] . to prove our hypothesis that the single lps spike test reflects the adsorption equilibrium, and not saturation, we added lps intermittently to reaction. methods: lps ( ng/ml) was mixed with ml deactivated fetal calf serum as a reflux solution, as previously described [ ] ; this concentration is much higher than that observed in septic patients. we created a closed circuit that incorporates pmx- r at / th the amount of an adult pmx and performed pmx-hp at ml/min for h. lps was added in two shots (post h: ng, ng/ml; post h: ng, ng/ml). lps was measured using the limulus amebocyte lysate test at , . , , , , and hr. after an initial decrease between and h, lps concentration did not decrease between and h after pmx-hp initiation. post lps pulse addition at h, it increased and then decreased till h. futher, it did not decrease between and h, but it increased and then decreased again after lps pulse addition post h (figure ). lps adsorption rates were . , . , and . % at , , and h, respectively. conclusions: lps adsorption capacity of pmx- r was maintained even after two additional shots of lps, suggesting that the constant lps concentration in the previously reported lps spike test might be indicative of adsorption equilibrium rather than saturation. a coohort study included patients admitted to three intensive care with sepsis / septic shock ( sepsis criteria ) and aki ( akin score). all patients were submitted to cvvhdf with the oxiris filter (baxter, usa) . the main clinical data, il , procalcitonin, endotoxin ( eaa ) and sofa score were evaluated at basal time ( t ) and at the end of the treatment ( t ). all data are expressed as mean ± sd or median and iqr . anova test was used to compare the changes in the time. results: patients were submitted to rrt with the oxiris filter for ± hours . patients had aki stage , patients aki stage and patients had aki stage. at t all groups had an high vasopressor fig. (abstract ) . lps concentration in lps pulse addition test support to maintain map ≥ mmhg. il , procalcitonin eaa and sofa total were also elevated with no difference between the groups. at t creatinine improved better in aki ( p< . vs. t ) and in aki ( p< . vs t ) then in aki group. map increased in aki ( p< . vs t ) and aki ( p < . vs t ) , but not in aki group. il , procalcitonin decreased more in aki ( p < . vs t ) then aki . at t sofa total was higher in aki then aki ( p< . ) and aki ( p< . ). conclusions: aki and aki stage patients submitted to bp with the filter oxiris respond better then aki stage patients . -this transalte in a better clinical course. -crrt with oxiris filter is useful in septic patients with aki, but aki stage septic patients represent an high risk group. a non-interventional, multicenter, non-randomized patient registry for multiple organ dialysis with the advos system multiple organ failure is a challenging problem in the icu. as an advanced dialysis system, the advos procedure can eliminate watersoluble and protein-bound substances, regulate the acid-base balance as well as fluid and temperature. in , a national registry was established to collect data under "real-life" conditions of patients treated with advos without any trial-specific interventions (drks id: drks ). methods: data from / to / from german hospitals (university hospitals in hamburg-eppendorf, mainz, essen, and klinikum weiden) were analyzed. clinical parameters, treatment settings and adverse events were documented. the -and -day mortality rates were compared with extrapolated rates based on the sofa score. results: patients with a median age of years (iqr - ), of whom ( %) were male, were evaluated. patients had a median sofa score of (iqr: - ) before the st advos treatment, which is associated with an expected mortality of %. the number of failing organs was (iqr - ): cardiovascular ( %), lungs ( %), liver ( %), kidneys ( %), coagulation ( %) and cns ( %). treatments with a median duration of (iqr: - ) hours were evaluated. were discontinued, of which ( %) were due to a device error. adverse events were documented, were related to the device (all due to clotting and recovered without sequelae). significant removal of protein-bound (bilirubin: . vs . mg/dl) and water-soluble toxins (bun vs and creatinine . vs . mg/dl). in addition, improvement in acid-base balance was observed: ph ( . vs. . ), bicarbonate ( . vs. . mmol/l) and base excess (- . vs. . mmol/l) ( table ) . -and -day mortality rates were % and %, respectively. in a cohort of patients with multiple organ failure, we observed an improvement in the expected mortality rate, especially if the advos procedure was applied early. adverse events are comparable to other dialysis therapies in intensive care patients. introduction: acute kidney injury (aki) due to ischemia-reperfusion affects onethird of the patients in cardiac surgery. we investigated the potential role of cyclosporine (csa) to prevent postoperative aki and mitigate inflammatory response to extracorporeal circulation (ecc). methods: double-blind, randomized, placebo-controlled single-center study. patients (n= ) scheduled for elective cardiac surgery were randomized to , mg/kg csa or placebo before the surgery. the primary objective was to assess the role of csa to reduce the incidence of postoperative aki. the secondary objective was to study csa induced changes in the inflammatory response to ecc. results: all enrolled patients were analyzed. postoperative aki was more pronounced in the cyclosporine group compared to placebo. or= . ( . - . ), % ci. the cytokine production in response to ecc was not affected by cyclosporine (figure ) . in patients undergoing cardiac surgery, a single preoperative dose of csa does not prevent the postoperative decrease in renal function. csa does not alter cytokine release in response to extracorporeal circulation. elevated post-ecc levels of pro-inflammatory cytokine il- are associated with kidney dysfunction and may be predictive. new generation adsorbent such as oxiris r was introduced as novel technique in renal support for critically ill patients [ ] . septic shock patients require decatecholaminization strategies emphasizing blood purification to remove catecholamine-producing mediators and evacuate overload fluid in interstitials. our -year-old female patient, admitted to icu after surgery with history of ovarium cancer. her septic shock was worsened with ards, hypercoagulable state and aki. vasopressors were set. patient was controlled with mode simv ,ps ,tv ml,peep ,fio %. renal support was implemented by diuretic and cvvh started on the second day. at first,regular adsorbent was used, post-filter mode was set, and periodic fluid removal target was ml/h. but after hours, no significant changes observed. oxiris r added and after hours passed, requirements of vasopressors reduced, tidal volume increased, hemodynamic parameters stabilized, urine production increased. it was continued for days and patient was recovered. our patient had fallen into inadequate cars stage in which not able to counter septic effects on vital organs (figure ). renal would be primary target for filtration and monitoring tool. adsorbent consisted of an and polyethyleneimine was useful to purify blood from endotoxins conjoined with slower filtration. continuous yet cautious process in cvvh evacuate fluid and mediators while maintain steady hemodynamics. biomarkers could not be evaluated due to limited resources, but improving parameters could be signs that showed recovery process had already took place. advanced hemofiltration is a privilege. implementing and enhancing it with new generation adsorbent would increase survivors by extracting unnecessary fluids and eliminating catastrophic endotoxins and mediators. consent to publish: written informed consent for publication was obtained from the patient. analysis of retrospective cohort study data of patients (pt) treated for dka at icu of kaunas clinics during - has been carried out. serum kalemia, glycemia; hypokalemia, hypoglycemia episodes; rate of insulin interruption for hypo-and normoglycemia during ketoacidosis; use of nah co for ketoacidosis, and los in icu were analysed. spss . was used for statistic calculations. traits evaluated as significant at p < . . at the beginning of dka treatment in totally hypokalemia ( . ± . mmol/l) was recorded in / pt ( . %). due to ignoring of blood ph ( . - . ( . ± . ) kalemia was falsely misinterpreted as "normo-" or "hyper-" . - . ( . ± . mmol/l) in / pt ( . %), thus disregarded so complicated by obvious hypokalemia additionally in / pt ( . %). in hypokalemia los in icu was . ± . vs . ± . h, p < . . insulin use has caused hypoglycemia ( . - . ( . ± . mmol/l)) in / pt ( . %), los in icu . ± . vs . ± . h, p < . .insulin use was interrupted in case of normoand hypoglycemia with still persisting ketoacidosis in / pt ( . %), los in icu was found to be . ± . vs . ± . hr, p < . . nah co was given for symptomatic treatment of ketoacidosis during first h of dka in / pt ( . %) with stable hemodynamic: hco - buffer has increased ( . ± . - . ± . mmol/l), p < . , but it didn't control ketoacidosis, and los in icu was . ± . . vs . ± . h, p < . . hypokalemia, hypoglycemia, precocious interruption of insulin use were recorded as complications of dka treatment. all of them have prolonged los in icu. symptomatic treatment of ketoacidosis with nah co had no effect on it, and prolonged los in icu as well. a growing interest exists about co derived parameters in shock management. central venous-arterial pco difference (p cv-a co ) is strictly related to cardiac output; central venous-arterial pco difference to arterial-central venous o content difference ratio, p cv-a co / c a-cv o , has been proposed as anaerobic metabolism when it's > . mmhg/ml [ ] . to evaluate p cv-a co /c a-cv o reliability in detecting anaerobic metabolism, we analyzed it in consecutive patients affected by mala admitted to our icu, considering these patients as a prevalent anaerobic metabolism model. we calculated, by douglas formula, central venous-arterial co content difference to arterial-central venous o content difference ratio, c cv-ca co /c a-ccv o , as a respiratory quotient surrogate. we performed arterial and central venous blood gas analysis simultaneously at admission, we calculated p cv-a co , p cv-a co /c a-cv o and c cv-a co /c a-cv o and we recorded scvo . we verified relationship between p cv-a co /c a-cv o and scvo and arterial ph, arterial lactates, sofa score at admission and c cv-a co /c a-cv o by linear regression analysis. pcv-aco /ca-cvo greatly increases in mala ( . ± . ). pcv-aco / ca-cvo (fig. ) shows significant co-variation with ph (r = . ; p= . ) and sofa score at admission (r = . ; p= . ). pcv-aco / ca-cvo has poor agreement with ccv-aco /ca-cvo (r = . ) and disagrees with it in identifying anaerobic metabolism, in our series, in fact, ccv-aco /ca-cvo is, in patients, < like an aerobic rq value. pcv-aco /ca-cvo shows better agreement with ph, sofa score and lactate level than scvo . in our series, p cv-a co /c a-cv o is good illness and acidosis severity marker, but it seems to be affected by ph value in accord with haldane effect [ ] . p cv-a co /c a-cv o , in our study, doesn't seem to be a reliable anaerobic metabolism marker nor a rq surrogate. it is thought that early administration of basal insulin to patients with diabetic ketoacidosis (dka) may improve outcomes. small studies have shown trends towards decreases in time to closure of anion gap (tcag), rates of rebound hyperglycemia following discontinuation of intravenous (iv) insulin, rates of hypoglycemia, intensive care unit (icu) length of stay (los), and hospital los [ ] [ ] [ ] [ ] . this was a single-center, retrospective chart review of our institution's dka protocol between january and august . patients that received early basal insulin within hours of initiation of iv insulin and before closure of the anion gap (ag) were compared to those that did not receive early basal insulin. the primary outcome was median tcag. secondary efficacy outcomes include: time on iv insulin infusion, time to de-escalation of level of care, hospital los, and re-elevation of ag. secondary safety outcomes included incidences of hyperglycemia, hypoglycemia, and hypokalemia. a total of patients were identified meeting inclusion and exclusion criteria. median tcag was longer in the experimental group ( vs. hours, p < . ). incidence of re-elevation of ag and incidence of hyperglycemia were lower in the experimental group. other outcomes were similar (figure ). early administration of basal insulin to patients with dka resulted in a longer tcag with a lower incidence of re-elevation of ag and hyperglycemia. early administration of basal insulin appears to be safe with respect to hypoglycemia and hypokalemia. glycaemic control continues to be a challenge in critically ill patients. stress induced hyperglycaemia has been associated with increased morbidity and mortality [ ] . conversely, patients receiving intensive glucose control have a higher risk of death [ ] . a quality improvement project was designed to develop a comprehensive insulin protocol that recognized pre-existing diabetes and reduced hypoglycaemia. data was collected prospectively in all adult patients admitted to the rah intensive care unit (icu) between october and august from the national icu audit database and electronic patient records. daily figures were collected for numbers of hypoglycaemic episodes (< mmol/l), "in range" ( - mmol/l) blood sugar measurements and patients with a pre-existing diagnosis of diabetes. data was collected and analysed using microsoft excel. results: patients were identified; patients ( . %) had pre-existing diabetes. a total of blood sugar measurements were reviewed; ( . %) were "in range" and hypoglycaemic episodes ( . %) occurred. there was no significant correlation between number of diabetic patients and measurements within range. of note, there was an increase in number of measurements per patient in the second half of the time period ( vs ). the development of this protocol has improved glycaemic control in our icu. there are considerably fewer episodes of hypoglycaemia and a large proportion of blood sugar measurements are in range. we hope to continue data collection and interrogate the prevalence of pre-existing diabetes further to reduce glycaemic variability. the optimal management of blood glucose levels for critically ill patients remains unclear. hypoglycemia, hyperglycemia and glycemic variability are associated with mortality. the time in targeted blood glucose range (tir) has been suggested to correlate with mortality depending on the status of antecedent glycemic control, but it has not been verified optimal tir and whether there is an optimal disease-specific tir. a retrospective observational study was performed at a single center. in the present study, we enrolled all critically ill patients admitted in intensive care unit from january to october. patients with diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome and patients who had < blood glucose readings were excluded. gathered information included, in part, demographics, comorbidities, severity of illness scores, diagnosis at admission, length of icu stay and hospital discharge status. the primary outcome was -day mortality. we analyzed to find the optimal tir for critically ill patients. several tirs were each tested for correlation with mortality. a total of , patients, . % of whom had diabetes, were studied. tir to mg/dl (or, . ; %ci, . - . ), tir to mg/ dl (or, . ; %ci, . - . ) and tir to mg/dl (or, . ; %ci, . - . ) > % was independently associated with mortality in critically ill patients respectively. the optimal tir did not differ depending on diagnosis at admission. in this retrospective evaluation, tir to mg/dl > % was independently associated with mortality in critically ill patients, especially those with good antecedent glucose control. these findings have implications for the design of future trials of intensive insulin therapy. the prevalence of chronic dysglycemia (diabetes and prediabetes) in patients admitted to swedish intensive care units (icus) is unknown. we aimed to determine the prevalence of such chronic dysglycemia and asses its impact on blood glucose control and patient-centred outcomes in critically ill patients. in this retrospective, observational study, we obtained routine glycated hemoglobin a c (hba c) measured in patients admitted to four tertiary icus in sweden between march and august . based on previous diabetes history and hba c we determined the prevalence of chronic dysglycemia (prediabetes, undiagnosed diabetes and known diabetes). we compared indices of acute glycemic control in the icu and explored the association between chronic dysglycemia and icu-associated infections, mechanical ventilation, renal replacement therapy, vasopressor therapy, and mortality within days. of patients, ( %) had chronic dysglycemia. of these patients, ( %) had prediabetes or undiagnosed diabetes and fig. (abstract p ) . results ( %) had a known diabetes diagnosis. during icu stay, patients with chronic dysglycemia had higher average blood glucose, spent less time in target glucose range, had greater glucose variability, and were more likely to develop hypoglycemia than patients without chronic dysglycemia. chronic dysglycemia was associated with greater need for renal replacement therapy (odds ratio . , % ci . - . ) and increased -day mortality (hazard ratio . , % ci . - . ) after adjustment for simplified acute physiology score . in contrast, chronic dysglycemia was not associated with mechanical ventilation, vasopressor therapy, or icu-associated infections. in four tertiary swedish icus, measurement of hba c showed that / of patients had chronic dysglycemia (prediabetes or diabetes). chronic dysglycemia was associated with marked derangements in glycemic control during icu stay, greater need for renal replacement therapy and with increased mortality at days. case report: modern antidiabetic therapie causes ketoacidosis am heiden, m emmerich krankenhaus bad oeynhausen, institut für anästhesie, bad oeynhausen, germany critical care , (suppl ):p the modern antidiabetic class of sglt -inhibitors, that are known to reduce the risk for cardiac events [ ] , are increasingly used in the last few years. a -year old male patient with diabetes mellitus suffered days after colectomy surgery from abdominal pain and nausea. the patient had an antidiabetic therapy with empaglifozin that was paused until day after surgery (nutrition start on day , weaning on day ). methods: this is a case report of one male patient seen in the icu setting. daily blood values including arterial blood gases, vital parameters and clinical status of the patient were observed and evaluated. the blood gases showed this metabolic acidosis: ph . ; pco . mmhg, bicarbonate mmol/l, be - . mmol/l, lactate . mmol/l, glucose mmol/l. a ketonuria despite normal blood glucose values was noticed, so that the diagnosis of ketoacidosis was clear. after analyzing the possible causes we found out, that empaglifozin in times of catabolism and fasting can cause this severe symptomatic. we terminated the therapie with empaglifozin and under the treatment with insulin the symptoms disappeared within days and the patient could be discharged from the icu on day after surgery. after one episode of ketoacidosis the therapy with sglt -inhibitors should lifelong never be started again. we recommend that intensivists should be aware of the modern sglt -inhibitors because of the shown severe complications and the increased use of this medication. consent to publish: written informed consent for publication was obtained from the patient. while obesity confers an increased risk of death in the general population, numerous studies have reported an association between obesity and improved survival among critically ill patients. this contrary finding has been referred to as the obesity paradox. this retrospective study uses two causal inference approaches to address whether the survival of non-obese critically ill patients would have been improved if they had been obese. the study cohort comprises , adult critically ill patients hospitalized at the intensive care unit of the ghent university hospital between and . obesity is defined as a body mass index of ≥ kg/m . two causal inference approaches are used to estimate the average treatment effect in the untreated (atu): a naive approach that uses traditional regression adjustment for confounding and that assumes missingness completely at random, and a robust approach that uses super learning within the targeted maximum likelihood estimation framework and that uses multivariate imputation of missing values under the assumption of missingness at random. obesity is present in . % of patients. the in-hospital mortality is . % in non-obese patients and . % in obese patients. the marginal associational risk difference for in-hospital mortality between obese and non-obese patients is - . % ( % confidence interval (ci) - . % to . %, p= . ). the naive approach results in an atu of - . % ( % ci - . % to - . %, p= . ), whereas the robust approach yields an atu of - . % ( % ci - . % to . %, p= . ). a robust causal inference approach that may handle confounding bias due to model misspecification and selection bias due to missing data mitigates the obesity paradox, whereas a naive approach results in even more paradoxical findings. the robust approach does not provide evidence that the survival of non-obese critically ill patients would have been improved if they had been obese. bowel management within an icu environment is often difficult. recent data collection from an intensive care unit at the rvi identified either loose stool or constipation on > % of patient days. it was postulated this could be improved with a more tightly controlled bowel management regimen. to test this hypothesis a step-wise bowel protocol was created and introduced. data was collected in the month period following its implementation with the following aims: ) assess effectiveness of the protocol ) further observe the reasons for loose or constipated stool on an diarrhea is an important problem in each critically ill pateints [ ] . we aimed to investigate the frequency and management of diarrhea in our icu. in this study patient retrospectively reviewed, in our icu between . . - . . . patients were divided into two group as diarrhea "positive" and "negative". patients with diarrhea had fluid or loose stools or more times a day. each diarrhea period of the patients with diarrhea was examined separately and compared with the group without diarrhea. nutritional status, enteral product formulation, leukocyte, neutrophil, albumin values, gastric sparing, antibacterial and antimycotic use, los in hospital and in icu were compared. in diarrhea positive group, on the day of hospitalization, laxative and/or enema administration, toxin a in stool, nitrogen balance before and after diarrhea, enteral product change in diarrhea, probiotic, metronidazole or oral vancomycin use were examined. the incidence of diarrhea was . %. the most common diagnosis of icu admision was respiratory failure ( - %) in both groups. diarrhea occurred in two days after laxative and/or enema treatment. enteral nutrition was higher in both groups (≥ %). nasogastric tube feeding was significantly higher in the diarrhea group (p= . ). there was no difference between nutritional product formulation and diarrhea development (p> , ). antibacterial use was high in both groups ( %); however, teicoplanin use was significantly higher in the group diarrhea negative group (p= . ). the los in icu, and hospital was higher in diarrhea group (p< . ). no difference in mortality rates (p> . ). many factors may cause diarrhea in icu, and diarrhea may adversely affect patient treatment and increase morbidity. we think that preventive methods are as important as the treatment of diarrhea. the use of parenteral glutamine is studied in number of rcts and systemic reviews (heyland d , wischmeyer p ), while there is a lack of data about the use of enteral glutamine. the aim of our study was to determine the effect of enteral glutamine supplementation on the incidence of hospital infections and death. design: retrospective cohort study. inclusion criteria: males and females > years of age, tbsa burned %- %, nasogastric intubation.patients were divided in two groups: glutamine group (n= ) and control group (n= ). in the study group enteral glutamine was administered to the patients for days after admission to the icu. baseline characteristics were well balanced between groups. no significant difference was found between groups on patients' age, sex, tbsa, need for mechanical ventilation and rate of inhalation injury. primary outcome was all-cause mortality. secondary outcome was rate of nosocomial infections (skin and skin structure infections (sssi), lower respiratory tract infections, urinary tract infections, bacteremia, sepsis). mortality rate was ( %) and ( %) in the glutamine group and the control group, respectively, p= . . rate of nosocomial infections was ( %) in the glutamine group and ( %) in the control group, respectively, р= . . rates of sssi, lower respiratory tract infections, urinary tract infections and sepsis did not differ significantly between the groups: ( %) and ( %), p= . ; ( %) and ( %), р= . ; ( %) and ( %), р= . ; ( %) and ( %), р= . , respectively. rate of bacteremia was significantly different between the groups: ( %) in the glutamine group and ( %) in the control group, p= . . retrospective design is a significant limitation of our study. enteral glutamine supplementation may reduce the incidence of bacteremia in burn patients, but has no influence on the incidence of other nosocomial infections and mortality. further large clinical trials are needed. with outcomes were assessed with multivariable logistic regression and cox proportional hazard analyses, adjusted for baseline risk factors and randomization. in sensitivity analyses, models were further adjusted for key regulators of ketogenesis to assess whether any effect was direct or indirect. late pn increased plasma hb as compared with early pn, with maximal effect on day (p< . for day to and for the "maximal effect" day in the patients). adjusted for baseline risk and randomization, plasma hb associated with a higher likelihood of earlier live weaning from mechanical ventilation (p= . ) and of earlier live picu discharge (p= . ). as plasma hb replaced the effect of the randomization, the hb effect statistically explained these benefits of the randomization. further adjustment for key regulators of ketogenesis did not alter these findings. plasma hb did not independently associate with the risk of infections and mortality. withholding early pn increased ketogenesis in critically ill children, an effect that statistically mediated part of its clinical benefits. critical care patients are prone to frequent feeding interruptions for various reasons including feeding intolerance. these interruptions can lead to adverse outcomes. the aim of the study was to determine the reasons for and the duration of interruptions of enteral nutrition (en). single-center observational, cross-sectional study in a -bed mixed icu of a tertiary hospital. duration: months. patients, aged . years old (± . ), that stayed in the icu > hrs and were fed with en were included. anthropometric data, bmi, time of initiation of prescribed en, type of en formula, daily calories delivered were recorded. energy intake was calculated according to espen guidelines ( kcal/ kg bw/day). the causes for and duration of interruption were reviewed from the patient's chart. apache ii and mnutric score was calculated for all patients. mnutric score ≤ was used to diagnose malnutrition. all patients included in the study were endotracheally intubated. apache ii was . ± . . % of patients had increased risk of malnutrition. icu stay was . ( . ± . ) days, and the in-hospital mortality was %. there were episodes of en interruptions over a median icu stay of . days. median . interruptions/patient. the most common reason for en interruption was gastric residual volume monitoring followed by diagnostic and therapeutic procedures (figure ). other reasons include surgery, intolerance and/or delayed feeding and extubation. the median lost feeding time was . hours/ day ( . - . ) for all causes, while the mean loss of total energy intake was kcal/day (± )/day. average body weight of the patients was kg (± ). caloric deficit was calculated at kcal/day or % of the prescribed caloric goal. the results of this study showed that interruptions can lead to substantial caloric deficit, malnutrition and adverse events. an interruptionminimizing protocol could be useful in order to reduce the missing hours and to improve the clinical outcomes. relationship of goal-directed nutritional adequacy with clinical outcomes in critically ill patients pc tah there are controversies surrounding the effects of optimal nutritional intake on clinical outcomes in critically ill patients. this study aimed at investigating the relationship of goal-directed energy and protein adequacy on clinical outcomes which includes mortality, intensive care unit(icu) and hospital length of stay (los), and length of mechanical ventilation (lomv). this was a single centre prospective observational study. nutritional requirements were guided by indirect calorimetry and -h urinary urea.nutritional intake was recorded daily until death, discharge, or until day of icu stay. clinical outcomes were collected from patient's hospital record. the relationship between the two groups (< % and ≥ % of overall nutritional requirement) with mortality outcomes was examined by using logistic regression with adjustment for potential confounders. terlipressin, despite being one of the main treatments for acute variceal bleeding, may lead to severe hyponatremia due to its antidiuretic activity.we aimed to identify risk factors for development of hyponatremia during terlipressin treatment. retrospective study of patients admitted to acute intermediate care unit for hypertensive upper gastrointestinal bleeding due to chronic liver disease who received terlipressin(december -decem-ber ).hyponatremia was defined as a decrease in na serum levels ≥ meq and severe hyponatremia as > meq within days of treatment. we studied patients, . % male, mean age of . years (sd . ). alcohol-related liver disease was the most frequent etiology. hyponatremia occurred in patients ( . %). serum na Δbetween - and - meq and serum na Δ>- meq occurred in . and . %, respectively (table ) . severe hyponatremia occurred in patients ( . %) and symptoms were reported in two cases (status epilepticus and altered mental status). patients with higher baseline levels of na were more susceptible to terlipressin-induced hyponatremia and a longer length of stay was observed in patients with serum naΔ>- meq ( . vs . days, p< . ). the prevalence of hyponatremia in our study was lower than previously reported.higher serum na at admission and aih as etiology of cirrhosis were predictors of terlipressin-induced hyponatremia. neither the cumulative dose of terlipressin nor the duration of treatment appear to be related to the development of hyponatremia a Δ h-[na] > mmol/l was associated with larger hazards of mortality ( figure ). an increase in serum sodium in the first hours of icu admission is independently associated with a higher mortality in patients admitted with mild hyponatremia, normonatremia, and hypernatremia. based on our findings, it is possible that mild hyponatremia may be a protective mechanism in critical illness, which questions common practice of routinely correcting serum sodium when it is too low. introduction: acute liver failure (alf) represents a life-threatening organ dysfunction associated with increased mortality and liver transplantation represents the only definitive treatment. the aim of this study was to assess the effects of renal replacement therapy in combination with hemoadsorption in alf patients. twenty-nine patients with alf admitted to the intensive care unit (icu) of fundeni clinical institute were included in the study. after icu admission, consecutive session of hemoadsorption in combination with continuous veno-venous hemodiafiltration were applied. number of organ dysfunctions and sirs criteria were recorded at icu admission. the following data were recorded before and after the hemoadsorption therapies: glasgow coma scale, pao /fio , creatinine, -hours urine output, bilirubin, leucocyte and platelet count, heart rate, mean arterial pressure and vasopressor support, c-reactive protein and procalcitonine. clif-sofa score was calculated before and after the therapy. icu length of stay and -days outcome were noted. the mean age in the study group was ± years. the median number of sirs criteria was [ , ] and the median number of organ dysfunctions was [ , ] . the use of hemoadsorption was associated with a decrease in creatinine (from . ± . to . ± . mg/dl, p= . ), bilirubin (from . ± . to . ± . mg/dl, p= . ) and platelet count ( ± / ul to ± /ul, p= . ). we also observed a decrease in clif-sofa score from . ± . to . ± . (p= . ). overall mortality was . % (n= ). six patients ( . %) underwent liver transplantation with % -days survival. the use of hemoadsorption in patients with alf is associated with improvement in liver and kidney functional tests and may represent a new therapy in bridging these patients to liver transplantation. introduction: impairment of intestinal mucosal barrier function is the initiating factor of sepsis. in order to explore the effect of lactic acid bacteria on intestinal barrier function impaired by sepsis, it is necessary to establish sepsis and lactic acid bacteria ecological models. however, how to construct these models is still unclear. co-cultures with a gradient of lactic acid bacteria and caco- cells were constructed. the symbiotic state was observed under an inverted microscope and lactate dehydrogenase (ldh) toxicity tests, transepithelial electrical resistance(teer) tests and western blots were used to determine effective concentrations of lactic acid bacteria in monolayer cell models. lipopolysaccharide (lps) was used to treat cells, and cell counting kit- , quantitative reverse transcription pcr(rt-qpcr) and enzyme linked immunosorbent assays (elisa) were used to determine the appropriate concentration for sepsis models. the number of living cells decreased significantly when the moi(number of lactic acid bacteria/cell number) reached ( figure , panels a, b). the release of ldh indicated that damage to cells began to increase when the moi exceeded (panels a, b). at an moi of . , resistance values began to increase over time, whereas resistance values began to decrease when the moi reached (panel ). as the number of lactobacilli increased, the expression of tight junction protein increased and then decreased (panel a, b, c). in sepsis model experiments, the cell survival rate began to decrease once the concentration of lps exceeded ^ ng/ml (panel ). rt-qpcr results showed that ng/ml lps significantly increased inflammatory cytokines (panel ), and elisa results consistently showed that tnf-α and il- increased significantly when lps concentrations reached ng/ml (panel a, b). it is feasible to construct a cell monolayer model of lactic acid bacteria and lps. the appropriate moi of lactic acid bacteria is . and the optimal concentration of lps is ng/ml. introduction: sepsis is associated with high mortality and morbidity. as the severity increases, physiological parameters such as ph changes are one of the most notable features in metabolic acidosis secondary to high lactate. currently there is no point of care test other than blood gas measurement that could detect these ph changes. this is challenging especially in prehospital environment. the aim of this study is to develop a novel rapid point of care testing using a sensor to detect ph change in blood. sensors were produced by screen printing graphene and silver electrodes and functionalizing the graphene working electrode with an active layer of melanin. a preclinical sensor model was produced by adding lactic acid to a citrated plasma sample thus altering its ph over a clinically relevant range. the ph sensors were exposed to modified plasma, recording any changes in the voltage. the relationship between the voltage potential and plasma ph was established using weighted least squares regression. a ph dependent change in the measured voltage, with respect to the ph of the solution, was observed with a sensitivity of - . mv/ph +/- . over a physiologically relevant ph range between ph . and ph . . in this first phase proof of concept study a low cost, ph sensor was fabricated and demonstrated to be effective in measuring the ph of the plasma. this is the first time that such a sensor has been demonstrated and validated to work in this preclinical model of acidosis. the technology demonstrated here is a promising candidate for a point of care test whereby abnormal blood ph levels can be detected and monitored outside of a laboratory environment in a rapid manner. further studies are now underway to detect this change in whole blood. (figure ) . over one year only a small proportion of patients (n= , %) were classified as 'intermediate high' risk and potential candidates for reperfusion therapies. the revised national early warning score (news) with modified glasgow prognostic score (mgps) is superior to the news for predicting in-hospital mortality in elderly emergency patients t mitsunaga jikei university school of medicine, emergency medicine, tokyo, japan critical care , (suppl ):p the national early warning score (news) was developed in the ukto identify the risk of death. the previous study showed that the modified glasgow prognostic score (mgps) correlate with frailty in elderly patients [ ] . the aim of this study is to evaluate the predict value of the revised news with mgps for in-hospital mortality (in days) in elderly emergency patients. this study is secondary analysis and was carried out in jikei university kashiwa hospital, in japan, from april to march . the acute medical patients aged and older were included. the news was derived from seven physiological vital signs. the mgps was derived from c-reactive protein (crp) and albumin. discrimination was assessed by plotting the receiver operating characteristics (roc) curve and calculating the area under the roc curve (auc). the aucs for predicting in days in-hospital mortality were . for revised news with mgps and . for the original news. the auc of the revised news with mgps was significantly higher than that of the original news for predicting in-hospital mortality (p < . ) (figure ) . our single-centred study has demonstrated the utility of the revised news with mgps as a high predictor of acute phase in-hospital mortality in elderly emergency patients. the diagnostic performance of the five main emergency department (ed) triage systems has been shown to be poor in distinguishing acute coronary syndromes (acs) from mild severity diseases in chest pain patients. these ed triage systems are either clinically-based, being more sensitive or ecg-based, more specific [ ] . the goal of the study was to evaluate if incorporation of cardiovascular risk factors (cvrf) into ecgbased triage could increase his diagnostic performance. cecidoc is a prospective, observational, single-center study in an academic hospital. all consecutive adult patients admitted for acute chest pain were included. we compared the ecg-based french triage system [ ] to a modified system upgrading patients with a normal ecg but significant cardiovascular risk from a low acuity triage score (waiting period before medical assessment of max. min.) to a high acuity triage score (waiting period before medical assessment of max. min.). the final diagnosis was determined after a -day follow-up. we predefined as being adequate a high-acuity triage score (level or ) for acs and a low-acuity score (level , or ) for mild severity diseases. a total of patients was enrolled over a -month period (age . ± . ; m/f ratio . ). triage scores of patients ( . %) with acs were compared to patients ( . %) with mild severity diseases. taking into account cvrf, the sensitivity of the triage system increased from to % whereas the specificity decreased from to %. area under the roc curve (auc) went from . to . (fig. ) . for chest pain triage at ed, addition of cardiovascular risk factors into ecg-based triage increases his diagnostic performance. approximately % of patients presenting to hospital with an intentional overdose require admission to an intensive care unit (icu) [ ] . there are currently no uk guidelines regarding the optimal use of ct head scans (cth) in this patient cohort [ , ] . this study aims to determine whether we should be performing ct head scans in obtunded patients with suspected overdose requiring admission to intensive care. we performed a retrospective search of the icnarc database for plymouth university hospital trust, looking for patients admitted to the icu with overdose or self-poisoning as a primary diagnosis. patients were identified and of these patients required intubation due to obtundation(gcs< ). there were males and females with an average age of years old. the median length of stay on the unit was day. of the patients has a past medical history of mental illness, and overdosed on prescribed medications. the average gcs recorded on admission was . of the ( %) patients had a cth on admission, of which were part of a trauma scan. were known overdoses and were suspected overdose as per the cth request form. the main rationale behind those requests were to exclude additional intracranial injury. none of those cth showed any signs of acute pathology (figure ) . in this retrospective study, obtunded patients with suspected or known overdose with no history of apparent trauma or injury do not benefit from cth. in the absence of a history of trauma or focal neurological signs our conclusions are that cth provides limited value in the management of these patients. the audit was carried out to objectively investigate the problems associated with technique of folley catheterization in emergency department and indoor units of internal medicine wards [ ] . introduction: cellular and molecular mechanisms, epigenetic aspects of acute clozapine poisoning are studied insufficiently. the aim of this study was to identify morphological and epigenetic alteratons in brain neurons during acute exposure to clozapine combined wit ethanol. the experiments were carried out on male wistar rats weighting - g (n= ). group i (control) received . % nacl solution enterally; group iiclozapine mg/kg in . % nacl solution; group iiiclozapine mg/kg in % ethyl alcohol. after hours euthanasia was performed. autopsy included withdrawal of brain samples for histological examination (n = ) and for determination of global dna methylation level (n = ). the global dna methylation level ( -mc%) was determinated by fluorimetric method. inter-group comparisons were made by kruskal-wallis test. histological examination of paraffin sections of brains stained with hematoxylin and eosin was performed by light microscopy. in acute сlozapine poisoning and its combination with ethanol morphological changes in neurons of the cerebral cortex were detected. in acute сlozapine with alcohol poisoning an increase of global dna methylation level was observed. probably the identified changes have a common pathogenesis which will be clarified in our further studies. there is limited information available regarding the prevalence of adder bites and the complications of envenomation. nhs data suggests there are adder bites annually in the uk with the last fatality in [ ] . we performed an audit into adder bites in south west wales to identify the number attending our emergency departments, their management and clinical course as well as any environmental factors that predict increased likelihood of being bitten or the severity of the bite. a retrospective study of adder bites attending emergency departments in south west wales was undertaken (jan to aug ). measurements included were patient demographics, clinical presentation, type of treatment (conservative vs anti-venom) and outcome. results: patients were included, age range - years ( figure ). the majority of bites occurred in sand dunes ( . %) and all bites were on extremities. anti-venom was administered to . % ( / ) of patients. there was a significant positive association between the use of anti-venom and the length of hospital stay (r = . ; p= . ) and a significant negative correlation between the anti-venom use and both diastolic and systolic blood pressure (p= . and . respectively p= . ). all patients fully recovered. in this study, we demonstrated that with a full clinical assessment on presentation it is safe to decide whether anti-venom is required. the current guidelines are safe and effective in the treatment of adder bites. μmol/l, for pao < . kpa and > . kpa, platelets < * ^ /l and > * ^ /l, and bilirubin > μmol/l. in our population of adult ed patients, the thresholds of vital values associated with increased -day mortality were very close to routinely used values, and most of the thresholds were included in the lowest urgency level in triage and risk-stratification scoring systems. the workload in the emergency room: direct assessment by the therapeutic intervention scoring system- and indirect assessment by the nasa task introduction: the number of emergency room admissions continues to increase each year, which increases the care workload of the emergency department staff, who should to use its theoretical and practical knowledge in order to provide quality care in difficult working conditions. the aim of our study was to assess the emergency room staff workload its impact on health workers and patients and to suggest an improvement strategy to decrease this workload. a prospective, monocentric cohort study with descriptive and analytic approach over one month (december ) conducted at the emergency department of an academic hospital. the workload endured by the emergency room staff was evaluated by the nasa task load index and on patients by the therapeutic intervention scoring system- . there were cumulative days of hospitalization in consecutive patients admitted to the emergency room. the average age was ± years. the average length of stay at the emergency room was about ± h. the average tiss- score was . ± . . factors associated with important care workload were: age ≥ years, diabetes, more than comorbidities, the use of intravenous antibiotics; the use of vasoactive drugs and the use of mechanical ventilation; a high tiss score was predictive of emergency room mortality. in the indirect assessment of the care workload, medical and paramedical staff were interviewed, % of them were under years old with a sex ratio of . . a high level of mental and physical workload was expressed by ed staff with considerable level of frustration; the ed staff suggested mainly to improve the working conditions, communication and to redefine tasks "who does what". our study had shown a significant workload in the emergency room, a process to reduce this workload is being implemented medical simulation is a modern teaching tool increasingly used in specialties such as anesthesia, emergency medicine and obstetrics. however, it's not widely used in specialties like cardiology, althought cardiovascular emergencies are very frequent. the purpose of our study was to assess the effectiveness of simulation-based medical education in the management of cardiovascular emergencies among moroccan graduate students. we conducted a prospective, observational, multi-centrer study including the students of three moroccan universities from the th to the th year of medicine who underwent phases: first a pre-test, then a theoretical and practical training on cardiovascular emergencies after which the students were separated in two groups, one undergoing the medical simulation training (group ) and one who didn't (group ), followed by a theoretical then a practical post-test on resusci anne and simman®. at last, the students were asked to answer a satisfaction survey. the reform procedure in the tunisian army consists in repairing the physical damage and deciding on the applicant's ability to continue working. terrorism increases the impact of the co-morbidity generated and the socio-economic consequences that result from it. the purpose of this work was to study the epidemiological, clinical and evolutionary profile of terrorist injuries, to specify the rates of consequent partial permanent disability (ppi) and the possibilities of returning to work. descriptive retrospective cross-sectional study of reform files on military personnel injured during anti-terrorist operations from fig. (abstract ) . changes in total bcpr rate in family-and friends-witnessed ohca cases with dispatcher-assisted instruction during -week period after the day of disaster during three years january to september . the data collection was carried out on the basis of a collection form. our wounded were male, % of whom belonged to the army. the average age was years and months ± . . half of our wounded were troopers. infantry and special forces were the most exposed military units. half of the accidents were recorded in the kasserine region ( cases). chronic post-traumatic stress disorder (cptss) was found in injured, followed by amputations in injured. the after-effects were psychological in %, physical in % and mixed in % of our injured. the ppi rate ranged from % to % in . % of injuries.. more than half of the injured had returned to their professional activity, % were put on reform for health reasons. our results showed that the esptc was the most recorded sequel, and that the ppi rate was significant in a quarter of our injuries. in our series, a third of our wounded were put on reform for health reasons. to state the importance of initial care and adequate and rigorous follow-up to recover a greater number of war wounded. introduction: the rapid response system (rrs) has been shown to decrease hospital mortality [ ] . the japanese coalition for patient safety has set a major goal for hospitals to more widely implement the rrs. however, prevalence and actual circumstances of use in acute care hospitals (including small scale hospitals) in japan are as yet not well-known. web-based questionnaires were sent to acute care hospitals (of scale beds-or-larger) of prefectures in western japan. each participant hospital selected a certain department which answered the questionnaire. the rrs included the medical emergency team (met), the rapid response team (rrt), and the critical care outreach team (ccot). we investigated the presence and circumstances of in-hospital emergency calls, rrs and other systems, and then illuminated issues to be solved. our study suggests that delays in patient transfer to the icu after rrt activation in the wards were associated with slower physiological improvement.these findings support further and larger studies. blood and blood products use in intensive care unit m akcivan, s bozbay, o demirkiran istanbul university cerrahpasa, anesthesiology and intensive care, istanbul, turkey critical care , (suppl ):p blood and blood product (bp) transfusions are frequently used in intensive care units (icu) [ ] . it is important to know transfusion epidemiology and the effect of adverse transfusion reactions and their effect on mortality and morbidity.we aimed to investigate the blood and bp transfusions in the icu. blood and bp transfusions in icu, between - were reviewed retrospectively. we evaluated each transfusion as a data and examined the pre-and post-transfusion laboratory values, demographic data, cause of icu admission and comorbidities. results: patients who underwent transfusion in the icu, and transfusion data from these patients were included. the most frequent cause of hospitalizations were respiratory failure and sepsis. the rate of patients transfused in the five-year period decreased from . % to . %. the hemoglobin threshold before transfusion decreased from . g / dl to . g / dl. a total of transfusion reactions were observed and the most common transfusion reaction was febrile non-hemolytic reaction. the most commonly transfused product was red blood cell suspension. transfusion reactions were found to be slightly higher in men than women in young age group(< y) (p = . and p= . , respectively). transfusion reactions were found to be more frequent in emergency transfusions (p < . ). the number of transfusions was significantly lower in patients with apache ii score < (p < . ). the need for transfusion was found to be higher in patients with hematological malignancy (p < . ). it was observed that as the mean number of transfusions increased the mortality is also increased (p < . ). transfusion therapies are the treatments that are vital but have a serious mortality and morbidity risk. in particular, intensive care patients should be considered in detail because of their specific features. restrictive transfusion practices have positive results. association between anemia or red blood cell transfusion and outcome in oncologic surgical patients. figure a) . the association between rbc transfusion and adverse events also remained after adjustment (or . [ . - . ] ; p < . ) ( figure b) . in oncologic surgical critically ill patients, there was an independent association between anemia (even moderate anemia) or rbc transfusion and patient outcomes. our findings highlight the need for further research to determine the optimal transfusion strategy in surgical oncologic patients. transfusion impaired skin blood flow when initially high e cavalcante dos santos, w mongkolpun, p bakos, al alves da cunha, c woitexen campos, jl vincent, j creteur, fs taccone erasme hospital, intensive care department, brussels, belgium critical care , (suppl ):p red blood cell transfusion (rbct) increases global oxygen delivery (do ) and may improve microcirculation. however, the effects on blood flow have been found to be conflicting. we studied icu patients with stable hemodynamic status (mean arterial pressure (map) ≥ mmhg for at least hours) and without active bleeding, who received a rbct. skin blood flow (sbf) was determined (periflux system , perimed, index finger; perfusion unit, pu) together with map, heart rate (hr), hemoglobin (hb), lactate levels and scvo before and after rbct. sbf was measured before rbct (t ) and after (t ) for each min. according to previous data indicating the lowest sbf value found in noninfected icu patients was pu, all patients were analyzed according to the baseline sbf (i.e. < pu -low sbf vs. ≥ puhigh sbf). the relative change of sbf (Δsbf) was calculated after rbct and the responders were defined by the function of > %. results: icu patients were studied. rbct was associated with increases in map and scvo but no change in sbf. at baseline, scvo was lower in the responders than in the non-responders (p= . ) and lower in patients with low sbf than in the high sbf (p= . ). there was no difference in hb, map, and lactate, between the patients with low and high sbf. after rbct, map rose in the responders (p< . ) and in the non-responders (p= . ), sbf (p< . ) rose in patients with low sbf, and sbf (p= . ) decreased in patients with high sbf. there was a negative correlation between baseline scvo (r= - . , p< . ) or baseline sbf (r= - . , p< . ) and the relative increase in sbf after rbct. rbct increases skin blood flow only when it is impaired at baseline. severe immune dysregulation is associated with adverse outcomes and is common in intensive care unit (icu) patients [ ] . erythropoietin-stimulating agents (esas) have both anti-apoptotic and immune-modulating properties [ ] . despite potential benefit, both the safety and efficacy of these agents remains unclear [ ] . here we evaluate the impact of esas on morality at hospital discharge in critically unwell adult patients admitted to the icu. we conducted our search strategy in accordance with a predetermined protocol. the use of ffp is associated with an increased incidence of complications such as acute respiratory distress and infections, and the rate of complications increased with the quantities of ffp transfused [ ] . pcc contain several important coagulation factors and it has been suggested that they could replace ffp. this has been shown mainly in case reports or series in which coagulation factor deficit was detected by using poc viscoelastic tests in trauma [ ] or traditional hemostatic tests in obstetric patients [ ] . multicenter observational study of the safety and efficacy of the prothrombin complex concentrate. a survey of anesthetists was conducted in maternity hospitals at various levels of care in the russian federation. data has been collected and processed. as a result, patients were analyzed. pph was determined as a volume of blood loss more than ml during vaginal delivery or cs. the most significant risk factors for pph were: preeclampsia or arterial hypertension and a history of postpartum hemorrhage. . % had no risk factors for pph. it was determined that the use of prothromplex iu decreased the number of patients with transfusion ffp - ml/kg by . % and increased the number of patients without transfusion by . %, compared with patients without use of prothromplex iu (figure ). no complications were detected. the use of pcc safety and efficacy reduce use of ffp during pph. the full analysis included patients on either hfc (n= ) or cryoprecipitate (n= ). the intraoperative and postoperative changes in etp and fibrinogen concentration are shown in table . for fibtem a (intraoperatively) and fibrinogen concentration (intraoperatively and postoperatively), the mean numerical values appeared higher with hfc than cryoprecipitate. fxiii (hfc: . %, . %; cryoprecipitate: . %, . %, at baseline and hr after surgery start), fviii and vwf were maintained throughout surgery in both treatment groups. this was also the case for laboratory tests activated partial thromboplastin time, prothrombin time and platelet count. the forma- coagulation parameters analyses showed broad overlaps between hfc and cryoprecipitate, with satisfactory maintenance of the clot quality parameters, fxiii concentrations and thrombin generation parameters. the study group includes men and women with a mean age of , vs. . years (p= . ) admitted with the diagnosis of multiple trauma. we found a directly proportional and highly significant statistical correlation between base excess and fibrinogen level diagnosed using the mcf/fibtem parameter(r= . , p< . )and an inverse proportional correlation between lactate level and fibrinogen level (r= - . , p= . ). in the roc analysis that uses as a variable the level of base excess and as a criterion of classification the fibrinogen deficit (mcf/fibtem< mm) it can be observed that at a value of be<- mmol/l, we can diagnose a fibrinogen deficit with a sensitivity of . % and a specificity of . % (auc= . ,p< . ). lactate appears to be inferior to the excess base (figure ) , but still has a good diagnostic power, a value of . mmol/l has a sensitivity of . % and a specificity of % (auc= . ,p< . ). the difference between the two roc curves ( . ) is statistically significant (p = . ). both base excess and serum lactate can be used to diagnose fibrinogen deficiency with the mention that base excess appears to have a higher sensibility and specificity ability. based goal-directed algorithm. this approach requires further clinical validation. we conducted a retrospective study comparing transfusion strategies in patients with major trauma between and . we retrieved demographic data and blood products administered from patients with at least one red-blood cell (rbc) transfusion. primary outcome was a reduction of rbc administration. secondary outcomes were mortality, icu length of stay and acute kidney injury. we included patients admitted in the icu due to severe trauma (sapsii: . ± . ), and mainly after emergent surgery ( . %). they featured a mean age of . ± . y, were predominantly male ( . %) and % were in shock. in the first hours of hospital admission a mean of . ± . rbc units were administered. most patients received a fibrinogen-based protocol (fbp) ( %), with an average of ± g of fibrinogen and ± fresh-frozen plasma (ffp) units, versus ± g of fibrinogen and ± ffp units in the ffp group. the fbp was associated with a decrease administration of rbcs in the first hours (r = - . ; p < . ), even after adjustment for severity (p= . ) and for tranexamic acid use (p = . ). it was associated also with a decrease of platelet transfusion (p= . ). fibrinogen-based protocol was not associated with a decrease in mortality, acute kidney injury or noradrenaline dose. treatment of tic in past years has progressively changed to a goaldirected fibrinogen-based approach. in our population, the use of fbp lead to a reduction of rbc administration in severe trauma patients. prospective, multicenter, randomized study comparing administration of clotting factor concentrates with a standard massive hemorrhage protocol in severely bleeding trauma patients the objective of this study was to assess the ability of the quantra® qstat® system (hemosonics) to detect coagulopathies in trauma patients. many level trauma centers have adopted whole blood viscoelastic testing, such as rotational thromboelastometry (rotem®, fig. (abstract ) . study treatment plan instrumentation lab) for directing transfusion therapy in bleeding patients. the quantra qstat system is a cartridge-based point-of-care (poc) device that uses ultrasound to measure viscoelastic properties of whole blood. and provides measures of clot time, clot stiffness and a test of fibrinolytic function. methods: adult subjects were enrolled at two level trauma centers which use a rotem based protocol to guide transfusion decisions. study protocols were approved by the site's ethics committee. for each subject, whole blood samples were drawn upon arrival to the emergency department and again, in some cases, after administration of blood products or antifibrinolytics. samples were analyzed on the quantra (at poc) in parallel to rotem delta (in lab). a total of patients were analyzed. approximately % of samples had a low clot stiffness (cs) values suggestive of an hypocoagulable state. the low stiffness values could be attributed to either low platelet contribution (pcs), low fibrinogen contribution (fcs), or a combination ( figure ) . additionally, % of samples showed evidence of hyperfibrinolysis based on the quantra clot stability to lysis parameter. samples analyzed on standard rotem assays showed a lower prevalence of low clot stiffness and fibrinolysis based on extem, fib-tem results. the correlation of cs and fcs vs equivalent rotem parameters was strong with r-values of . and . , respectively. this first clinical experience with the quantra in trauma patients showed that the qstat cartridge detected coagulopathies associated with critical bleeding and may be useful for directing blood product transfusions in these patients. ability to perform testing at poc may provide additional clinical advantage. the objective of the study was to describe the conditions of use of fibryga® g, a new, highly purified, human fibrinogen (hf) recently granted a temporary import authorization for use in congenital and acquired fibrinogen deficiencies in france. observational, non-interventional, non-comparative, retrospective study conducted in french hospital centres using fibryga®. data from patients with fibrinogen deficiency having received fibryga® from december to july were retrieved from their medical files. indications, modalities, efficacy and safety outcomes were recorded. indications encompassed non-surgical bleeding (nsb) either spontaneous or traumatic, including post-partum hemorrhage (pph), bleeding during surgery (sb) or administration to prevent bleeding during planned surgery. treatment success was defined as control of the bleeding or hemoglobin loss < % for bleeding treatment and as absence of major perioperative hemorrhage for pre-surgical prevention. this analysis included patients aged , ± . years and % were male. all presented an acquired fibrinogen deficiency requiring administration of hf. indications were nsb (n= , . %) including ( . %) pph, sb (n= , . %), and prevention of sb (n= ; , %). cardiac surgeries were the main procedures associated with treatment and prevention of sb. mean total doses of fc were . ± . g, . ± . g and . ± . g for nsb, sb and prevention of sb. success rates were . % ( %ci . - . %), . % ( %ci . - %) and . % ( %ci . - %) respectively. for pph, mean dose of hf was . ± . g with a success rate of . % ( %ci . - %). overall, tolerance was good. fibrinogen concentrate fibryga® is mostly used for bleeding control. in one third of patients, hf was administered preventively to avoid bleeding during surgery. use of fibryga® was associated with favourable efficacy outcomes. functional testing for tranexamic acid effect duration using modified viscoelastometry t kammerer , p groene , s sappel , p scheiermann , st schaefer ruhr-university bochum, institute of anaesthesiology, heart and diabetes center nrw, bad oeynhausen, germany; ludwig-maximilans university, department of anaesthesiology, munich, germany critical care , (suppl ):p tranexamic acid (txa) is the gold standard to prevent or treat hyperfibrinolysis [ ] . effective plasma concentrations are still under discussion [ ] . in this prospective, observational trial using modified viscoelastometry we evaluated the time-course of the antifibrinolytic activity of txa in patients undergoing cardiac surgery. methods: patients were included. modified viscoelastometry (tpa-test) was performed and txa-plasma-concentration, plasminogen-activatorinhibitor- (pai- ) and pai-antigen-plasma-concentrations were measured over h. additionally, in vitro dose-effect-curves from blood of healthy volunteers were performed. data presented as median with interquartile range (q /q ). results: txa plasma-concentration was increased compared to baseline (t : μg ml - ) at every time-point with a peak concentration min (t ) after application (p< . ; see fig. a ). lysis was inhibited from min (lysistime tpa-test : p< . ; lysisonsettime tpa-test :p< . ). maximumlysis tpa-test was decreased at t (t : % ( / ) vs. t : % ( / ); p< . ). of note, after h some patients (n= ) had normalized lysis whereas others (n= ) had strong lysis inhibition (ml< %;p< . ) up to h. high and low lysis groups differed regarding kidney function (cystatin c: . mg l - ( . / . ) vs. . mg l - ( . / . );p= . ) and active pai- ( . ng ml - ( . / . ) vs. . ng ml - ( . / . );p= . ). in-vitro, txa concentrations > μg ml - were effective to inhibit fibrinolysis. in our trial, after h there was still completely blocked lysis in patients with moderate renal impairment. this could be critical with respect to postoperative thromboembolic events [ ] . here modified viscoelastometry could be helpful to detect the individual fibrinolytic capacity. introduction: peri-operative coagulopathy correction based on viscoelastic hemostatic assays (vhas) and single-factor coagulation products has changed the paradigm of bleeding management in cardiac surgery [ ] . in a retrospective study, we analysed patients with emergency surgery for thoracic acute aortic dissection (taad), before and after the introduction of fibrinogen concentrate in clinical practice. data were collected from paper and electronic records. the study was approved by the institutional ethical committee. patients were included in the analysis, operated in , before fibrinogen concentrate was approved for human use, and in - . therapy was guided by a rotational thrombo-elastometry (rotem) algorithm. exclusion criteria were non-compliance with the institutional protocol and intra-operative death. we investigated allogeneic blood transfusion (abt), fibrinogen use, peri-operative bleeding (pob), surgical reexploration and post-operative complications (poc). the groups were similar in gender, age, body weight, additive euro-score and aortic cross-clamp time. fresh frozen plasma, cryoprecipitate and red blood cell transfusion were lower in the fibrinogen group, but not platelet transfusion (table). , % of patients in the study group received fibrinogen concentrate and median dose was g (iqr - ). day postoperative chest tube drainage and surgical reexploration were significantly lower. there were no differences in stroke, renal replacement therapy, mechanical ventilation time and icu stay. in patients with taad surgery, rotem-guided algorithms which include fibrinogen concentrate are associated with less (pob), surgical re-exploration and abt. further research is needed to document the role of vhas and concentrated factors in reducing (poc). andexanet alfa (aa, portola pharmaceuticals, san francisco, ca) represents a modified factor xa agent which is approved antidote for apixaban and rivaroxaban. andexanet alfa may also neutralize the anti-xa effects of betrixaban and edoxaban. this study aims to compare the relative neutralization of these four anti-xa agents by andexanet alfa in different matrices. andexanet alfa was diluted at mg/ml. apixaban (a), betrixaban (b), edoxaban (e) and rivaroxaban (r) were diluted in ph . , . m tris buffer (tb), blood bank plasma (bbp) and in % albuminated buffer (ab) at . - . ug/ml. anti-xa activities of all four agents were measured in three systems and the reversibility indices of aa were profiled. the reversibility index (ri ) of anti-xa effects by aa was determined at - ug/ml. each of the four agents produced varying degrees of inhibition of anti-xa at . - . ug/ml, the ic ranged . - . ug/ml in bbp, . - . ug/ml in ab and . - . ug/ml in tb. andexanet alfa produced a concentration dependent reversal of all four anti-xa agents. in the bbp, the ri values for a ( ug/ml), b ( ug/ml), e ( ug/ml) and r ( ug/ml). in the ab, the ri values for a ( ug/ml), b ( ug/ml), e ( ug/ml) and r ( ug/ml). in the tb, the ri values for a ( ug/ml), b ( ug/ml), e (> ug/ml) and r ( ug/ml). each of the four anti-xa agents exhibit varying degrees of matrix independent anti-xa potencies in different systems, the collective order follows edoxaban > apixaban > betrixaban > rivaroxaban. andexanet alfa produced matrix dependent differential neutralization of the anti-xa effects of these agents. individualized dosing of andexanet alfa may be required to obtain desirable clinical results. the diagnostic and prognostic value of thromboelastogram (teg) in sepsis has not been determined. this study aimed to assess whether teg is an early predictor of coagulopathy [ , ] and is associated with mortality in patients with sepsis. in total, patients with sepsis on intensive care unit admission were prospectively evaluated. we measured teg and conventional coagulation tests(ccts)on preadmission and observed for development of , days and , , days respectively. multivariable logistic regression was utilized to determine odds of icu/hospital mortality. the parameter of teg (maximum amplitude, reaction time; ma/r ratio) was calculated to evaluate sepsis-induced coagulopathy. the admission patients were divided into three groupsma/r group(ma/r= - mm/min); ma/r group(ma/r> mm/min)and ma/r group(ma/r< mm/min). in our cohort of patients with severe sepsis, coagulopathy defined by ma/r ratio was associated with increased risk of icu/hospital mortality. introduction: blood sampling for coagulation assessment is often carried out in either arterial or venous samples in the intensive care unit (icu). there is controversy as to the accuracy of this method due to the inherent differences in physicochemical properties as well as the underlying effects of individual diseases in arterial and venous blood. clot microstructure has shown to be a new biomarker (fractal dimension-d f ) which encompasses the effects of diseases in all aspects of the coagulation system [ , ] . in this study, we compared the effect of all these factors in venous and arterial blood to see if there is a difference in the clot microstructure and quality. patients admitted to a tertiary intensive care unit and busy teaching hospital were recruited. arterial and venous blood was sampled from an arterial line and central venous catheter in situ from the same patient. standard markers of coagulation (pt, aptt, fibrinogen, full blood count), rotational thromboelastometry (rotem), whole blood impedance aggregometry and measured clot microstructure (d f ) were measured on both arterial and venous samples. no significant difference was observed in standard laboratory markers, rotem and platelet aggregation between arterial and venous blood. there were no differences in the fractal dimension (d f ) between the arterial and venous blood samples (d f . ± . vs . ± . respectively, p= . ). samples from patients with critical illness give comparable results from either arterial or venous blood despite their underlying pathophysiological process or treatment. this confirms blood for coagulation testing can be taken from arterial or venous blood. clinicians in the emergency setting use a wide range of hemostatic markers to diagnose and monitor disease and treatment. current methods rely on the anticoagulant effect of citrate on whole blood prior to laboratory analysis. despite the well-recognized modulatory effects of citrate on hemostasis, the use of anticoagulated blood has clear analytical advantages, including repeat sampling and storage. however by altering the physiological state of the blood reproducibility and accuracy of the test is affected. recent studies have shown the potential of a novel functional biomarker of clot formation: fractal dimension (d f ), that may give an improved diagnostic accuracy. in this study we assessed the potential of this new biomarker in scientifically measuring the effects of recalcification of citrated samples. methods: healthy volunteers were included. unadulterated and sodium citrate samples of blood were taken from each volunteer. citrated samples were recalcified using ( m cacl ). in the study we compared unadulterated whole blood d f results to citrated d f results and repeated the citrated d f experiments times for each sample over a hour period to ascertain reproducibility. the d f of citrated blood was significantly lower than that of unadulterated blood ( . ± . vs . ± . , p< . ). the results of the citrate samples when tested times over hrs gave a coefficient of variation of . %. for the first time we show that a functional biomarker of clot microstructure, d f , can precisely quantify and measure accurately the direct effect that the addition of the anticoagulant sodium citrate has on whole blood clot microstructure. the study also shows that the test is reproducible and has potential utility as a biomarker of acute disease in the emergency setting in citrated blood. this procedure now needs to be evaluated in a group of acute disease states. in this study, we analyzed the hematological abnormalities of dengue patients by thromboelastography (teg) at initial and -hour of fluid resuscitation. methods: this is a cross-sectional study evaluating teg readings of dengue patients with different severities presenting to the emergency department. laboratory confirmed dengue patient (positive ns antigen or igg/igm) was consecutively sampled. teg readings were taken at presentation and after -hour of fluid resuscitation. twenty dengue patients with varying severity had a median reaction time (r), α -angle, k time, maximum amplitude (ma) and lysis % (ly ) of . min, . ο , . min, . mm and . % respectively. mean fibrinogen was normal before and after fluid infusion. there is a non-significant reduction in ma with prolongation of other teg parameters between different dengue severities. there is a statistically significant reduction of α-angle and ma between pre and post -hour fluid resuscitation (p= . and p= . ). normal fibrinogen with low ma, which signifies a weak clot strength, may indicate either a platelet reduction, platelet dysfunction or both. reduction in ma and α-angle post fluid resuscitation is an alarming finding. this is in contrast with previous teg studies although none of it used normal saline exclusively, studied initial fluid resuscitation in emergency department settings or studied a subject with dengue. a bigger study, especially in severe dengue is needed to validate our findings. agreement between the thromboelastography reaction time parameter using fresh and citrated whole blood during extracorporeal membrane oxygenation with teg® and teg® s m panigada, s de falco, n bottino, p properzi, g grasselli, a pesenti fondazione irccs ca´granda ospedale maggiore policlinico, intensive care unit, milano, italy critical care , (suppl ):p the r (reaction time) parameter of kaolin-activated thromboelastography (teg) may be used to assess the degree of heparinization of blood during ecmo. a teg analysis is usually performed on two types of samples: fresh (f) or citrated-recalcified (c) whole blood. teg® can perform the analysis on c and f whole blood, the new teg® s (haemonetics corp., ma, usa) only on c whole blood. aim of the study was to compare the response of r to heparin using the two types of samples and two teg devices methods: during a three months period at fondazione irccs ca' granda -policlinico of milan, teg was performed (using teg ® and teg s® with and without heparinase, an enzyme that degrades heparin) on consecutive ecmo patients (as part of the gatra study, nct ) and in consecutive non-ecmo patients in whom a teg was requested for clinical purposes. bland altman analysis and lin's concordance correlation coefficient were used to assess agreement results: a total of paired samples were taken ( in-ecmo and off-ecmo). ecmo patients received . ( . - . ) iu/kg/h of heparin. among non-ecmo patients, of them did not receive any dose of heparin, two of them a very low prophylactic dose ( . and . iu/ kg/h, respectively), and one of them . iu/kg/h of heparin. using teg® , r was - . (- . ; . ) min shorter on c compared to f blood in patients receiving heparin (this difference disappeared using heparinase) and only - . (- . ; . ) min shorter in patients notreceiving heparin. r was - . (- . ; . ) min shorter using teg® s (which performs the analysis only on c blood) than teg® on f blood (figure ) . when evaluating the effect of heparin using teg, clinicians should be aware that results obtained using citrated-recalcified or fresh whole blood are not interchangeable. using citrated-recalcified blood to perform teg might lead to underestimation of the effect of heparin trauma patients are at high risk for venous thromboembolism (vte). the east guidelines recommend low molecular weight heparin (lmwh) for vte prevention and antixa monitoring after initiation of the medication or after adjusting doses in certain populations [ ] . studies have shown standard enoxaparin dosing of mg every hours may result in low antixa levels [ ] . this study aims to evaluate the efficacy of a pharmacist-lead protocol for adjusting enoxaparin dosing based on antixa levels in trauma patients. this single center retrospective chart review included adult trauma patients admitted from / / to / / . per protocol, patients with body mass index (bmi) ≤ kg/m were initiated on enoxaparin mg twice daily, and patients with bmi > kg/m were initiated on enoxaparin mg twice daily. peak antixa levels were drawn to hours after at least the third dose of enoxaparin with a goal therapeutic range of . - . iu/ml. the primary objective was time in days to goal peak antixa level. secondary objectives include vte occurrence, bleeding attributed to lmwh, and dosing regimens utilized. subgroups were analyzed based on body mass index (bmi). of patients identified, patients met inclusion criteria. median time to therapeutic antixa level was days (iqr - ). of patients fig. (abstract ) . agreement between teg® s and r teg® on citrated recalcified and fresh whole blood with bmi ≤ kg/m , patients ( . %) were dosed initially per protocol and / patients ( . %) met goal antixa level at first check (table ) . of patients with bmi > kg/m , patients ( . %) were dosed initially per protocol and / patients ( . %) met goal antixa level at first check. our results indicate the protocol is safe due to lack of bleeding attributed to enoxaparin, but less than % of patients achieved goal antixa level at first check. however, despite low rates of achieving goal antixa level, vte rates also remained low. introduction: most patients in the icu are given prophylactic anticoagulation with a fixed dose of mg once daily of enoxaparin (clexane) if cct is normal and mg if cct is low. studies on non icu patients have shown that afxa is below desired range for venous thromboembolism (vte) prevention. in the icu, many factors might influence afxa levels including weight, creatinine clearance (cct), shock and other medication. atxa activity was not yet reported in a big mixed icu population with variable morbidity. our study hypothesis is that enoxaparin is underdosed in most cases and routine afxa activity should be monitored in all icu patients. preventive enoxaparin ( mg qd) was given to all patients unless therapeutic dose was needed or contraindication existed. levels of afxa activity were taken hours after the rd dose. therapeutic vte preventive effect was defined as afxa activity of . - . . patient data was collected from medical files. the study is still ongoing, preliminary results were analyzed for patients. of patients ( %) had afxa activity below normal (subtherapeutic). weight and cct were negatively correlated with afxa activity (figure ). mean weight in the subtherapeutic afxa was significantly higher than the therapeutic group ( . vs. . respectively, p= . ). cct in the subtherapeutic afxa was significantly higher than the therapeutic group ( . vs. . respectively, p= . ). the normal cct group (> ) had significantly more patients with subtherapeutic afxa ( vs , p= . ). in our icu, % of the patients receive insufficient vte prophylaxis. overweight patients and patients with normal cct should probably receive higher enoxaprin dose. afxa activity should be routinely monitored in icu patients. in this study we use a new bedside biomarker to test its ability to measure anticoagulation effects on patients who present with acute first time deep vein thrombosis (dvt). dvt requires oral anticoagulants to prevent progression to potentially fatal pulmonary embolism and recurrence. therapeutic efficacy monitoring of direct oral anticoagulants (doac) including rivaroxaban is problematic as no reliable test is currently available. advances in hemorheological techniques have created a functional coagulation biomarker at the gel point (gp) which allows quantitative assessment of: time to the gel point (t gp ), fractal dimension (d f ) and elasticity (g') [ , ] . the prospective observational cohort study measured t gp , d f , g', standard coagulation and cellular markers in first time dvt patients at three sample points: pre-treatment and approximately and days following mg bd and mg od rivaroxaban respectively. strict inclusion and exclusion criteria applied. results: dvt patients (mean age years [sd± . ]; male, female) and non-dvt patients were well matched for age, gender and co-morbidities. mean t gp on admission was s (sd± . s) and . s (sd± . s) for dvt and non-dvt respectively. doac therapy significantly increased t gp to . s (sd± . s) after days, and subsequently increased to . s (sd± . s) at days as shown in table . d f , g' and standard hemostatic markers all remain within the normal range. conclusions: t gp demonstrates its utility in determining the anticoagulant effect of rivaroxaban. the significant difference in t gp between males and females needs further exploration. localized stasis as a result of transient provoking factors appears not to generate a systemic strength fig. (abstract p ) . correlation of anti factor xa activity with patient cct and weight. anti fxa activity value below . (red line), was considered "non-effective prevention" introduction: trauma remains the leading cause of death all over the world. to better exploit the trauma care system, precise diagnosis of the injury site and prompt control of bleeding are essential. here, we created a nursing protocol for initial medical care for trauma. the aim of this study was to evaluate the impact of protocoled nursing care for trauma on measures of quality performance. this was a retrospective historical control study, consisted of consecutive severe trauma patients (injury severity score > ). people were divided into two groups: protocoled group (from april to march ) and control group (from april to march ). we set the primary endpoint as mortality for bleeding. the secondary endpoints included time allotted from arrival to start of ct scan and surgery, administration rate of several drugs (sedations, painkillers, preoperative antibiotics, and tranexamic acid). for the statistical analysis, continuous variables were expressed as median (interquartile range) and were compared by wilcoxon rank sum tests given a nonnormal distribution of the data. we included patients in the study: in the control group before the introduction of the protocol, in the protocoled group. as a primary endpoint, the mortality for bleeding was similar between two groups ( % in the control group and % in the protocoled group). as a secondary endpoint, the time to ct initiation [group a ( - ) min vs group b ( - ) min; p < . ], and emergency procedure [group a ( - ) min vs group b ( - ); p < . ] were shortened by the protocol introduction. furthermore, the administration rates of sedations, painkillers, preoperative antibiotics, and tranexamic acid were increased in the protocoled group compared with the control group. although the mortality as a patient-oriented outcome was not affected, improved quality of medical care by nursing protocol introduction may be suggested in this analysis. this single-institutional prospective study included patients with uprf who were admitted to the trauma surgical intensive care unit (tsicu) and survived until discharge to home between and . we evaluated the activities of daily living after the discharge using physical and mental component scores of sf- ® and defined physical dysfunction (pd) as physical function (pf-n) score of or less. we divided the patients in the pd (n= ) and control (without pd, n= ) groups and compared the groups. the patients had experienced blunt injuries, including falls ( %) and pedestrian injuries ( %). the mean age was . years (men: . %); the median injury severity score was (interquartile range: - ); and the mean length of tsicu stay was . days. the average period from the injury until the survey was . months. there was no difference between the pd group and the control group in the patient characteristics, fracture type, pelvic fixation, and complications. at the time of the survey, the pd group had significantly more painful complaints than the control group (pd: . %, c: . %, p < . ), and had more physical and mental problems. the sf- ®subscale score showed a significant positive correlation between physical function and body pain, mental health respectively. the percentage of those who were able to return to work was not different in both groups (pd: . %, c: . %). in the multivariate analysis of pd, only age (odds ratio: . , % ci: . - . , p = . ) was relevant. long-term pd was observed in % of patients with uprf. the elderly were particularly prominent, and there was an association between pain and mental health. cells (rbc) this can lead to inhibition of oxygen transport function and development of hypoxia. currently used methods for analyzing the state of rbc either do not have sufficient accuracy or require lengthy analysis and expensive equipment. the use of a simpler and more informative electrochemical approach to assessing the state of rbc is very promising. electrochemical measurements in rbc suspensions (~ • cells / l) were carried out in a special electrochemical cell [ ] in the potentiodynamic mode in the potential range from - . to + . v using the ipc pro mf potentiostat (kronas, russia); optical measurements were performed using an eclipse ts inverted microscope (nikon, japan), a cfi s plan fluor elwd x / . lens (nikon, japan); rbc morphology was recorded in real time using a ds-fi digital camera (nikon, japan). when examining rbc of patients with severe multiple trauma a decrease in the ability of rbc to change their shape during electrochemical exposure was observed, indicating a decrease in deformability, which can lead to a disruption in the oxygen supply to tissues. at the same time, with the stabilization of the patient's condition a restoration of the ability of rbc to change morphology was detected which in turn could have a positive effect on the rheological characteristics of the blood (fig. ) . the results of the analysis of red blood cells using electrochemical changes in their morphology can be used as an additional method for the diagnosis of critical conditions. severe trauma should be treated immediately. whole-body ct (wbct) is widely accepted to improve the accuracy of detecting injuries. however, it remains the problem of time-consuming. therefore, we focused on the scout image taken in advance of wbct. detecting major traumatic injuries from a single scout image would reduce the time to start treatment. a previous study suggested that even specialists could not easily find chest and pelvic injuries using wbct scout image alone. in this study, we aimed to develop and validate deep neural network (dnn) models detecting pneumo/hemothorax and pelvic fracture from wbct scouts. we retrospectively collected anonymous wbct scouts together with their clinical reports at the osaka general medical center between january , , and december , . we excluded incomplete, younger than years old, postoperative, and poorly depicted images. the part of this dataset from january , , until december , , was used for validation and the rest for training dnn models. pneumo/hemothorax detection model and pelvic fracture detection model were trained respectively. accuracy, and areas under the receiver operating characteristic curves (aucs) were used to assess the models. the training dataset for pneumo/hemothorax contained images (mean age years; % female patients), and for pelvic fracture consisted of images ( years; %). the validation dataset for the former contained images ( years; %), and for the latter consisted of images ( years; %). the models achieved % accuracy and an auc of . for detecting pneumo/hemothorax, % and . for pelvic fracture. our results show that dnn models can potentially identify pneumo/ hemothorax and pelvic fracture from wbct scouts. increasing the number of samples, dnn model could accurately detect severe trauma injuries using wbct scout image. clinical information system (cis) is a computer system used in collecting, processing, and presenting data for patient care. it can reduce staff workload and errors; help in monitoring quality of care; track staff's compliance to care bundles; and provide data for research purpose. however, the transition from paper record format to electronic record involves changes in all kind of workflow in icu. therefore, an effective, efficient and evaluative rollout plan was required to minimize the risk that might arise from the new practice. methods: . small groups training were provided. a working station with different case scenarios were set up for practices. . individual tutorials were conducted to clarify questions. emphasis on patient care was always top priority. . contingency plans were available in case of server breakdown and power failure. downtime drills were conducted to prepare the staff in emergency situations. . step-by-step transition from paper record to electronic format was gradually carried out. a plan was discussed among cis team with clear dates and goals. . new items in cis were first reviewed and amended in team meeting until consensus was made; then were promulgated to all staffs during handover before implementation. fig. (abstract p ) . the effect of therapy on the electrochemically induced change in the morphology of red blood cells in patients with combined trauma . staff compliance and outcomes were then monitored; further review and amendment would be possible if necessary. cis roll-out plan was smooth. all staffs were able to integrate cis into the daily routine. the contingency plans were well acknowledged. new items were followed as planned. ongoing enhancement in cis was put forward on nursing orders, handover summary, and integration with inpatient medication order entry (ipmoe) system. with emerging benefits cis brings along, our staff has more time to devote to direct patient care. human input in data interpretation and clinical judgment on top of cis play an irreplaceable role in patient care. the daily request for laboratory tests in intensive care units is a common practice. although common, this strategy is not supported, since more than % of the exams requested with this rationale may be within the normal range [ ] . misconduct based on misleading results, anemia, delirium and unnecessary increase in costs may happen [ ] . we have developed a strategy to reduce laboratory tests without clinical rationale. observational retrospective study, from july to june . the number and type of laboratory orders requested, the epidemiological profile of hospitalized patients, the use of advanced supports, the average length of icu stay and the impact in outcomes such as mortality and hospital discharge at a private tertiary general hospital in the city of rio de janeiro / rj -brazil were analyzed. a strategy was implemented to reduce the request for exams considered unnecessary. approximately , patients underwent icu during this period. the epidemiological profile and severity of patients admitted to the unit were similar to those observed historically. there was a significant reduction (> %) in the request for laboratory tests and there was no negative impact on outcomes such as mortality, mean length of stay and no greater use of invasive resources. over the period evaluated, the estimated savings from reducing the need for unnecessary exams were approximately $ , per year. the rational use of resources in the icu should be increasingly prioritized and the request for routine laboratory tests reviewed. a strategy that avoids such waste, when properly implemented, enables proper care, reducing costs and ensuring quality without compromising safety. evaluating the medication reconciliation errors in icus after implementing a hospital-wide integrated electronic health record system a rosillette, r shulman, y jani university college hospital, centre for medicines optimisation research and education, london, united kingdom critical care , (suppl ):p introduction: medication errors in intensive care unit (icu) are frequent [ ] and can arise from a number of causes including transition of care. our aim was to investigate the impact of an integrated electronic health record system (ehrs) on medication reconciliation (mr) errors occurring at critical steps: during the transition from an icu to the hospital ward and from the ward to hospital discharge. the objective was to examine the influence of icu admission on long-term medication. we performed a monocentric study in icus of a university-affiliated hospital using drug chart and medical notes review to identify mr errors before, during and after icu admission. data were collected retrospectively from ehrs for consecutive patients discharged from the icu between june- july , and who were newly initiated on specific drugs of interest. results: drugs of interest were initiated in icu. many of these were continued after hospital discharge as shown in table . there was appropriate discontinuation of all the antipsychotics newly initiated in icu. other than anticoagulants, there was no reason documented for continuation of the initiated drugs. the planned durations were documented more often after hospital discharge than icu discharge for the following drug classes (% of patients with a plan after icu discharge to the ward; % after home discharge): antibiotics ( . %; . %), and steroids ( . %; . %), but less so for analgesics ( . %; . %), insomnia ( . %; . %), and gastroprotective drugs ( . %; . %). our study has shown that medications initiated in the icu can be inadvertently continued at icu and hospital discharge due to failure in documenting indication or duration. systems are required to deprescribe icu only drugs at discharge or communicate a plan for ongoing treatment. introduction: the surviving sepsis campaign advocates the use of care bundles to guide the management of sepsis and septic shock [ ] . our study aim was to assess compliance with a locally introduced sepsis pathway and to review intensive care unit admission outcomes. we carried out a prospective audit of patients admitted to the icu at royal surrey county hospital with a diagnosis of sepsis between / / and / / , assessing compliance with local sepsis bundle delivery, outcome of icu admission and degree of associated organ dysfunction. results: patients were identified, male ( . %), with a mean age of . ( - ). mean st hour sofa score on icu was . ( - ). % of patients required vasopressors, with % requiring noradrenaline > . mcg/kg/min, and % requiring an additional vasopressor/ inotrope. % required niv, % invasive ventilation and % rrt. icu mortality was %, in-hospital mortality %, mean icu stay days ( - ), and mean length of hospital stay days . in the presence of septic shock mortality was % with post-resuscitation lactate > , versus % in patients with no vasopressor requirement or lactate < (p< . ). the sepsis bundle was delivered in one hour to patients ( %). where the bundle wasn't completed, antibiotics were delayed in % of cases and blood cultures weren't taken in %. where the bundle was fully delivered, unit mortality was % vs. % where it was not (p< . ), but there was no significant difference in hospital mortality ( % vs. %, p> . ) or rates of vasopressor requirement, niv, ippv or rrt. there is room for improvement in timely delivery of the sepsis bundle in our hospital and various measures are being instituted. though there was no significant difference in hospital mortality, icu mortality was significantly lower in patients when the bundle was fully delivered. surviving sepsis campaign recommends h and h sepsis resuscitation bundle for sepsis. the study was done to assess the feasibility of the guideline and the compliance to sepsis- recommendations at an emergency department. prospective interventional study was conducted during one year. were involved in the study all sepsis cases with a qsofa ≥ . were assessed a composite of six components (measurement of serum lactate, obtaining blood culture before antibiotic administration and provision of broad-spectrum antibiotic before the end of h and provision of fluid bolus in hypotension, attainment of target central venous pressure assessed by cardiac ultrasonography, target lactate to normal level before the end of h ). time base line was the first medical contact at triage zone. secondary outcomes of study were the mortality rate and length of stay at intensive care unit (icu). were involved in the study, patients (mean age ± years, sex ration , ). pulmonary infections were the main cause of sepsis ( %) and urinary tracts infections ( %). at h components were achieved in % of cases [lactates ( %), blood culture ( %) and provision of antibiotics ( %)]. at h components were executed in % of cases (fluid provision achievement in %, ultrasonography assessment in % and normal lactate target achieved in %) (figure ). the reliability-adjusted rate for completion of the hours and hours bundle was at %. patients compliant to composite bundle got the mortality benefit (odds ratios = . , % [confidence interval, . - . ]). the study, however, did not show any benefits of mean intensive care unit (icu) length of stay. faisability of - h bundle ratio was at %. it has shown a significant improvement in adaptation and mortality benefit without reducing mean hospital/icu length of stay. more adapted procedures are needed to improve results targeting full compliance of patients to the - h bundle sepsis management. patterns and outcome of critical care admissions with sepsis in a resource limited setting m edirisooriya maddumage , y gunasekara , d priyankara national hospital of sri lanka, medical intensive care unit, colombo , sri lanka; sri jayawardenepura general hospital, department of critical care, nugegoda, sri lanka critical care , (suppl ):p introduction: paucity of epidemiological data is a major barrier in expansion of critical care services, especially in resource limited settings. we evaluated the patterns and the outcome of critically ill patients with sepsis admitted to a level medical intensive care unit in sri lanka. a retrospective cohort study was performed to describe the characteristics and outcome of patients with sepsis, admitted to a medical intensive care unit. sepsis is defined according to sepsis definition. we examined critically ill patients admitted over a period of months. sepsis was the commonest presentation, accounted for . % of all admissions. mean age was . ± . years. septic shock was present in . % on admission. pneumonia ( . %) was the commonest cause, while leptospirosis ( . %) and meningoencephalitis ( . %) accounted for fig. (abstract p ) . sepsis - h bundle components (% of goals achievment) second and third commonest causes of sepsis respectively. the sofa score on admission ( . ± . vs . ± . , p< . ), occurrence of aki ( % vs . %, p< . ) and the length of icu stay ( . days vs . days, p < . ), were significantly higher in sepsis than in patients without sepsis. icu mortality in sepsis (n= ) did not show a significant difference to nortality (n= ) in those without sepsis ( % vs %, p= . ). patients with leptospirosis had a mean sofa score of . , however the mortality ( . % vs %, p = . ) was similar to others with sepsis. in contrast, mortality related to sepsis was significantly high ( %, p< . ) in the packground of immunosuppression (n= ). respiratory failure secondary to pneumonia was the commonest cause of critical care admission with sepsis. sepsis related icu mortality was high in the background of immunosuppression. introduction: training in placement, and the subsequent safe confirmation of position, of a nasogastric (ng) tube, relies on clinicians completing an e-learning module at our trust. feeding through an incorrectly placed ng tube is a 'never event,' associated with significant morbidity and mortality [ ] . analysis of these incidents reveal that the misinterpretation of chest radiographs, by medical staff, who had not received competency-based training, is the most frequent cause [ ] . e-learning has revolutionized the delivery of medical education [ ] , however, there are barriers to its use [ ] . we hypothesized that, by taking e-learning content, and delivering it face-to-face, we would improve training rates, and thus patient safety. a questionnaire was completed by critical care doctors, concerning their knowledge of the existence of the e-learning module, whether they had completed formal training in ng tube placement, and how confident they were, on confirming correct positioning, using a point likert scale. all clinicians underwent training in the interpretation of ng placement, using chest radiographs. after the session they were asked to re-appraise how confident they felt. results were compared using paired t tests. confidence improved in all, rising from a pre-test average score of . (sd= . ), to post-session . (sd= . ), p=< . . prior to the intervention, % of the doctors were aware of the trust guidelines, but only % had completed the training. after the session, % were aware of the guidelines, and % had completed the training (figure ) . conclusions: e-learning is a useful tool, but has its limitations. by using course content, delivered with more traditional learning methods, we im-proved the number of appropriately trained clinicians, and thus the safe use of ng tubes in our unit. a systematic review of anticoagulation strategies for patients with atrial fibrillation in critical care a nelson, b johnston, a waite, i welters, g lemma university of liverpool, liverpool, united kingdom critical care , (suppl ):p there is a paucity of data assessing the impact on clinical outcomes of anticoagulation strategies for atrial fibrillation (af) in the critical care population. this review aims to assess the existing literature to evaluate the effectiveness of anticoagulation strategies used in critical care for atrial fibrillation. only studies contained analysable data. anticoagulated patients had a lower mortality at days and days post admission to critical care, however there was an increased incidence of major bleeding events compared to the non-anticoagulated population. thromboembolic events were comparable in both cohorts. data from current literature is scarce and inferences regarding the effectiveness of anticoagulation in patients in critical care with af requires further investigation and research. every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last twenty years, however, % of patients admitted to an icu will die during their admission [ ] . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover [ ] . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction [ ] . a checklist was created to review the information shared and to score the handover. this checklist was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing handovers on the icu. there is a notable discrepancy in the quality of handovers of new patients ( figure ). this is true of handovers between doctors, nurses and a combination of the two. it is also true of all staff grades. whilst a doctor may have reviewed the patient prior to their arrival, % (n= ) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight ( %, n= ), their height ( %, n= ), whether the patient has previously been admitted to an icu ( %, n= ) and whether the patient has any allergies ( %, n= ). the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. post intensive care syndrome-family (pics-f) describes new or worsening psychological distress in family and caregivers after critical illness but remains poorly studied within specialist groups [ ] . we aim to define the degree of pics-f within our tertiary referral cardiothoracic centre and map change over the course of months. caregivers attended a -week multi-professional clinic alongside patients. peer support was facilitated through a café area and a caregiver group psychology session was offered with individual appointments if required. caregiver surveys were completed including: caregiver strain index; hospital anxiety and depression scale (hads); and insomnia severity index. patients also completed hads questionnaires. repeat surveys were completed at and months. results: over cohorts, caregivers attended, of which were spouses ( %), children ( %), and others ( %), with caregivers completing surveys at months. patients' median apache score was (iqr - . ) and median icu length of stay was days (iqr - . ). most admissions were from scheduled operations ( %). severe caregiver strain was present in / ( %) with changes to personal plans ( %) the most common sub category. hads demonstrated caregivers ( %) with anxiety and ( %) with depression. caregiver anxiety exceded that of patients', only reaching fig. (abstract p ) . each handover was scored according to the information accurately given to icu staff similar levels at months, while depression remained static ( figure ). median number of nights with 'bothered' sleep was (iqr - . ) and % of caregivers expressed problems with sleep. conclusions: significant psychological morbidity in caregivers from our tertiary cardiothoracic centre is in keeping with the general icu population [ ] . caregiver strain was reduced suggesting higher levels of resilience. future work should address mental wellbeing, particularly anxiety, to minimise the effects of pics-f. burnout syndrome is an illness that has increasingly affected health professionals. it is characterized by great emotional stress, physical and mental exhaustion and depersonalization of the individual. more serious cases can lead to job loss or even suicide. the described work identifies the burnout level of the multidisciplinary team through a specific questionnaireburnout syndrome is an illness that has increasingly affected health professionals. it is characterized by great emotional stress, physical and mental exhaustion and depersonalization of the individual. more serious cases can lead to job loss or even suicide. the described work identifies the burnout level of the multidisciplinary team through a specific questionnaire methods: application of a questionnaire suitable for the multidisciplinary group in november . the same was answered by professionals among physicians and nursing team. there was no identification of employees. after analysis of the results it is observed that % of the group presents initial burnout, % with the syndrome installed and about % with characteristics of greater severity. main factors found were: mental and physical exhaustion during the work day, the level of responsibility existing in the activity and the perception of disproportionate remuneration by work performed. all interviewees presented some degree of burnout or high risk to develop it. the most severe cases should be traced through occupational medicine and anti-stress measures with reorganization of work performance should be discussed in order to reduce the prevalence of this syndrome. introduction: burnout affecting the psychological and physical state of healthcare workers is recognized in the last years. burnout has been shown to affect the quality of care. whilst some risk factors have been identified, there are gaps within the literature related to mental health and burnout. the aim of this study is to measure levels of burnout across icu units in the metropolitan setting. to determine the level of burnout we used surveys, the maslach burnout inventory human services survey (mbi-hss) and the centre for epidemiologic studies depression scale (ces-d). with the mbi-hss we analysed different variables of burnout; exhaustion, cynicism and emotional exhaustion. basic demographic data and information regarding workout schedules were collected. we studied prevalence and contributing risk factors using and analysing the outcomes of the self-scoring questionnaires. analysis was performed using descriptive statistical analysis. there were respondents, % scored the threshold for depressive symptoms on the ces-d depression scale. interestingly, % (ci . - . %) of those meeting the score for depressive symptoms identified as having frequent restless sleep compared with % ( . - . %) from those not meeting. gender did not affect depressive symptoms % of females and % of males met the threshold. with the mbi-hss for exhaustion the mean was . (sd . ) which is a high level of exhaustion, the second variable cynicism the mean score was . (sd . ), which was considered high. the final variable was emotional exhaustion the mean was . (sd . ), this is considered moderate levels of emotional exhaustion. fig. (abstract p ) . hospital anxiety and depression scale (hads) scores for patients and caregivers at baseline, months, and months there was high prevalence of burnout in icu in all different categories as well as depressive symptoms. age and gender had no affect on burnout. interestingly, we identified that sleep and shift variables were linked to increased burnout. following the implementation of a fully integrated ehrs on march at our university-affiliated hospital we conducted a prospective study in icus by analysing pharmacists' contributions during data collection periods of days at , , and weeks post implementation. a pharmacists' contribution was defined as contacting the physician to make a recommendation in a change of therapy/ monitoring [ ] . the types of contribution were: a medication errorrectification of an error in the medication process; an optimizationproactive contribution that sought to enhance patient care, and a consult -reactive intervention in response to a request. a panel of experts composed of a senior pharmacist, a consultant, a nurse, and a pharmacy student assessed the impact of each contribution, scoring low impact, moderate impact or high impact. there were pharmacist contributions recorded in the periods. of these, ( . %) were medication errors, ( . %) were optimizations, and ( . %) was a consult ( table ) . % of the contributions were assessed as having medium impact, % as high impact and % as low impact. in general, the consultant assessed fewer contributions as having high impact compared to other members of the panel, with contributions assessed as high impact by the consultant versus by the senior pharmacist. implementing an ehrs in combination with contributions of clinical pharmacists can prevent medication related issues. interestingly the types of incident did not change over time. introduction: most icu's are noisy and may adversely affect patients outcomes and staff performance [ ] . who reports that the noise level in hospitals should not exceed db at daylight and db at night. the aim of this study is to evaluate the noise levels in intensive care unit, to apply awareness training to intensive care staff in terms of noise and to compare the noise levels before and after education. noise measurement areas are separated into points including patient bedsides, nurse desk, staff desk, wareroom, corridor and entrance of intensive care unite. measurements were performed times per day. after day, awareness training were given to staff in terms of harmful effects of noise. after the training, noise measurements were repeated during days. after total days the measurements were terminated. noise was measured with incubator analyzer (fluke model: bio-tek serial no: ). the mean noise values before and after the training were not statistically different from the mean average noise values (p> . ). when the time of measurement were compared, the noise levels were higher between - hours to other measurements before and after the training statistically (p= . ). seventeen different noise measurement areas were compared in terms of noise level, there was no statistically significant difference (p> . ). the differences were examined at the same hours between before and after training. contrary to expectations, noise levels were found to be higher after training statistically (p< . ). all of noise measurements were higher than the threshold values that who recommended. increased noise levels in critical care units may lead to harmful health effects for both patients and staff. our results suggest that much noise in the icu is largely attributable to environmental factors and behavior modifications due to education have not a meaningful effect. critical care medicine has focused on continuous, multidisciplinary care for patients with organ insufficiency in the face of lifethreatening illness. despite significant resource limitation low income countries carry a huge burden of critical illness. available data is insufficient to clearly show the burden and outcomes of intensive care units in these developing countries [ ] . the objective of our study is to evaluate the morbidity and outcomes of patients admitted to the intensive care unit of a tertiary university hospital in hawassa, ethiopia. this was a prospective observational study. data was registered and analysed starting from patient admission to discharge during a month period beginning september . data regarding demographics, sources of admission, diagnosis, length-of-stay and outcomes were analysed. the total number of patients admitted to the icu was , with patients dying over a one year period. the highest admission was from emergency medical unit, % and the lowest source was from pediatrics department, %. out of these, . % were males. the mean age was years ( - ). the most frequent aetiologies of morbidity in the admitted patients were traumatic brain injury ( . %), acute respiratory distress syndrome ( . %) and seizure disorder ( %). average median length of stay was . days (interquartile range: . - . ). the overall mortality rate was . %. the top four causes of death in the icu were respiratory illness at % followed by sepsis with multiorgan failure at %, trauma ( %) and central nervous system infection ( %). infection morbidity and mortality remains very high and needs institution of aggressive preventive strategies. the increase in frequency of trauma patients need to receive due attention. sepsis causes a high number of deaths, though overtaken by respiratory illnesses. improving the overall system of icu may achieve better outcomes in resource limited countries. introduction: icu mortality has been widely studied in the literature in relation to outcome index that primarily value organic failure [ ] . however, early mortality, in the first hours of admission has been little documented in the literature. the aim of this study is to analyze factors related to early mortality in icu. retrospective study at a second-level hospital. time of study was months. patients who died in icu were included, patients were classified according timing of dead, including those who died within the first hours of icu admission. the variables analyzed were age, sex, comorbidity, charlson index, apache ii, need for supportive treatments, more frequent admission diagnosis, origin and support treatment limitation decisions. the statistical study was carried out using the spss statistical program. patients were included during the study period, ( . %) died within the first hours of admission. no differences in the needs of support treatments were observed, more than % of patients received mechanical ventilation and vasoactive therapies. table shows characteristics of patients. half of icu deaths occur within the first hours of admission. severity at icu admisison was the main factor related with early mortality. severe stroke and coronary disease were the most frequent causes of early deaths in icu. in august the royal college of anaesthetists published guidelines on care of the critically ill woman in childbirth and enhanced maternal care [ ] . approximately babies are born across the area covered by leicester university hospitals that includes two large maternity units and is part of the uk ecmo network. this audit sets out to assess current practice and form a basis for future planning, which will likely be representative to most major obstetric centres. a retrospective audit of all patients admitted to 'intensive care units' in leicester over a month period following publication of the guidelines. the focus was on patients admitted to general adult intensive care and excludes all patients cared for in 'enhanced obstetric care' units. simple standards were proposed relating to accessibility, resuscitation, follow up and multi-disciplinary learning. in total women were identified with a broad range of diagnosis. the intensive care services are split across hospitals and we found this led to a number of problems. the presence of trained staff to resuscitate a newborn were easily accessible, no steps to provide necessary equipment pre-emptively were present in any centre. none of our critical care units had a plan for perimortem section. on-going reviews by the obstetric and midwifery teams were very variable. contact with the infant and breastfeeding support was also poor. despite the large number of deliveries significant work needs to be done in order to come in line with the new national guidelines for critically ill woman in childbirth. clearly defined pathways around escalation of care, resuscitation of both the mother and baby, integrating care of the mother and the infant in the first few days of life, and multidisciplinary learning events are being produced de novo in response to these guidelines, some of which will be illustrated in the associated poster. interprofessional collaboration scale [ ] . data were analyzed with ibm spss . results: it was found that cooperative attitudes with an average score of to are considered to be of average significance. interprofessional cooperation at an average score of , states that the level of cooperation is high and the quality of working life averages to , suggesting that it is very good. as far as professional satisfaction is concerned, nurses are happy, content and satisfied with their work, despite workload and burnout conclusions: interprofessional cooperation at the icu of the general hospital of larissa is high, but satisfaction from wages, resources, working environment and conditions is low. in addition, the results showed that improvements in hospital communication between staff, has a positive impact on the quality of professional life (table ) . contrasting with previous reports, decreased admissions per unit population in older and oldest age groups, and those with high comorbidity, suggest resource constraints may have influenced admission discussion and decision-making over the -year study period in wales. further investigation is warranted. icu discharge into weekends and public holidays: an observational study of mortality n mawhood, t campbell, s hollis-smith, k rooney bristol royal infirmary, general intensive care unit, bristol, united kingdom critical care , (suppl ):p introduction: up to a third of in-hospital deaths in icu patients occurs following ward stepdown [ ] . discharge time seems to be associated with in-hospital prognosis, but meta-analyses have not shown a difference in weekday compared to weekend discharge [ , ] . however, papers that examined discharge 'into' out-of-hours days, particularly on fridays, have found differences [ ] . our aim was to assess whether discharge from icu 'into' out-of-hours (ooh -weekends and public holidays) is associated with in-hospital mortality or re-admission to icu, and whether these patients were seen on the wards ooh by medical staff. all adults discharged from the general icu to a ward at the bristol royal infirmary in december - were included. in-hospital mortality rates were assessed for each day, with 'into weekdays' defined as sunday to thursday and 'into ooh' friday, saturday and the day before a public holiday. a subset of patients with data on readmission rate to icu was also examined. all available notes from patients discharged into ooh in were reviewed. the study included patients with a subset of with readmission data. sets of notes were reviewed from patients discharged into ooh (figure ). the in-hospital mortality was significantly higher in patients discharged into ooh ( . % vs . %, p= . ). within the subset, ooh was associated with in-hospital mortality or readmission to icu ( . % vs . %, p= . ), though readmission rate alone was not ( . % vs %, p= . ). of patients discharged into ooh, once on a ward % were reviewed by a specialty doctor but . % were not seen. this is the first study to examine icu discharge 'into' ooh days including public holidays. we found increased hospital mortality in ooh, similar to other studies [ ] . up to a fifth of high-risk icu stepdown patients were not reviewed by a doctor on ooh days. exploring the experiences of potential donors' family members (fm) in a follow up clinic is crucial to analyze the effects of organ procurement (op) on the bereavement process, to gain insight on the reasons of family refusals (fr), and to improve family care during op. a mixed-method study involving fm at and months after patients' death was developed and approved by local ethics committee. fm of potential donors after brain (dbd) and cardiac death (dcd) treated in careggi teaching hospital, florence (italy) were eligible if adult and consenting. invitation letters were sent to the entitled months after death and those who actively responded were involved in an encounter with a multidisciplinary group including a clinical psychologist, two nurses and two cultural anthropologists with expertise in op. organ replacement procedures such as ecmo (extracorporeal membrane oxygenation), lvad (left ventricular assist device) and dialysis are routinely used to treat multi-organ failure (mov). globally transplantation programs struggle with increasing organ shortage. patients (pts) with mov are a potential source for procurement. however, outcome data after kidney transplantation (ktx) from such donors are sparse. we retrospectively studied the cadaveric ktx at the charité berlin in and identified donors with ongoing organ replacement procedures. donor and recipient risk factors were assessed. overall patient and graft outcomes were analyzed at months post-transplant. a total of kidneys were transplanted. we identified ktx from donors with mov ( following cardio-pulmonary resuscitation, with acute renal failure - on dialysis) (figure ). in donors, a venoarterial ecmo was implanted during ecls-resuscitation. one donor needed a veno-venous ecmo due to ards, and donor had a lvad implanted due to cardiac failure. the donor age was ± . years (yrs). in addition, donors had at least one cardiac risk factor. the kidney donor risk index averaged . (sd ± . ) and s-creatinine prior to ktx was . (sd ± . one way to expand the potential donor pool is donation after circulatory death (dcd), and a strategy to reduce the complications related to the ischemic time is the use of normothermic regional perfusion (nrp) with extracorporeal membranous oxygenation (ecmo) [ , ] . we compare the use of standard nrp with an effective adsorption system inflammatory mediators (cytosorb®) in the regional normothermic reperfusion phase via regional ecmo, that involves a reduction in cellular oxidative damage, assessed as a reduction in levels of proinflammatory substances. we report a case series of dcd-maastricht iiia category donors, treated in ecmo with nrp, to maintain circulation before organ retrieval, in association with cytosorb® in patients. during perfusion, from starting nrp (t ), blood samples are collected times, every minutes (t , t , t ). during treatment with cytosorb®, lactate levels progressively decrease, ast and alt increase less than without cytosorb®, as sign of improvement in organs perfusion ( figure ). nrp with cytosorb® might help to successfully limit irreversible organ damages and improve transplantation outcome [ ] . development and implementation of uniform guidelines will be necessary to guarantee the clinical use of these donor pools. introduction: shock is a common complication of critical illness in patients in intensive care units (icus), who are undergoing major surgery. this condition is the most common cause of death in postsurgical icus. nowadays, there are different icu scoring systems for predicting the likelihood of mortality, such as apache or sofa. nevertheless, they are used rarely because they also depend on the reliability and predictions of physicians. in these sense, gene expression signatures can be used to evaluate the survival of patients with postsurgical shock. methods: mrna levels in the discovery cohort were evaluated by microarray to select the most differentially expressed genes (degs) between groups of those that survived and did not survive days after their operation. selected degs were evaluated by quantitative real time polymerase chain reactions (qpcr) for the validation cohort to determine the reliability of the expression data and compare their predictive capacity to that of established risk scales. introduction: this study evaluates the prognostic ability of frailty and comorbidity scores in patients with septic shock. the -day mortality rate of individual medical conditions are also compared. the burden of comorbid illness and frailty is increasing in the critical care patient population [ ] . outcomes from septic shock in patients with chronic ill-health is poorly understood. interstitial lung disease is a group of diseases associated with poor prognosis in the intensive care unit despite major improvement in respiratory care in the last decade. the aim of our study is to assess factors associated with hospital mortality in interstitial lung disease patients admitted in the intensive care unit and to investigate the long-term outcome of these patients. we performed a retrospective study in an intensive care unit of teaching hospital highly specialized in interstitial lung disease management between and . a total of interstitial lung disease patients were admitted in the intensive care unit during the study period. overall hospital mortality was %. two years after intensive care unit admission, / patients were still alive ( %). one hundred eight patients ( %) required invasive mechanical ventilation of whom % died in the hospital (figure ). acute exacerbation of interstitial lung disease was associated with hospital mortality (or= . [ . - . ] ), especially in case of acute exacerbation of idiopathic pulmonary fibrosis. multiorgan failure (invasive mechanical ventilation with vasopressor infusion and/or renal replacement therapy) was associated with very high hospital mortality ( / ; %). survival after intensive care unit stay of patients with interstitial lung disease is good enough for not denying them from invasive mechanical ventilation, except in case of acute exacerbation for idiopathic pulmonary fibrosis patients. if urgent lung transplantation or extracorporeal membrane oxygenation are ruled out, multiorgan failure should lead to consider withholding or withdrawal life support therapies. Αgi is a malfunctioning of the gi tract in icu patients associated with prolonged mechanical ventilation, enteral feeding failure and high mortality risk. the wgap of esicm proposed a grading system for agi. four grades of severity were identified: agi grade i, a selflimiting condition; agi grade ii (gi dysfunction), interventions are required to restore gi function; agi grade iii (gi failure); agi grade iv, gi failure that is immediately life threatening. the aim was to evaluate the feasibility of using agi grades i and ii as predictors of malnutrition and -year mortality in critically ill patients methods: single-center retrospective cohort study in a tertiary university hospital ( - ). agi grade iii and iv patients were excluded. Αnthropometric data, gi symptoms (vomiting,diarrhea), feeding intolerance, gastric residual volumes and abdominal hypertension were recorded. daily prescribed caloric intake was calculated using a standard protocol and daily achievement of caloric intake was recorded. mnutric score was calculated for all patients. a score ≤ was used to diagnose malnutrition. patients ( % men, mean age years) that stayed in the icu for > hours were included in the study. % were at high nutritional risk. -year mortality was %. the prevalence of agi ii was %. age, gender, bmi, mortality and energy intake did not differ significantly between patients with agi ii and those with agi i (table ) . logistic the study aimed to assess the effects of icu admission on frailty and activities of daily living in the ≥ 's population at -months. a prospective observational study with data used as a subset of the vip- trial [ ] . research ethics committee approval from the mater misercordiae university hospital (mmuh). inclusion criteria -≥ years of age and acute admission to icu from may to july . data collected on consecutive patients. frailty and activities of daily living (adl) were assessed using the clinical frailty score (cfs) and the katz index of independence in activities of daily living (katz). results: csf pre-admission frailty was present in % of patients, increasing to % at months ( figure ). % of survivors at -months had a cfs score increase by ≥ point. pre-frail and frail cfs patients suffered an average -point deterioration in their instrumental activities of daily living (iadl). % of katz patients were fully functional preadmission, deteriorating to % at months. % of patients declined by adl at months. % of the deceased were deemed fully functional initially. we demonstrate an association between an icu admission event and enduring functional decline at months. icu admission resulted in patients acquiring on average . new iadl limitations despite their initial cfs. this is echoed in a study by iwasyna et al. who also showed similar deteriorations in iadl and cognitive impairment [ ] . katz benefits may be best used in describing functional decline. % of patients developed at least one new limitation. however, the cfs takes into account iadl's and thus may be more sensitive in predicting the functional outcomes of an icu event at months. frailty: an independent factor in predicting length of stay for critically ill t chandler, r sarkar, a bowman, p hayden medway maritime hospital, critical care, gillingham, united kingdom critical care , (suppl ):p frailty has attracted attention in the healthcare community in recent years, as it is associated with worse outcomes and increased healthcare costs [ ] . our objective was to study the impact of frailty as recorded by clinical frailty scale(cfs) to prospectively evaluate the effect of frailty on hospital length of stay (los). a retrospective analysis of consecutively admitted critical care (cc) patients' data (jan' -oct' ) was performed. electronic health records were used to collect demographics, cfs and clinical outcomes. statistical analysis was performed using stata. students t-test, simple and multiple (adjusted for age, disease severity/icnarc score) linear regression were used for comparison between groups and to see group effect. we excluded extreme outliers (los> days; n= ). frailty was defined as cfs> . out of the patients (male %), ( %) were emergency admissions, the rest elective (table ) . ( %) were non-frail. the mean los were days (d) ± and d± (p< . ) in the frail and non-frail patients respectively. for emergency patients, los were d(± ) and d(± ) for the groups, (p< . ). for elective patients; los were d(± ) and los d(± ), (p= . ) for frail and nonfrail respectively. after adjusting, los was significantly higher in frail patients by days ( %ci , ; p< . ), by days ( %ci , ; p= . ) and by days ( %ci , ; p< . ) for total cohort, elective and emergency admissions respectively. the los was days higher in frail than non-frail (p< . ) for cc survivors. frailty was associated with significantly increased los in this cohort, independent of age and illness severity. hospital capacity planning should take this into consideration when modelling bed allocation fig. (abstract p ) . clinical frailty score -month trend robust clinical governance requires analysis of patient outcomes during an icu admission [ ] . on one adult icu weekly mortality meetings are used for this purpose and aid multidisciplinary reflections on individual patient deaths. however, such reviews run the risk of being subjective and fail to acknowledge themes which may relate to preceding or subsequent deaths. this paper describes a new mortality review process in which: a) reviews are structured using the structured judgement review (sjr) framework [ ] ; and b) themes are generated over an extended period of time to create longitudinal learning from death. the sjr framework has been developed by nhs improvement for the new medical examiner role, looking at inpatient deaths. we adapted this to better suit the icu creating a novel review structure. this involves explicit judgement comments being recorded, and the use of a scoring system to analyse the quality of care during the patient's stay with a focus on elements of care delivered on the icu. tabulation of this information allows analysis over time, identifying trends across all patients, and in specific subgroups. this framework has been rolled out at the st george's cardiothoracic icu weekly mortality meetings. themes that have emerged include parent team ownership, delayed palliative care referrals and inadequate documentation of mental capacity. this will continue as part of a three-month trial and following review of this trial may be extended to other critical care units in the trust. this system allows greater insight into patient deaths in a longitudinal fashion and facilitates local identification of problems at an early stage in a way that is not possible within the traditional mortality review format. the nature of the process means that key areas for change can be identified as a routine part of the clinical week. [ ] . in this study, we evaluated three distinct machine-learning methods for predicting possible patient deterioration after surgery. the data was collected retrospectively from the catharina hospital in eindhoven. this dataset contained all the surgeries conducted in the hospital from up to . the variables in this dataset were tested on their ability to differentiate between patients with a normal recovery versus patients with an unplanned icu admission after being admitted to the ward. the dataset contained variables related to either the preoperative screening, surgery or recovery room. all variables were tested for statistical significance using a univariate logistic regression (lr), from which a subset of statistically significant (p< . ) variables was created. these variables were used to train three different types of models, namely, the lr, support vector machine (svm) and bayesian network (bn). the network structure of the bn was designed using expert knowledge and the probabilities were inferred using the data. the three models were validated using five-fold cross-validation, resulting in the following areas under the receiver operating characteristic curve: . ( . - . ) for lr, . ( . - . ) for svm and . ( . - . ) for bn (fig. ) . the results indicate that machine learning is a promising tool for early prediction of patient deterioration. the bn was included because it permits incorporating clinical domain knowledge into the learning process. however, its performance resulted inferior to the lr and svm. in future work, we will investigate alternative domainaware methods, and compare the performance with that of the clinical experts. intensive care unit (icu) admission decisions of patients with a malignancy can be difficult as clinicians have concerns about unfavourable outcomes, such as mortality [ ] . a diagnosis of a malignancy is associated with an almost -fold increased likelihood of refusal of icu admission [ ] . recent large long-term mortality studies of patients with a malignancy admitted to the icu are scarce. therefore, our aim was to compare mortality of patients with either a hematological or a solid malignancy to the general icu population, all with an unplanned icu admission. all adult patients registered in a national intensive care evaluation registry with an unplanned icu admission from to were included. subsequently, we divided these patients into cohorts: cohort (all patients with a hematological malignancy), cohort (all patients with a solid malignancy), and cohort (a general icu population without malignancy). as primary outcome, we used -year mortality, and as secondary outcome, icu and hospital mortality. we included , ( . %) patients in cohort , , ( . %) patients in cohort and , ( . %) in cohort ( table ). the year mortality of patients of cohort , , and was . %, . % and . %, respectively (p< . ). age, comorbidities, organ failure, and type of admission (i.e. surgical or medical) were positively associated with -year mortality in all cohorts (p < . ). one-year mortality is higher in both patients with a hematological malignancy and patients with a solid malignancy compared to the general icu population. in addition, several factors were positively associated with -year mortality, i.e., age, comorbidities, medical icu admission, and organ failure. future research should focus on predictive modelling in order to identify patients with a malignancy that may benefit from icu admission. introduction: drug abuse is associated with immunosuppression in multiple mechanisms. despite that, the only study retrospectively reviewing drug abusers in the icu demonstrated less infections and better outcomes. we compared matched patient populations in order to fully understand whether drug abuse is a risk factor for infection and a predictor of poorer prognosis as is perceived by most physicians. we hypothesized that the drug abusers admitted to the icu will fare as good as or better than non-abuser icu patient populations. methods: this is a prospective study done between the years - on the entire patient population of the detroit medical center. after the drug abuse population was identified, controls were matched according to age and admission icu units. patients charts were reviewed and data regarding baseline demographics, infectious complication and outcome was extracted. data was retrospectively collected for drug abusers and matched controls. comorbidities and hospital admission diagnosis were significantly different between the two groups. disease severity scores were significantly higher in the drug abuser's patient group (dapg) on admission and during the icu stay. dapg had significantly more organ failure: more need for ventilation ( . % vs . % in the dapg (p< . )), more ards ( % vs . %, p= . ), more renal failure ( % vs . %, p= . ) and more need for renal replacement therapy ( . % vs . %, p< . ) .they had longer hospital length of stay (los). there was no difference in icu or hospital mortality. multivariable modeling did not find drug abuse to be an independent risk factor for hospital mortality, icu mortality (hosp: or = . , p = . ; icu: or= . , pp = . ), but was a risk factor for a longer hospital los (me= . , p < . ). drug abuse is not an independent risk factor for mortality or icu los. drug abusers should be evaluated like other patients based on baseline comorbidities and disease severity. this is a small audit which although it did not include general icu still reflects the need for encouraging clinicians and patients to speak freely regarding escalation plans. medical decsions is clinician led however this audit was carried by nursing staff as we have a duty to be advocate for our patients involvement in medical care [ ] . a retrospective analysis of independent risk factors of late death in septic shock survivors c sivakorn , c permpikul , s tongyoo (fig. ) . the pap and katz scales seem to be adequate for predicting mortality of critically ill patients admitted to a medical icu. this finding may help in the elaboration of future icu mortality scoring systems, as well as in more rational use of resources. however, further multicenter studies are needed to better elucidate these results. adherence this last group was chosen because of its experience and specific training in the field of bioethics as a control group or reference. a total of respondents participated in the study. . % were emergency physicians, . % intensivists, . % emergency nursing, . % icu nursing, . % resident doctors, . % medical students and . % other professions. we observed variability in the responses observed not only between different groups of professionals but even within the same group reflecting the difficulty in decision making. variability was observed regarding decisions in end of life ethics conflicts. a high degree of similarity with the group of master in bioethics was observed in the responses issued by medicine students. the barriers and facilitators to framing goals of patient care (gopc) and factors motivating decision making is relatively unexplored [ , , ] . a three part survey of physicians at an australian hospital in a culturally and linguistically diverse suburb ( table ) . identification of levels of confidence and barriers and facilitators to gopc discussion and decision making was the main outcome measure. factors influencing decision-making was analysed through scenarios. results: out of eligible participants responded; female, male, clinical experience - years. level of confidence was ranked between "somewhat confident and very confident." all but one respondent had six months of icu experience. no differences in the level of confidence among physician groups. barriers and facilitators were identified; poor prognosis and patient or family request were most common facilitators; conflict between treating teams and the patient/surrogate and language barriers were most common barriers. factors driving gopc decision-making included clinical, value judgement, communication, prognostication, justice and avoidance. numerous barriers and facilitators were identified. factors driving decision making did not just consider clinical factors; conflict and we aimed to investigate physician-related factors contributing to individual variability in end-of-life (eol) decision-making in the intensive care unit (icu). qualitative study with semi-structured interviews with specialists in critical care, (experience - years) from swedish icus. data was analyzed in accordance to principles of thematic analyses. most of the respondents felt that the intensivist's personality played a major role in eol decisions (table ) . individual variability was considered inevitable. views on acceptable outcome: respondents experienced that the possible outcome for patients was interpreted very differently and subjectively among colleagues, and what seemed an acceptable patient-outcome for one doctor, was not acceptable for another. values: most of the respondents were well aware that they might be affected by their own values and attitudes in the decision-making process. interestingly, several respondents mentioned that they thought that patients that were marginalized by society, especially drug-abusers could be at risk for receiving decisions to limit life sustaining treatments (lst) more often than others. none of the respondents thought that their own religious beliefs played any part in decision making. fear of criticism: among the less experienced respondents there was a clear sense of fear of making a questionable assessment of the patient's medical prognosis. there was a fear for criticism from colleagues that were not directly involved in the decision-making, and may have made another decision. this created a wish among younger respondents to defer or avoid participating in decision-making. physician-related, individual variability in eol decisions primarily consisted of differing views on acceptable outcome, values and fear of criticism. can (figure ). within each quartile of sofa score, mortality was highest in patients with pneumonia and peritonitis and lowest in patients with cellulitis (see figure ). the sepsis- consensus definition identified organ dysfunction as the hallmark feature of sepsis [ ] . in developing sepsis- , the sequential organ failure assessment (sofa) score was chosen for its prognostic value and relative ease of implementation clinically [ ] . we propose an update based on epidemiologic data from two intensive care databases that more effectively captures organ dysfunction in the context of sepsis- . using the mimic-iii (exploration) and e-icu (validation) databases, we extracted patients with suspicion of infection to form the study cohort. the predictive power of each sofa component was assessed using the area under the curve (auc) for in-hospital mortality. a logistic model with the lasso penalty was used to find an alternative statistically optimal score. results: by utilising alternate markers of organ dysfunction (e.g. lactate, ph, urea nitrogen) we demonstrated a significant improvement in auc for several versions of the new score, sofa . ( figure ). the sofa score can be updated to reflect current advances in clinical practice. using epidemiologic data, we have shown that substitution of existing components with more powerful measures of organ dysfunction may provide an improved score with greater predictive power. moreover, sofa . exhibits equivalent ease of implementation, but better reflects organ dysfunction in the context of sepsis- . introduction: risk of acute organ failure (aof) in cancer patients(pts) on systemic cancer treatment isunknown. however, % of non-hematologic and % of hematologic cancer pts will need admission to intensive care unit (icu). ipop-sci- / is a prospective cohort study designed to ascertain the cumulative incidence of aof in adult cancer pts. single centre prospective cohort study with consecutive sampling of adult cancer pts admitted for unscheduled inpatient care while on, or up to weeks after, systemic cancer treatment. primary endpoint was aof as defined by quick sofa. six months accrual expected an accrual of pts to infera population risk aof with a standard error of %. between / and / pts were on systemic anticancer treatment, had unscheduled inpatient care and were eligible for inclusion and were included. median age was years, % were male, % had adjusted charlson comorbidity index (cci) &gt; and hematologic cancers accounted for % of pts. the cumulative risk of aof on hospital admission was % ( %ci: - ); and of aof during hospital stay was % ( %ci: - ). aof was associated with older age, cci &gt; ,hematologic malignancy, shorter median time from diagnosis and &gt; prior line of therapy. on admission, % of pts were considered not eligible for artificial organ replacement therapy (noaort) and % of pts who developed aof while inhospital were judged noaort. overall, ( %) of aof pts wereadmitted to icu, . % for aort. median follow up . months (min ; max ). inpatient mortalitywas %, with icu mortality rate of %, with median cohort survival . months ( %ci: . - . ). on multivariate analysis, aof was an independent poor prognostic factor (hr . ; %ci . - . ). risk of aof in cancer pts admitted for unscheduled inpatient care while on systemictreatment is %, and risk of icu is %. aof in cancer pts was an independent poor prognostic factor. a severity-of-illness score in patients with tuberculosis requiring intensive care u lalla, e irusen, b allwood, j taljaard, c koegelenberg tygerberg academic hospital, internal medicine, division of pulmonology and icu, cape town, south africa critical care , (suppl ):p we previously retrospectively validated a -point severity-of-illness score aimed at identifying patients at risk of dying of tuberculosis (tb) in the intensive care unit (icu). parameters included septic shock, human immunodeficiency virus with cd < /mm , renal dysfunction, ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (pao :fio ) < mmhg, diffuse parenchymal infiltrates and no tb treatment on admission. the aim of this study was to validate and refine the severity-of-illness score in patients with tuberculosis requiring intensive care. we performed a prospective observational study with a planned post-hoc retrospective analysis, enrolling all adult patients with confirmed tb admitted to the medical intensive care unit from february to july . descriptive statistics and chi-square or fisher's exact tests were performed on dichotomous categorical variables, and t-tests on continuous data. patients were categorized as hospital survivors or non-survivors. the -point score and the refined -point score were calculated from data obtained on icu admission. results: forty-one of patients ( . %) died. the -point scores of nonsurvivors were higher ( . +/- . vs . +/- . ; p= . ). a score ≥ vs. < was associated with increased mortality ( . % vs. . %; or . ; %ci, . - . ; p= . )( table ) . post-hoc, a pao :fio < mmhg and no tb treatment on admission failed to predict mortality whereas any immunosuppression did. a revised -point score (septic shock, any immunosuppression, acute kidney injury and lack of lobar consolidation) demonstrated higher scores in non-survivors ( . +/- . vs. . +/- . ; p< . ). a score ≥ vs. ≤ was associated with a higher mortality ( . % vs. . %; or . ; %ci, . - . ; p< . ) ( table ) . the -point severity-of-illness score identified patients at higher risk of death. we were able to derive and retrospectively validate a simplified -point score with a superior predictive power. chronic critical illness remains a scientific challenge, from its conceptualization to its impact on patient prognosis [ ] . we evaluated the long-term evolution of icu survivors by identifying the real burden of prolonged critical illness on survival, quality of life and hospital readmissions. we conducted a prospective cohort in brazilian hospitals including icu survivors with an icu stay > h. we compared the patients diagnosed with chronic critical illness with the other patients. telephone follow-up at and months. quality of life was measured by the sf- questionnaire. it was observed that % of patients had some definition of chronic critical illness. chronic critically ill patients had higher mortality at months (p= . ). this difference is mainly due to higher intrahospital mortality (p= . ). mortality after hospital discharge was similar between groups. there was no difference in hospital readmission rate at months. various scores are developed to predict pulmonary complications such as ariscat for patients at-risk of postoperative pulmonary complication [ ] and lips for patients at-risk of lung injury [ ] . the aim of this study was to compare these scores with ours for predicting pulmonary complications in mechanically ventilated patients in sicu. this prospective observational study was conducted in sicu at a university hospital. adult patients admitted to sicu and required mechanical ventilation > hours were included. primary endpoint was the composite of pulmonary complications including pneumonia, ards, atelectasis, reintubation, and tracheostomy. multivariate analysis was performed to identify risk factors of pulmonary complications and the predictive score was developed. the roc analysis was performed to compare power of ariscat, lips and our newly developed score for predicting pulmonary complications. outcomes in intensive care units have been reported to be better in higher-volume units [ , ] . we compared outcomes for high-risk patients between low and higher volume units. audit data from irish icus is analysed and reported by the intensive care national audit & research centre (icnarc) in london. icnarc report risk-adjusted mortality rates in all patients and in low-risk patients(predicted mortality rate < %) for each unit, using the icnarch- model to predict the risk of death. we used this data to calculate the proportion of high-risk patients(predicted mortality > %) in each unit, the mortality rate for high-risk patients, the riskadjusted mortality rate and we compared the overall risk-adjusted mortality between low and high volume units. the median number of annual new-patient admissions among participating units was ; units below this were defined as lowvolume and those above as high-volume units. the proportion of all admissions to each unit who were high-risk ranged from % to %(mean %). unit mortality rates for high-risk patients ranged from % to %. the ratio of observed to expected mortality(standardized mortality ratio -smr) for high risk admissions in each unit ranged from . to . (mean . ). in fig. introduction: adl weakening is often seen after intensive care and called postintensive-care syndrome (pics). this is also seen in even outside icu and proposed to be called post-acute-care syndrome (pacs), especially in elderly patients. in patients with infection, sofa score is famous for predicting in-hospital mortality, but there are no tools for predicting adl weakening during admission. to search for risk factors for adl weakening during admission other than the age, we conducted a retrospective observational study. the subjects were surviving patients with infection, aged from to who were admitted to our department from april , to may , . information of basic characteristics, laboratory data on admission and adjunctive therapies were extracted from our database. we use barthel index (bi) as adl evaluation, and the bi at discharge were evaluated by nurses. we stratified patients by bi at discharge of over or not, and investigated factors that predicted it. we compared each factor between groups, and perform a logistic regression analysis with those that had a significant effect clinically or statistically. despite improved outcomes of intensive care unit (icu) patients, sleep deprivation remains a major concern after icu discharge. multifaceted causes make it difficult to treat and understand [ ] . not many studies have explored sleep deprivation beyond icu. this is evidenced by findings from a recent systematic review [ ] which included studies with only one study [ ] reporting sleep deprivation beyond icu. the aim of this paper is to present findings of sleep deprivation beyond icu from a larger study that examined the experience of critical illness in icu and beyond in the context of daily sedation interruption. hermeneutic phenomenology was used to conduct the study. participants aged years and above who fulfilled the enrolment criteria were enrolled into the study. the cohort comprised male and female participants. in-depth face to face interviews at two weeks after discharge were conducted and repeated at six to eleven months. interviews were audio taped, transcribed and thematically analysed. significant statements were highlighted and categorized for emergent themes. six participants continued to experience sleep deprivation up to eleven months after icu. two cited dreams about icu, three could not explain why they continued to fail to sleep and one stated that he continued hearing icu alarms in the silence of the night. sleep deprivation continues beyond icu due to nightmares, delusional memories and unexplained reasons. further research is needed to establish causes of sleep deprivation and explore ways to promote sleep in critical illness survivors after icu discharge. frailty is being increasingly seen as an independent syndrome. frail patients now account for an increasing proportion of hospital and critical care admissions [ ] . we aimed to compare frailty and mortality in our intensive care unit. clinical frailty score (cfs) was incorporated within the electronic health record (ehr) . we performed this retrospective analysis on the data collected between jan' and oct' . the predictor and outcome for this study were frailty and hospital mortality respectively. all demographic data, acute physiology score, critical care and hospital outcome data were automatically collected in the ehr and recorded. we used a cut off of cfs> and above to define non-frail and frail respectively. chi-squared test, simple and multiple logistic regression were used. adjustment was done for icnarc score and age. total number of patients was , of which ( . %) died in hospital. within the patients< years (n= ), ( %) were recorded as frail or vulnerable. the number of elective and emergency admission were ( %) and ( %) respectively. in the frail and nonfrail, mortality rates were % and . % (p< . ) respectively, with odds ratio of . ( % ci . , ; p< . ) ( age is a well-known risk factor for critical care (cc) outcome and is incorporated into many prognostic tools; however, this has been criticized for assumption of normal physiology for young at baseline. in recent years, frailty in cc prognostication has been of interest, with meta-analysis correlating worsening outcomes with increasing frailty [ ] . in this study, we compared the effect of frailty versus age for determining hospital survival for critically ill patients. we conducted a prospective cohort in brazilian hospitals including survivors of an icu stay > h. we compared chronic critically ill patients (icu stay> days) and the other patients. we performed psychological and functional presential assessment in patients within hours of icu discharge and by telephone at and months. the prevalence of chronic critically ill patients was %. regarding outcomes, chronic critically ill patients had a higher incidence of depressive symptoms than other patients in the immediate post-icu discharge (p = . ), as well as a higher incidence of muscle weakness (p < . ). however, in subsequent evaluations, we found no difference between groups regarding psychological symptoms -depression, anxiety and post-traumatic stress. higher functional dependence was observed in critically ill patients, but without difference in the quality of life score, both in the physical (p = . ) and mental (p = . ) domains. chronic critically ill patients, when compared to patients with stay> h, have a higher incidence of depressive symptoms at icu discharge. this difference disappears in the follow up. chronic critically ill patients present higher levels of functional dependence but without repercussions on quality of life scores. introduction: activation of the inflammatory response after cardiac arrest (ca) is a welldocumented phenomenon that may lead to multi-organ failure and death. we hypothesized that white blood cell count (wbc), one marker of inflammation, is associated with one-year mortality in icu treated ca patients. we used a nationwide registry with data from five academic icus to identify adult ca patients treated between january st and december st . we evaluated the association between the most abnormal wbc within hours of hospital admission and one-year mortality. we accounted for baseline risk of death using multivariable logistic regression (adjusted for age, gender and h sequential organ failure assessment [sofa] score). a total of , patients were included in the analysis. of those patients , ( %) were alive one year after ca. we plotted wbc against baseline risk of death and through graphic examination of a locally weighted scatterplot smoothing (lowess) curve found the lowest risk of death to be associated with a wbc of (e /l) ( figure mrps were identified by a specialist icu pharmacist during this programme and classified by their significance on a scale of one to four. logistic regression was used to determine if demographic factors were associated with the occurrence of a clinically significant mrp -a significance score of two or above (figure ) . the adjusted model included age, icu los, hospital los, apache ii, number of days of renal replacement therapy, number of days of ventilation, the number of medications prescribed at icu discharge, and the who analgesia classification at ins:pire. there were increased odds of having a clinically significant mrp for hospital los (or results: · % (n= ) of patients required at least one pharmacy intervention. the median number of interventions required per patient was one (iqr - ); the maximum number was six. mrps were recorded in this cohort. the most common intervention was clarifying duration of treatment (n= ), followed by education (n= ), and correcting drug omissions (n= ). the bnf drug class most frequently associated with mrps was neurological (n= ), which comprises analgesics (n= ) and psychiatric medications (n= ) ( figure ). this was followed by cardiovascular medications (n= ), gastrointestinal medications (n= ), nutritional medications (n= ), and others (n= ). many icu survivors experience mrps. the most common class of mrp was neurological, reflecting the high incidence of chronic pain and psychiatric illness in this population following discussion with icu staff, ward staff and fy doctors, a formal standardized handover system was introduced. this involved a verbal handover to the appropriate fy by an icu doctor and the patient drug chart to be rewritten in icu at the time of handover. the next change was to display posters on the wards to alert staff that the medical team are to be contacted when a patient comes to the ward from icu and to ensure the drug chart is completed. the baseline data showed a median time delay of hours, with one patient waiting hours for a drug chart. following the interventions the median time delay has decreased to hours within months as demonstrated in figure . the changes have received positive feedback from icu staff, ward staff and fy doctors. the aim of reducing the time delay by % has been achieved with the median time delay now hours. this has improved patient safety by significantly reduced delays in medications and through the introduction of a standardized handover. this has also provided an opportunity for junior doctors on the wards to seek clarification regarding medications and the clinical management plan for the patient. this has established a communication channel between icu and the wards making patient care safer and more effective. telemonitoring outside the icu is scarce. but with innovative wearables measuring respiratory and heart rate wirelessly, culture on intrahospital telemonitoring should definitely change. however, culture has been known to be one of the most crucial success factors in innovation, especially in health care. human design thinking is a promising tool in health care innovation but rarely used in a multidisciplinary team to initiate an innovation culture and stimulate sustainable collaboration. the aim of this study was to initiate a pilot project with a multidisciplinary team to start using wearables for early warning score (ews) on a clinical ward. human design thinking was used to write a value proposition on wearables in clinically admitted neutropenic hematologic patients in an academic center. a multidisciplinary team was performed to cover all disciplines involved in the technical, clinical and administrative parts of the project. a vendor was chosen based on its product specifications in relation to the present hospital monitoring infrastructure. in design thinking sessions, critical appraisal of multiple telemonitoring factors was performed by sub teams and a canvas projectplan was constructed. the project team was formed of registered nurses, physicians, itspecialists, electronic health record consultants; a critical care physician was appointed as project leader. the main critical factors were: unseamlessly transmitting of both heart and respiratory rates including appropriate movements filtering to the nurse's smartphones direct uploading into electronic health record with automated ews calculation nurse driven protocol on ews follow up. philips healthcare with their intellivue guardian wearable biosensor was the chosen vendor ( figure ). design thinking in a multidisciplinary health care team could positively influence the innovation culture. scientific evaluation of this wearable will focus on both nurse's acceptance and data storage and is expected in the summer of . severity, readmission and lengh of stay were lower in patients receiving discharges directly to home. it seems like a safe way to discharge low-risk short stay patients. it seems to save resources and reduce costs, as well as the need for hospital beds. however, futher estudies are needed to actualy evaluate this safety. forty-four cultures were analyzed with eplex ( figure ). complete agreement with conventional diagnostics was observed in / cases. no false-positive results were observed, yielding a sensitivity and specificity of % and % respectively for target pathogens. time to result was, on average, . h faster with eplex compared to conventional diagnostics. antimicrobial therapy could have been optimized in patients based on the eplex result, but treatment was only changed in one case (e.coli ctx-m+) receiving meropenem . h before the antibiogram was available. the eplex blood culture panels provide high accuracy and significantly faster results. the current implementation offers substantial potential value at a minimal cost, and is a feasible approach to -h/ days blood culture diagnostics in many hospital settings. however, efforts to increase adherence are needed. the rapid increase of extended spectrum β-lactamases (esbl)-producing pathogens worldwide makes it difficult to choose appropriate antibiotics in patients with gram-negative bacterial infection. cica-beta reagent (kanto chemical, tokyo, japan) is a chromogenic test to detect beta-lactamases such as esbl from bacterial colonies. the purpose of the study was to reveal whether cica-beta reagent could detect esbl-producing pathogens directly from urine rather than bacterial colonies to make a rapid bedside diagnosis of the antibiotic susceptibility of gramnegative pathogens. we conducted a prospective observational study from july to october . patients were eligible if they were performed urinary culture tests and gram negative pathogens were detected at least + from their urine samples. the urine sample was centrifugated at x g for min. the supernatant of sample was re-centrifugated at x g for min and the pellet was mixed with cica-beta reagent. the test was considered positive when the enzymatic reaction turned from yellow to red or orange. (fig. ) . the bundle approach could be an effective strategy to prevent hospital-acquisition of drug-resistant pathogens in icus. fig. in the aspect-np trial, c/t was noninferior to mem for the treatment of habp/vabp. we evaluated outcomes from that study in the subgroup of pts failing current antibacterial therapy for habp/vabp at enrollment. methods: aspect-np was a randomized, controlled, double-blind, phase trial in which mechanically ventilated pts with habp/vabp received g c/t or g mem every h for - days. pts with > h of active gram-negative antibacterial therapy within h prior to first dose of study therapy were excluded, except those pts failing current treatment (i.e. signs/symptoms of the current habp/vabp were persisting/worsening despite ≥ h of antibiotic treatment). primary and key secondary endpoints, respectively, were -day all-cause mortality (acm) and clinical response at test of cure (toc; - days after end of therapy) in the intent to treat (itt) population. pts failing current antibacterial therapy for habp/vabp were prospectively categorized as a clinically relevant subgroup. at baseline, failing current therapy for habp/vabp was reported in / ( %) c/t and / ( %) mem itt pts, mostly piperacillin/ tazobactam ( %), rd/ th-generation cephalosporins ( %), fluoroquinolones ( %), and aminoglycosides ( %). baseline demographic and clinical characteristics in this subgroup, including prior therapy regimen, were generally similar between treatment arms. there were greater proportions of patients with esbl+ enterobacterales ( %) and pseudomonas aeruginosa ( %) in the c/t arm than the mem arm ( % and %, respectively). lower -day acm was seen with c/t than mem, as evidenced by % confidence intervals for treatment differences that excluded zero ( figure ); statistical significance cannot be assumed because subgroup analyses in this study were not corrected for multiplicity. conclusions: c/t was an effective treatment for habp/vabp pts who had failed initial therapy. catheter-related blood stream infection (crbsi) is common serious infections and associated with increased mortality in intensive care units (icu). one of the most important strategy to prevent crbsi is to minimize the duration of central venous catheterization. we built a medical team consisting of doctors, nurses and pharmacists in icu to discuss whether patients needed central venous catheter (cvc) in terms of monitoring hemodynamics and administering drugs, and recommend catheter removal to attending physicians every day in april . the purpose of this study is to evaluate whether our team-based approach could shorten the total duration of catheterization and reduce crbsi. this was a retrospective historical control study conducted from april to october in the icu of a tertiary care hospital in japan. every patient admitted to the icu during the study period was eligible if they were inserted cvc. patients were divided into groups: conventional (from april to march ) or intervention (from april to october ). we set the primary endpoint as onset of crbsi. the secondary endpoints included the duration of central venous catheterization, the length of icu stay and hospital mortality. crbsi was defined as bloodstream infection in patients with cvc, not related to another site. we included patients: in the conventional group and in the intervention group. the reduced, though nonsignificant, tendency of crbsi was observed in the intervention group [hazard ratio, . ( % confidence interval, . - . ; p = . )]. the intervention group was significantly associated with reduced duration of central venous catheterization ( days vs days; p < . ). no difference was observed in the length of icu stay and in-hospital mortality between groups. the team-based approach to assess cvc necessity could shorten the duration of central venous catheterization and might reduce crbsi. introduction: empiric antibiotic therapy decisions are based upon a combined prediction of infecting pathogen and local antibiotic susceptibility, adapted to patients' characteristics. the objective of this study was to describe the pathogen predominance and to evaluate the probability of covering the most common gram-negative pathogens in icu patients with respiratory infections. methods: data were collected from multiple us and european hospitals as part of the smart surveillance program ( ). mic (mg/l) testing was performed by broth microdilution, with susceptibility defined as follows for p. aeruginosa & enterobacterales: ceftolozane/tazobactam results: hospitals from countries provided gram-negative respiratory isolates from patients located in an icu in the us ( %), eastern europe ( %) and western europe ( %) in . the most common pathogens isolated were p. aeruginosa ( %), k. pneumoniae ( %), e. coli ( %), and a. baumannii ( %). among enterobacterales, % ( / ) were esbl positive. figure provides the probability of covering the most common respiratory gram-negative pathogens from icu patients. co-resistance between commonly prescribed first line β-lactam antibiotics is common: when nonsusceptibility (ns) of one agent was present, susceptibility to other βlactams was generally < %. ceftolozane/tazobactam provided the most reliable in vitro activity in both empiric and adjustment prescribing scenarios compared to other β-lactam antibiotics. ceftolozane/tazobactam ensured a wide coverage of the most common gram-negative respiratory pathogens demonstrating high susceptibility levels and provided the most reliable in vitro activity in both empiric and adjustment antibiotic prescribing scenarios. further studies are needed to define the clinical benefits that may translate from these findings. evaluation of compliance of icu staff for vap prevention strategies on the outcome of patients a kaur fortis hospital, critical care, mohali, india critical care , (suppl ):p ventilator-associated pneumonia is the most common nosocomial infection diagnosed in adult critical care units. it is associated with prolonged duration of mechanical ventilation, increased icu stay and increased mortality. it continues to be a major challenge to the critical care physicians despite advances in diagnostic and treatment modalities. the primary objective of the study was to determine the compliance of icu staff towards vap prevention bundle and secondary objective was to determine the incidence, risk factors and outcome of vap patients. single center, prospective, observational study carried out from february to july . patients mechanically ventilated for more than hours and satisfying the inclusion and exclusion criteria were enrolled in the study. vap was diagnosed using the cdc criteria and clinical pulmonary infection score. vap preventive strategies were employed and compliance of icu staff was assessed. a total of patients were admitted to icu over the set time period and out of them patients were ventilated for more than hours. among them only patients fulfilled the inclusion and exclusion criteria and were enrolled in the present study. excellent compliance was observed in head end elevation, sedation vacation, stress ulcer prophylaxis, and heat moist exchanger filter use, good compliance in oral care and hand hygiene and moderate to poor compliance in subglottic suctioning. the incidence of vap was . % with a vap rate of . / ventilator days. there was a significant correlation between primary diagnosis, hemodialysis, massive blood transfusion and development of vap (p< . )). mean duration of ventilation (p< . ) and mortality (p< . ) were highly significant in vap patients. conclusions: improvement in compliance towards vap bundle and reduction of risk factors can help decrease incidence of vap and related morbidity and mortality. preventive strategies are effective in reducing ventilation-associated pneumonia (vap) in adults [ , ] . in paediatric population there are no data about vap prevention, so we introduced a new bundle (vap-p) based on the available evidence for adults. this was designed as a before-after study. we enrolled all patients admitted to -bed medical-surgical paediatric icu at gemelli hospital in rome, requiring mechanical ventilation for at least hours. patients with pre-existing tracheostomy were excluded. vap-p has been introduced since in order to improve quality of assistance. our bundle consisted in twice a day oral hygiene with chlorhexidine swab, daily check of oral bacterial colonization and aspiration prevention. comparison was made with an historical group including patients admitted before vap-p introduction (since to ). all data about demographics, antimicrobial therapy, icu stay and treatments, were collected. results: patients were included ( after and before vap-p introduction). ( %) events of vap were recorded in vap-p group compared to ( %, p= . ) vap-p group had less vap per days of mechanical ventilation ( / compared to . / p= . ). multivariate analysis yielded an or of . ( %ci . - . ) for vap incidence after bundle introduction. mortality rate was slightly reduced in vap-p group ( . %vs . % p=ns). patients who developed vap required more days on mechanical ventilation and had higher mortality rate ( vs days p< . and %vs % p= . , respectively). our vap-p seems effective in reducing vap incidence in critically ill paediatric population. introduction: ceftolozane/tazobactam (c/t) is a new antibiotic against mdr gramnegative bacteria infections, whose target population are the critically ill patients. even though / g dose safety administered as a hour-infusion has been already assessed, these patients can be under renal replacement therapy (rrt) and suffer changes in their volume of distribution (vd) that may affect antibiotic concentrations. the objective was to determine concentration reached by g c/t ( hour infusion) in septic patients on rrt (cvvhdf) and interdose behavior. we have used rrt machine prismaflex with oxyris filter and m . hplc-uv method was used for simultaneous quantification of c/t. study population consisted of three obese critically ill patients with sepsis, on cvvhdf while receiving g c/t every hours. samples were taken of prefilter, post filter blood and effluent, min before infusion and , and hours after the end of it. we found great interpatient variability with the lowest cconcentration values in the patient with more hemodynamic instability using oxyris filter. even though cmax was less than reported in healthy subjects, we found similar values of auc and t ½ in comparison with healthy population studies. cmax of t was also compromised in comparison with values reported in healthy subjects, but with higher auc and t ½. cvvhdf contributes to c/t clearance. m filter showed the least clearance and higher values of auc and t ½. extraction rate was similar in all patients and filters (figure ) . cmax achieved may be impaired because of the varying vd caused by obesity and rrt, but not affecting the antibiotic characteristics and behaviour. we conclude that because of the variety of clinical conditions, c-concentration is compromised particularly in hemodynamically unstable patients. however, the small sample doesn´t let us extrapolate these results. the extended infusion seems to be adequate to achieve the interdose antibiotic concentration. the use of biomarkers in sepsis is useful for early diagnosis and prognosis. the desired marker should be sensitive, specific, fast and accurate. procalcitonin (pct) measurement is approved by the fda even its efficacy is still under question. the determination of alfatorquetenovirus (ttv) could be a useful marker [ ] . we analyzed samples from patients admitted to icu with clinical suspicion of sepsis. analytical data of c-reactive protein (crp), neutrophils and procalcitonin were collected. the sofa and apache ii scales were calculated and patients stratified according to these values in good and poor prognosis. ttv quantitative determination was carried by using a quantitative crp . we calculated area under the curve (auc) of ttv plasma levels as a function of time. the statistical analysis involved u-mann-whitney and spearman test, using chi for qualitative variables. results showed a not significant (ns) inverse relationship between the ttv auc and the patient proinflammatory level. a tendency (ns) was found between poor prognosis and the pct median values and crp being higher in the poor prognosis.group. a trend showed lower ttv dna count related to worse prognosis. an inverse relationship was found between pct and crp values and the ttv copies /ml plasma, ns correlation in the case of pct. there was a clear trend between the neutrophils´expansion and the regression line slope, obtained between ttv loads in the first two study steps. fig. (abstract p ) . patient pk/pd measurements value> . ), suggesting that the adsorptive mechanism wasn't primarily mediated by plasma protein. ha was saturated after adsorption of a total of . ± . mg of van. the adsorptive kinetics showed an exponential reduction of van mass that reached a plateau after minutes of circulation. in our study, simulating in vivo conditions of hp using ha during sepsis, a rapid and clinically relevant removal of van has been shown. after hours of hp, we suggest to assess van plasma concentration and a loading dose of van should be considered. however, not knowing the potential interactions with other drugs, further in vivo studies are warranted to confirm these findings. assessing the volume of blood taken for blood culture and culture positivitydo we need to take less blood? it is commonly accepted that larger blood culture (bc) volumes (bcv) increase the yield of true positive cultures, and optimally cc of blood should be obtained per set ( bottles). only scarce data exists on the matter of optimal bcv. it is unknown what is the minimal volume that is acceptable for bc. the objective of this study was to determine the association between bcv and the rate of positive bc. blood taken for cultures in bd bactec plus aerobic/f negative bottles was collected from icus and acute care floors at hospitals at the dmc over months. blood volume was estimated automatically from blood background signal data in the bd bactec fx instrument. cultures were analyzed for each bottle. data was summarized for every month as the average volume and number of cultures taken and rate of positive bc for every unit. units were classified according to unit type (icu, medicine, surgery, mixed, emergency department (ed), organ/bmt or "other" which did not fit the previous categories) and analyzed as a group. a total of cultures were taken in units. there is a positive association between bv and positive bc rate for ed and "other" units (irr= . , p= . for the ed, irr= . , p< . for "other" unit). all other units had no association between bv and positive bc rate (figure ). secondary analysis, excluding pediatric units, gave very similar results. when comparing bv between unit types, the ed and "other" unit had significantly lower bv ( . ml in the ed and . ml in "other" unit compared to . ml in the icu, . ml in surgery, . ml in mixed and . ml in bmt). the correlation between bv and positive bc rate is probably limited to units taking very low bv for cultures. units taking volumes above ml show no improvement in positive bc rate when higher volumes are taken. better prospective studies should be done to further establish the minimal bcv needed and spare unnecessary blood loss to hospitalized patients without compromising bc yield. de-escalating antibiotics in sepsis with the use of t mr in a bed greek university icu c vrettou, e douka, i papachatzakis, k sarri, e gavrielatou, e mizi, s zakynthinos st icu department, university of athens, evangelismos general hospital, icu, athens, greece critical care , (suppl ):p in septic patients, the early use of appropriate empiric antibiotic therapy reduces morbidity and mortality. de-escalation refers to narrowing the broad-spectrum antibiotics once the pathogen and sensitivities are known. t magnetic resonance (t mr) is a novel method of detecting eskape pathogens. we aim at investigating if using t mr technology can expedite de-escalation of broad spectrum antibiotics. this is a prospective observational study conducted in our -bed university icu. inclusion criteria were critically ill patients age> y.o., with newly diagnosed sepsis and clinical suspicion of eskape bloodstream infection. a sample for t mr and a blood culture (bc) sample were collected simultaneously from the patients enrolled. the t mr bacteria panel test was run according to the manufacturer's guidelines and the bcs were processed according to the hospital standard procedures. we recorded clinical data and administered antibiotics. results: patients were included in the study. mean time to culture positivity was hours while mean time to t mr result was . hours. in patients the results of t mr were in concordance with the bcs. in the remaining cases, the bcs were negative while the t mr detected one or more eskape pathogens. there were no false negative results. de-escalation in at least one drug was applied to patients ( . %). no escalation was applied to patients ( . %) and antibiotic escalation in ( . %). conclusions: t mr provides a quicker detection time that could shorten the time to targeted therapy. in our population this corresponded to early (within - h) antibiotic de-escalation in approximately / of the included patients. antibiotic stewardship in icu. a single experience l forcelledo , e garcía-prieto , l lópez-amor , e salgado , j fernández dominguez , m alaguero , e garcía-carús the increasing antibiotic resistance in microorganisms urged interventions such as the antibiotic stewardship programs in icu focused on reducing the inappropriate use of antibiotics by improving the antibiotic selection, the dosage, administration route and length as well as improving clinical outcomes and reducing antibiotic resistance. retrospective study where antibiotic consumption was analysed and measured in days of therapy (dots) between and in a medical-surgical icu of a university hospital where a multimodal educational program was established. specific training in infectious diseases in critically ill patients, periodic clinical and formative sessions fig. (abstract p ) . correlation of blood culture positivity rate with blood culture volume by unit type were performed for icu staff and specific leaders within the icu staff designated. results: patients were admitted to icu. there was a reduction of , % in dots (figure ), reduction in antimicrobial resistance rates ( , in , , in [days of resistant microorganism/ patientdays]) without an impact in icu global mortality ( , % in , , % in ). the resistant bacteria registered were acinetobacter baumannii, s. aureus mr, blee and carbapenemase-producing enterobacteriaceae, pseudomonas aeruginosa mr and clostridium difficile. the safe in antimicrobial consumption was € ( % reduction). the icu stay decreased from , days ( ) to , ( ) , with no variation in mean apache ii ( , ) . the bigger decrease in antibiotic consumption was in colistin related to the reduction in resistance bacteria, in special acinetobacter baumannii, in linezolid and in piperacilin/tazobactam, even more remarkable in due to shortage of supplies which meant an increase in meropenem. the application of an antibiotic stewardship program in icu succeeded in reducing antibiotic consumption, antibiotic resistance and costs without an impact in clinical outcomes like mortality or icu stay. clinical outcomes of isavuconazole versus voriconazole for the primary treatment of invasive aspergillosis: subset analysis of indian data from secure trial p kundu, s kamat, a mane pfizer limited, medical affairs, mumbai, india critical care , (suppl ):p the secure trial was designed to compare the safety and efficacy of isavuconazole (a) versus voriconazole (v) for primary treatment of invasive mould disease caused by aspergillus and other filamentous fungi. the present analysis is aimed at comparing the indian subset of patients with that of the overall trial population and to ascertain any similarity or difference in the primary efficacy endpoint and safety/tolerability in these two groups. in secure trial, patients in one group received (i) & another patients received (v). the indian subset had patients. we have done a qualitative analysis as the sample size of the indian subset was small. non-inferiority of (i) to (v) in terms of all cause mortality from first dose to day was assessed in overall patients. the treatment difference between (i) and (v) group in the indian subset of patients was analyzed. proportion of patients who had to discontinue treatment due to teaes was analyzed. the all-cause mortality in the overall trial population met noninferiority margin (table ). in the indian subset, it was higher for (i) than (v). there was a lower incidence of ocular, hepatobiliary, skin & subcutaneous tissue disorders in the (i) treated patients (see table ). in indian subset, the above adverse events were less in the (i) group, but statistical inference could not be done due to small sample size. however, similar trend of less number of patients discontinuing therapy due to teaes in the (i) treated patients was seen in the overall patients & the indian subset. the all-cause mortality in the indian subset was higher in the (i) patients. a trend similar to the overall population regarding safety parameters favoring (i) was seen in the indian patients. considering the significantly higher prevalence of ia in india, suitably powered study design is necessary to draw definitive conclusions on the non-inferior efficacy & better safety & tolerability of (i) over (v) in patients of ia. introduction: ventilator-associated pneumonia (vap) is one of the most frequent healthcare-associated infections, correlated with increased mortality,extended hospital stay and prolonged mechanical ventilation. considering the latest outbreak of multiresistant a. baumannii infections in the critically ill patients with vap, there is a growing concern regarding challenges of the antibiotherapy in these patients. although ceftazidim-avibactam is considered to have limited effects on a. baumannii, it is reported to have a synergic activity in combination with other antibiotics. we performed a retrospective, observational study which included icu patients diagnosed with vap(cpis > ). oxa a. baumannii was isolated from the tracheal secretions using a rapid molecular diagnostic platform(unyvero a system). patients were divided in two groups according to the antibiotherapy:group a meropenem + colistin and group b meropenem + colistin + ceftazidim-avibactam.statistical analysis was performed using graphpad applying t-test and kaplan-meier curves, having the in-hospital mortality as primary outcome and days of mechanical ventilation and hospital stay as secondary outcomes. mean age(y.o) in group a was and in group b and in both groups mean charlson comorbidity index was points. survival percent was higher in the group treated with ceftazidim-avibactam ( % vs %, p = . )- (fig. ) . length of stay was significantly decreased in group b ( . days vs days in group a, p = . ). number of days under mechanical ventilation was also decreased in the ceftazidim-avibactam group ( vs ) but the data was not statistically significant. in light of the important thread of multiresistant a. baumannii and the lack of therapeutic measures, the synergistic activity of ceftazidim-avibactam use in combination with other antibiotics may be a promising approach to lower the mortality and hospitalization in critically ill patients diagnosed with vap. impact of patient colonization on admission to intensive care on and days mortality g dabar , c harmouch , e nasser ayoub , y habli , g sleilaty , j infections caused by multi resistant bacteria are a major health problem, especially in icus, and it may be associated with high mortality rates. colonization precedes infection in most instances; therefore it may be a marker of a poor outcome. we tried to determine the impact of colonization on mortality at and days in a population of patients admitted to one medical and one surgical icu in the same institution. medical records review over three years - of all patients admitted to one surgical et one medical icu at hotel dieu de france hospital staying more than h. colonization to resistant bacteria was defined as mrsa, esbl, mdr, and vre. all patient received a nasal and rectal screen on icu admission, in intubated patients tracheal aspirate was considered as colonization in the absence of clinical respiratory tract infection. demographics, apache, sofa, immunosupression, charleston comorbidity index, length of stay, mechanical ventilation, hospitalization and antibiotic use in the previous month were collected. mortality at and days was assessed through medical records or phone call. pearson chi-square was calculated for the association of colonization and mortality at and days, and subsequently odd ratio was estimated. introduction: critically unwell patients have been observed to respond unpredictably to traditional intermittent dosing (id) schedules of vancomycin, likely due to the complex physiological derangements caused by critical illness. continuous infusion (ci) of vancomycin has been suggested to overcome such problems by allowing more regular therapeutic drug monitoring and subsequent effective dose titration [ ] . this study conducted at a tertiary intensive care unit, reports our experience following implementation of a continuous vancomycin infusion protocol. prospective data was collected over two consecuative periods of three months, initially capturing plasma levels for id (target level of - mg/l) followed by reviewing plasma concentration levels in a ci protocol (target level of - mg/l). patients recieving renal replacement therapy were excluded. a total of intermittent vancomycin prescriptions were administered and dosing levels observed. in the three month ci period, patients received ci vancomycin and levels subsequently checked. the ci protocol resulted in increased blood sampling ( samples in ci group vs. samples in id cohort). two non serious incidents were reported in the ci cohort relating to preparation of vancomycin. both groups had a comparable median time to therapeutic range ( hours). however, ci vancomycin group had a greater proportion of first samples outside the desired therapeutic range ( %vs %) (figure ). as the therapy continued, ci vancomycin demonstrated a greater propensity towards consistent therapeutic levels than that observed with id. % of patients on a ci regime achieve the desired target levels compared to % in the id cohort (fig. ) . it was positive for single or multiple microbes in ( . %) and ( . %) samples respectively. single or multiple resistance genes were detected in ( %) and ( %) samples respectively. bfpcr was positive only for bacteria in ( . %), virus in ( . %) and for both in ( . %) cases. influenza a was found in ( . %) cases. the most common organisms in community and hospital acquired pneumonia were streptococcus pneumoniae ( / ) and a. baumannii ( / ) respectively. bacterial cultures were concordant with bfpcr in / ( %) of positive cases. decisions to change antibiotics could be taken earlier based on bfpcr (p< . ) than if were based solely on culturesboth in culture positive ( . ± . vs . ± . hrs) and negative cases ( . ± . vs . + . hrs) where antibiotics would have remained unchanged. based on bfpcr antibiotics were escalated in ( %) patients and teicoplanin ( / ) was most often stopped. bal bfpcr were obtained significantly earlier, identified more organisms and bacterial resistance than culture reports and lead to more frequent and earlier antibiotic changes. severe community-acquired pneumonia (scap) is a frequent cause of hospitalization and mortality. ceftaroline is efficacious for treatment of cap (port risk class iii or iv). most severe patients were excluded from the clinical trials, so the efficacy of ceftaroline in these kind of patients is unknown methods: this is a health record-based retrospective before-after study in a tertiary care hospital. all scap patients admitted in icu between november and february receiving ceftaroline were included. control group included patients with same inclusion criteria but receiving ceftriaxone. propensity scores to adjust for potential baseline differences between groups were performed. levofloxacin or azythromicin were administered in both groups. primary outcome was the change in sofa score over the first h and secondary were days of mechanical ventilation, respiratory failure at h, need of rescue antibiotics, length of stay and mortality results: there were patients in ceftaroline group and in ceftriaxone group. baseline characteristics were similar except from more intubated patients in ceftaroline group (figure ). there were less respiratory failure at h in patients with ceftaroline treatment (- . % vs. - . %; p , ), but no differences in other organ failures, mortality, days of mechanical ventilation or los. there were more need of rescue antibiotics in ceftriaxone group ( . % vs . . %; p , ). we found more streptococcus pneumoniae isolation in ceftaroline group ( ( . %) vs ( . %); p = . ); more empiric use of oseltamir ( ( . %) vs ( . %); p = . ), but no more influenzae infections ( ( . %) vs ( . %); p = . ). s. aureus was detected in patient in ceftaroline group and in in ceftriaxone group. introduction: acute respiratory failure (arf) due to pulmonary infections is a usual cause of intensive care unit (icu) admission. immigration patterns and iatrogenic immune-suppression have made tuberculosis (tb) a common disease in western europe. severe tb requiring icu care is rare. nevertheless, mortality associated with active tb and arf is poor [ ] . adult patients with tb admitted to icu from - were identified retrospectively. diagnosis was based on: positive cultures of sputum, bronchial aspirates or bronchioalveolar lavage fluid. demographic characteristics, reasons for admission, hiv status, anti-tb treatment and mortality were recorded. total of patients with tb were admitted to icu. mean apache ii score was , ± , . sixteen were male. mean age , ± , years. eight ( %) were hiv-positive, ( %) diabetes mellitus type , ( %) chronic liver disease. six ( %) had other causes of immunesuppression. main causes for icu admission were arf due to non- mycobacterium tuberculosis pathogens in %, acute liver failure in %, septic shock due to non-respiratory cause in %. overall, % were on anti-tb treatment at time of admission. tb involved the lung parenchyma in all patients. pleural involvement was present in % and lymph node in %. extrapulmonary sites were present in %: urogenital, gastrointestinal, bone marrow. pathogens identified in over-infections: % gram positive coccus, % gram negative bacilli, % fungal, % mdr-pathogen. one patient hiv-positive suffered arf due to pneumocystis jiroveci. overall, % died during icu stay. besides its latent evolution, mortality of tb patients admitted to icu is extremely high. arf due to over-infection seems to be the main cause for icu admission and mortality. better preventive approach of these patients may improve their outcome. introduction: human african trypanosomiasis (hat) is rarely encountered by critical care clinicians, but is an important differential for fever in the returning tropical traveler. late disease is characterized by seizures, fever and multi-organ failure [ , ] . we present an anonymized case presenting from an endemic area in zambia referred for tertiary critical care management. the patient was too obtunded to give informed consent and his relatives could not be contacted despite extensive efforts. a middle-aged man with no past medical history from rural zambia presented to a local clinical officer post with fever and arthralgia. he was treated twice with anti-malarial medication without resolution of symptoms. two months later he was admitted febrile and obtunded to a local hospital with worsening confusion. he was transferred hours by ambulance to our facility in lusaka, which is the only public tertiary critical care unit in zambia results: gcs on arrival was e m v without localizing neurology. microbiology investigations were negative, including for toxoplasma, cryptococcus, hiv or malaria. the patient suffered a generalized seizure followed by a sustained gcs of and was admitted to the icu for invasive ventilation and seizure control. peripheral blood smears demonstrated trypanosomes consistent with hat secondary to trypanosoma brucei rhodesiense. he was commenced on melarsoprol but rapidly deteriorated, with signs of melarsoprol-induced arsenic encephalopathy and subsequent tonsillar herniation. his death was confirmed by neurological criteria. conclusions: icu management of fulminant hat involves supportive neurocritical care plus melarsoprol, a toxic arsenic compound with common side effects of hepatotoxicity and dysrhythmia. arsenic encephalopathy occurs in % of late hat, with a fatality rate of % [ ] . early diagnosis is associated with a % survival rate in developed world travelers repatriated from endemic areas [ ] . lithium chloride to prevent endothelial damage by serum from septic shock patients (in vitro study) a kuzovlev the aim of the study was to investigate into effectiveness of lithium chloride (licl) as agent that prevents damage to the monolayer of endothelial cells under the action of serum from multiple trauma patients with septic shock. methods: serum from pts with septic shock (sepsis- ) and healthy donors was withdrawn. monolayer of ea.hy endothelial cells were incubated for hrs at °c with healthy person's serum and with septic patient's serum without licl and with it at concentrations of . mmol, . mmol, mmol, mmol. licl was added hour before the change of serum. after incubation cells were washed and fixed with % paraform solution and permeabilized with % triton x- solution. fixed cells were stained with primary antibodies to vecadherin and then incubated with secondary antibodies conjugated with oregon green fluorescent dye as well as with phalloid red and hoechst dye . images were processed by fluorescence microscope and imagej . p and metavue . programs. western blotting was used to detect antibodies to ve-cadherin, claudin and gsk- beta. statistics included mann-whitney test and chi-square test. incubation of a monolayer of endothelial cells with % serum of septic shock patients led to loss of ve-cadherin contacts and decrease of claudine. preincubation with licl . mmol did not prevent dismantling of claudine, actin, ve-cadherins; . mmol licl prevented it (p> . ), but at higher concentrations ( mmol, mmol) almost completely protected endothelial monolayer from destruction of intercellular contacts (p< . ). serum had almost no effect on the phospho-gsk- β level after min, min, min and hr, but caused a significant ( %) decrease in its level after and hrs. licl ( mmol) caused a significant increase in phospho-gsk- β already mins and up to hrs after exposure. licl prevents septic damage to the monolayer of endothelial cells in vitro in a gsk- beta mediated way. introduction: the autonomic nervous system (ans) controls both heart rate and vascular tone, which are known to be impaired during septic shock (ss) . acute inflammation is presumed to increase arterial stiffness of large arteries in experimental studies [ ] . the objectives of this work are to verify if standard ss resuscitation modulate mechanical vascular properties and to verify if alterations in these vascular properties and ans activity are correlated. a protocol of fecal peritonitis septic shock and standard resuscitation (fluids and noradrenaline) was applied on pigs. the arterial blood pressure waveform was recorded in the central aorta and in the femoral and radial arteries. the characteristic arterial time constant tau was computed at the three arterial sites, based on the twoelement windkessel model [ ] . the total arterial compliance (ac) and the total peripheral resistance (tpr) were also estimated. baroreflex sensitivity (brs), low frequency (lf, . - . hz) spectral power of diastolic blood pressure, and indices of heart rate variability (hrv) were computed to assess ans functionality. results: septic shock induced a severe vascular disarray, decoupling the usual pressure wave propagation from central to peripheral sites, as shown by the inversion of pulse pressure (pp) amplification, with a higher pp in the central aorta than in the peripheral arteries during shock. the time constant tau together with ac and tpr were independently decreased. a decrease in brs, lf power, and hrv describe an ans dysfunction. after the administration of fluids and noradrenaline, both vascular and autonomic dysfunction persisted and these were found to be significantly correlated. measures of mechanical vascular function and ans activity could represent an useful end-point to guide further clinical investigations and refine our understanding of ss mechanisms, especially under medical treatment. introduction: lipopolysaccharide (lps), is a component of gram-negative bacteria known for its activation of the host immune system. the phospholipid transfer protein (pltp) has previously been shown to promote the binding of lps to lipoproteins, to limit inflammation and to lower mortality following injections of lps or bacterial infection. the aim of the present study was to investigate the role of pltp and lipoproteins in the detoxification of lps from the peritoneal cavity. injection of lps intra-peritoneally (ip) ( mg/kg) to wild type (wt) and pltp knocked-out mice (pltp-ko) (n = per group). mass concentration and activity of lps were quantitated by lcmsms analysis of -hydroxymyristate and lal bioassay, respectively. lipoprotein fractions in plasma were separated by ultracentrifugation (n= vs n = ). following intra-peritoneal injection, clearance of intra-abdominal lps was faster and plasma neutralization was more efficient in wt than in pltp-ko mice ( figure ) . indeed, lps found in plasma of wt mice was proportionally less active, sustaining a higher capacity for wt mice to neutralize lps (figure b) . quantitative dosage of lps in portal blood, minutes after ip injection, revealed that plasma lps associates rapidly with the lipoprotein fraction (hdl plus ldl), and in higher proportions as compared to pltp-ko mice ( [ - ] % vs [ - ] %, respectively; p < . ). in line with previous studies, these observations now indicate that, lps readily associates with lipoproteins in a neutralizing process pltp mediated. finally, even with a heavy lps load ( mg/kg), the bulk of lps was still found in the lipoprotein fraction ( [ - ] %), suggesting that lipoproteins plus pltp in wt mice have a high capacity to detoxify intraperitoneal lps. in a model of peritonitis, lipoproteins and pltp were found to constitute key playors for peritoneal clearance and neutralization of lps. it emerges as a key pathway for the resolution of the inflammatory response in peritonitis. introduction: autotaxin (atx, enpp ) is a secreted enzyme present in biological fluids that catalyses the production of lysophosphatidic acid (lpa). lpa is a bioactive phospholipid evoking various cellular responses in most cell types. upregulated atx levels have been reported in various chronic inflammatory diseases. given the established role of lpa in the inflammatory response, we investigated a possible role for the atx/lpa axis in lps-induced endotoxemia. methods: lps was injected intraperitoneally ( mg/kg) in mice producing % atx levels (atx df/+ , heterozygous null mutant mice), in mice producing - % reduced atx levels upon inducible inactivation (r creer t /enpp n/n mice) and in mice expressing - % increased atx levels (enpp -tg mice). kaplan-meier survival analysis was performed. atx activity was measured using the toos activity assay. results: atx df/+ mice that produce almost % reduced serum atx levels show increased survival compared to their littermate controls. for the inducible inactivation of atx, enpp n/n targeted mice were crossed with the r cre-er t mice and tamoxifen induction enabled temporal control of floxed gene expression. r creer t /enpp n/n mice were more protected against lps-induced endotoxemia compared to control mice. enpp -tg mice overexpressing autotaxin and showing a -fold increase in plasma levels do not display improved survival rates compared to control group. conclusions: atx participates in systemic inflammation, as reduced atx levels in circulation decrease lethality of mice from caused by lps. the excess amount of circulating atx does not exacerbate the systemic inflammatory response to lps. introduction: pneumonia (pn) is a prevalent and severe infectious lung disease. host genetics plays an essential role in the pathogenesis of infectious diseases including pn [ ] . the aim of the study was to analyze the variability of genes associated with neutrophil activation in pneumonia. to identify differential expressed genes (degs) in communityacquired (cap) and hospital-acquired pneumonia (hap) dataset «genome-wide blood transcriptional profiling in critically ill patients -mars consortium» (gse ) from gene expression omnibus was analyzed (logfc≥ . , fdr-corrected p-value< . ). degs associated with neutrophil activation were selected according to gene ontology go: («neutrophil activation»). with the use of gtex portal and blood eqtl browser, we searched for esnps (expression single nucleotide polymorphisms) in whole blood for neutrophil activation genes differentially expressed in cap/hap. these esnps were further analyzed for their association with pn via the global biobank engine (gbe). a total of degs from gse correspond to go: genes ( up-and down-regulated) of which genes were common to cap and hap. functional enrichment of degs based on disgenet detected top- diseases associated with these genes (fdr-corrected p-value< . ): myeloid leukemia, chronic; sepsis; asthma; lung diseases; allergic asthma. for these genes esnps common to gtex portal and blood eqtl browser were identified. more than half of all variants were located on the second chromosome and influenced the expression of tnfaip and il rap genes. among all esnps we identified variants associated with pn in the gbe (table ) . we identified genes related to neutrophil activation, genetic variability of which was associated with pneumonia. sepsis was induced in wild-type c bl mice (n= ) and cse knockout mice (n= ) by i.p. injection of cfu/mice mdr p. aeruginosa. similar experiments were repeated after cyclophosphamide induced neutropenia. survival was recorded for days. mice were sacrificed for determination of bacterial load and myeloperoxidase (mpo) activity as a surrogate marker of myeloid cell recruitment. cytokines were measured in serum by legendplex inflammatory panel. total leukocytes from mice spleens, with or without pretreatment with the h s donor gyy , were incubated with x cfu/ml mdr p. aeruginosa. bacterial clearance was recorded. we observed a significant decrease in survival of cse -/mice as compared to cse +/+ mice ( % vs. %; p: . ). this survival advantage was eliminated in neutropenic mice ( % for both groups, p: . ). cse -/mice had increased pathogen load in the liver ( . ± . vs . ± . , p: . ) and lung ( . ± . vs . ± . , p: . ). mpo activity was lower in cse -/mice in the liver ( ± vs ± , p: . ) and lung ( ± vs ± , p: . ). cse +/+ mice had increased serum levels of il- ( . ± . vs . ± . of cse -/-, p: . ); mcp- ( . ± . vs . ± . , p: . ) and gm-csf ( . ± . vs . ± . , p: . ). phagocytic activity of leukocytes from cse -/mice was reduced compared to cse +/+ mice. this deficit was eliminated after gyy pretreatment (fig. ) . deficiency of host-derived h s leads to increased susceptibility to mdr p. aeruginosa infection due to an inefficient neutrophil chemotaxis and neutrophil mediated phagocytosis. acknowledgement funded by the itn horizon marie-curie european sepsis academy introduction: neuroinflammation often develops in sepsis along with increasing permeability of the blood-brain barrier (bbb), which leads to septic encephalopathy [ ] . the barrier is formed by tight junction structures between the cerebral endothelial cells [ ] . we investigated the expression of tight junction proteins related to endothelial permeability in brain autopsy specimens in critically ill patients deceased with sepsis, and analyzed the relationship of bbb damage and measures systemic inflammation and systemic organ dysfunction. case series included all adult patients deceased with sepsis in the years - with brain specimens taken at autopsy available. specimens were categorized according to anatomical location (cerebrum, hippocampus, cerebellum). the immunohistochemical stainings were performed for occludin, zo- and claudin. patients were categorized as having bbb damage if there was no expression of occludin in the endothelium of cerebral microvessels. results: % ( / ) developed multiple organ failure before death. . % ( / ) had septic shock. the deceased with bbb damage had higher sofa maximum scores ( vs. , p= . ), and had more often procalcitonin levels above ( % vs. %, p= . ). bbb damage in cerebellum was more common in cases with c reactive protein above mg/l as compared with crp less than ( % vs. %, p= . ). absence of zo- expression in cerebral meningeal samples associated with bbb damage ( % vs. %, p= . ). positive blood cultures (n = ) were associated to absence of zo- expression in cerebellar glial cells ( % vs. %, p= . ). in fatal sepsis, damaged bbb defined as loss of cerebral endothelial expression of occludin ( figure ) is related with severe organ dysfunction and systemic inflammation. loss of zo- in endothelial cells associates with bbb damage, and sepsis contributes to zo- loss in cerebellar glial cells. oxylipins are oxidative breakdown products of cell membrane fatty acids. animal models have demonstrated that various vasoactive oxylipin pathways may be implicated in septic shock pathophysiology but these have been poorly studied in humans. oxylipin profiling was performed on serum samples collected on enrolment to the vanish (vasopressin vs. norepinephrine as initial therapy in septic shock) trial. samples were analysed with liquid chromatography-mass spectrometry. patients were followed up until days. results: samples were collected from of ( . %) patients on inclusion to the trial and ( . %) had died by days. non-survivors were found to have higher levels of a number of oxylipins including: , -dihydroxyeicosatrienoic acid (dhet) (p< . ), , -dhet (p= . ), (s)-hydroxyeicosatetraenoic acid (p= . ), -hydroxyoctadeca-pentaenoic acid (p= . ) but lower levels of the precursor eicosapentaenoic acid (p= . ). when corrected for multiple comparisons with the benjamini-hochberg test, only , -dhet remained significant (p= . ). although there was a difference in median , -dhet levels between survivors and non-survivors, many values were below the level of detection (n= / ( . %)). as such, we also analysed - -dhet as a binary variable (figure ). patients with detectable , -dhet were more likely to die (hr . [ % ci . - . ], p< . ) and have a higher median lactate (p = . ) and total sofa score (p< . ) than those patients where baseline , -dhet was undetectable. our study suggests the oxylipin , -dhet may be associated with septic shock severity and -day mortality. these results are consistent with the known vasodilatory actions of this class of oxylipin. more work is needed to confirm its exact role in septic shock and whether this pathway is amenable to therapeutic intervention. introduction: activation of neutrophils is a mandatory stage and a sensitive marker of systemic inflammatory conditions that can lead to the development of multiorgan failure. the aim of the study was to investigate into the antiinflammatory effects of lithium chloride on human neutrophils in vitro. study was carried out on neutrophils isolated from the blood of healthy donors. % of neutrophils were activated by mkm fmlp, % -by ng/ml lipopolysaccharide (lps); then their activity was evaluated by fluorescent antibodies to cd b and cd b degranulation markers. intact and activated neutrophils were treated with a solution of lithium chloride ( mmol). immunoblotting was used to assess gsk b activity in neutrophils. mann-whitney criterion and p< . were used for statistics. results: lithium chloride mmol decreased the level of expression of cd b on intact neutrophils by % (p= . ), cd b by % (p= . ). fmlp increased cd b expression on neutrophils by . times (p= . ), cd b by . times (p= , ). addition of lithium chloride solution to fmlp activated neutrophils reduced the expression of cd b (p= . ) and cd b (p= . ). lps increased cd b and cd b expression by . times (p= . , p= . , respectively); addition of lithium chloride reduced the expression of cd b (p= , ) and cd b (p= . ) on neutrophils. fmlp led to a dephosphorylation of gsk- b by % (p< . ), lithium chloride increased its phosphorylation by % (p < . ). adding lithium chloride to activated fmlp neutrophils restored the level of gsk- b phosphorylation by % compared to controls (p< . ). lithium chloride modulates the inflammatory activation of neutrophils by bacterial components through the phosphorylation of gsk b in neutrophils. human host immune responses to lipopolysaccharide: a comparison study between in vivo endotoxemia model and ex vivo lipopolysaccharide stimulations using an immune profiling panel dm tawfik introduction: sepsis, a leading cause of mortality among critically-ill patients in the icu, recently recognized by the who as a global health burden. patients that suffer from sepsis exhibit an early hyper-inflammatory immune response which can lead to organ failure and death. in our study, we assessed the immune modulations in the human in vivo endotoxemia model and compared it to ex vivo lipopolysaccharides (lps) stimulation using transcriptomic markers. methods: eight healthy volunteers were challenged with intravenous lps in vivo. in parallel, blood from another volunteers was challenged with lps ex vivo. blood was collected before and after hours of lps challenge and tested with the immune profiling panel (ipp) prototype using the filmarray® system. the use of ipp showed that markers from the innate immunity dominated the response to lps in vivo, mainly markers related to monocytes and neutrophils. comparing the two models, in vivo and ex vivo, revealed that most of the markers were modulated in a similar pattern ( %). some cytokine markers such as tnf, ifn-γ and il- β were under-expressed ex vivo compared to in vivo. t-cell markers were either unchanged or up-modulated ex vivo, compared to a down-modulation in vivo. interestingly, markers related to neutrophils were expressed in opposite directions, which might be due to the presence of cell recruitment and feedback loops in vivo. the majority of ipp markers showed similar patterns of expression post-lps challenge in both models, except for several markers related to neutrophils and t-cells. the ipp tool was able to capture the early immune response in the human in vivo endotoxemia model, which is a translational model mimicking immune host response in septic patients. introduction: serum levels of tyrosine kinase receptor mer and its ligand gas predict mortality in septic patients in the intensive care unit. however, whether their early measurement at emergency department (ed) presentation also predicts mortality and organ failure still needs to be clarified. in this multicentre observational study, septic patients admitted to italian eds were included [ ] . at ed presentation blood samples were taken for routine biochemical analyses and serum mer and gas measurement. urinalyses, blood gas analyses and chest x-ray were routinely performed. mortality at and days, as well as the presence of organ damage such as acute kidney injury (aki), thrombocytopenia, pt-inr derangement and sepsis-induced coagulopathy (sic) were evaluated according to baseline levels of mer and gas . in conclusion, neither mer nor gas are early predictors of mortality in septic patients at ed presentation. however, mer independently predicted the development of sic, thrombocytopenia and pt-inr derangement in this population. glycocalyx shedding correlates with positive fluid balance and respiratory failure in patients with septic shock n takeyama, y kajita, t terajima, h mori, t irahara, m tsuda, h kano aichi medical university, department of emergency and critical care medicine, aichi, japan critical care , (suppl ):p endothelial hyperpermeability would play a major role in septic shock related organ failure. the aim of this study is to clarify the relationship between glycocalyx shedding and respiratory failure, sofa score, plasma angiopoietin (ang)- level and patient survival. methods: plasma samples were collected from septic shock patients from admission to icu discharge and healthy volunteers. plasma syndecan (syn)- and ang- were measured and clinical data was also collected. septic shock patients were classified into groups according to the time-course change of syn- levels. excess syn- (> ng/ml) during to days and remaining high following to days were assigned to group i. excess ang- during to days and decreased following to days were assigned to group ii. moderate increase (< ng/ml) during to days were assigned to group iii. results: plasma syn- levels are positively associated with increased ang- levels (r = . , p= . ), suggesting that ang- is involved in endothelial hyperpermeability. fluid balance and ventilator-free days (vfd) are significantly increased in group i as compared with group iii. sofa score, apache ii and patient outcome does not show any differences between groups i, ii, and iii. the positive correlation between glycocalyx shedding and fluid balance indicates plasma syn- may be a valuable marker for endothelial hyperpermeability. the negative correlation between glycocalyx shedding and vfd indicates plasma syn- may be a valuable marker for respiratory failure. the plasma level of syn- for prognosis and organ failure excluding ards in patients with septic shock requires further investigation. serial procalcitonin measurements in the intensive care unit at hiroshima university hospital k hosokawa, s yamaga, m fujino, k ota, n shime hiroshima university hospital, department of emergency and critical care medicine, hiroshima, japan critical care , (suppl ):p introduction: serum procalcitonin (pct) is a promising biomarker for differentiating bacterial infections from other inflammatory states. moreover, including serial pct measurements in the management of acute respiratory infection reduces the duration of antibiotic therapy without increasing the mortality. however, limited real-world information is available regarding the use of pct in intensive care units (icus). we extracted and analysed data from january to december , from all the orders and results of pct measurements in the icu ( beds) at hiroshima university hospital. a total of , pct measurements from icu patients were included. in patients, pct was tested ≥ times during a single icu stay. serial pct measurements showed a fade-out pattern ( [ %] patients), a second day-peaked decrease pattern ( [ %] patients), and a series of negative patterns ( [ %] patients). compared to patients who demonstrated the fade-out pattern, those who demonstrated the second day-peaked decrease pattern had higher mortality rates ( % vs. %, p < . ). approximately one-third patients in the icu who had decreasing serial pct values demonstrated the second day-peaked decrease pattern. since this group of patients had poorer survival, further studies are needed to clarify the association between a late rise in pct levels and delayed therapeutic intervention. the research was performed on full-term newborns; no clinical signs of bacterial infection were diagnosed. on the , , days the plasmà concentration of il- ß, il- , il- , tnf-α, g-csf, sfas, fgf, no was determined by capture elisa; cd cd , cd cd , cd cd , cd , cd , cd , hla-dr, cd , cd , cd cd , lymphocytes in apoptosis -immunophenotype analysis. by applying the statistical cluster population analysis of the immunological criteria under study we have evaluated the feasibility of sepsis diagnostics at the admission to the intensive therapy unit. the diagnostic rule for sepsis has been formulated by applying the "decision tree" approach to the "r" statistic medium. the cluster analysis confirms the presence of two clusters (presence of absence of sepsis: these two components explain the . % of the point variability). the diagnostic rule for the early diagnostics of sepsis is as follows: disease develops providing during the first hours cd ≥ . %, no≤ . mkmol/l or cd ≤ . %, cd ≤ . %, cd ≥ . % or cd ≤ . %, cd ≤ . %, cd ≤ . % and lymphocytes annexinv-fitc+pi-≥ . %. newborns featured the confirmed sepsis development. the accuracy of this diagnostics amounts to . %; sensitivity to . %; specificity to . %; diagnostic false positive share to . %; diagnostic false positive share to . %; positive result accuracy to . %; negative result accuracy to . %. the aggregate determination of cd , cd , annexinv-fitc+ pi-, cd and the plasma concentration of no enables the pre-clinical diagnostics of sepsis development. efficacy of pancreatic stone protein in diagnosis of infection in adults: a systemic review and metaanalysis of raw patient data j prazak , p egimann , i irincheva , mj llewelyn , d stolz , lg de guadiana-romualdo , r graf , t reding , hj klein , ya que fig. (abstract p ) . impact of h lactate and bio-adm values in patients with elevated lactate level at admission. the green curve in the left km-plot illustrates data from patients with events; the red curve patients with events. the green curve in the right km-plot illustrates data from patients with events; the red curve patients with events. of note, differences in numbers between admission (n= ) and h (n= ) is related to initial mortality introduction: adrenomedullin (am) is a peptide synthesized in vascular endothelial cells and cleared by the lungs. the use of am as an inflammatory biomarker and his predictive value has been studied in critically ill patients, but not yet in veno-venous extracorporeal membrane oxygenation (ecmo). the purpose of this study was to describe the plasmatic levels of am in patients supported with ecmo for acute respiratory failure methods: am (normal values < . nmol/l) was measured at time points: immediately before (t ), -h (t ) and -h after (t ) ecmo initiation and immediately before (t ) and -h (t ) after ecmo removal, in consecutive patients with severe respiratory failure supported with ecmo enrolled in the gatra study (nct ) at fondazione irccs ca' granda -policlinico of milan. data are reported as median ( th - th percentile). statistical analysis was performed using logistic and random effects regression models (to account for repeated measurements within individuals) results: a total of measurements were taken in consecutive patients. am (nmol/l) decreased along the course of ecmo: t = . ( . - . ), t = . ( . - . ), t = . ( . - . ), t = . ( . - . ), t = . ( . - . ) (mean diff.= - . , %: ci - . , - . ). am was lower in patients with viral compared to bacterial ards (mean diff.= - . , %ci - . , - . ) (figure ). am was higher in more severe patients (sofa>= , n= ) compared to less severe patients (sofa< , n= ): . ± . vs . ± . nmol/l, respectively p< . . basal values of am could not predict mortality at days (or= . , %ci: . - . ) after conditioning for sofa score and respiratory failure etiology conclusions: am plasmatic values seem to be higher in more severe patients and in patients with bacterial ards. am decreased along the ecmo course but could not predict mortality in our group of patients fig. (abstract p ) . plasmatic adrenomedullin during ecmo heparin binding protein (hbp) is released from activated neutrophils upon stimulation of b integrins. this pro-inflammatory effect generates the hypothesis that it can be a sepsis biomarker for patients admitted at the emergency department (ed) methods: the prompt study (clinicaltrials.gov nct ) took place at the ed of six greek hospitals. participants were admitted with suspected acute infection and at least one vital sign change. hbp was measured by an enzyme immunosorbent assay in plasma. sepsis was diagnosed by the sepsis- criteria. the primary study endpoint was the sensitivity for the diagnosis of sepsis. outcome prediction was the secondary endpoint. a total of patients were enrolled; had sepsis. the most common infections among patients without and with sepsis were upper respiratory tract infections in . % and . %; community-acquired pneumonia in . % and . %; and acute pyelonephritis in . % and . %. median hbp was . and . ng/ml respectively (p: . ). following analysis of the area under the curve (auc) it was found that the best discriminatory cut-off for sepsis was . ng/ml. the comparative diagnostic performance of hbp versus qsofa score is shown in figure . the odds ratio for sepsis with hbp above . ng/ml was . (p: . ). at the same cut-off point the sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) for the prediction of early death after hours was %, . %, . % and % respectively. hbp is more sensitive but less specific than qsofa for the diagnosis of sepsis in the ed. the rule-out prediction of early death seems the great merit. chronobiological and recurrence quantification analysis of temperature rhythmicity in critically ill patients introduction: rhythmicity and complexity of several circadian biomarkers, such as melatonin, cortisol and temperature have been found to be modified by critical illness. we examined the potential alterations of core body temperature (cbt) fluctuations and complexity in three groups (n= ): patients with septic shock upon icu admission (group a, n= ), patients who developed septic shock at icu hospitalization (group b, n= ) and controls (group c, n= ). the hourly, average cbt was computed for h upon icu admission and discharge in groups a and c, as well as during septic shock onset in group b. cosinor analysis of cbt curves was performed leading to the estimation of mesor (mean value), amplitude (the difference between peak and mean values) and acrophase (phase shift of maximum values in hours). complexity of cbt signals was evaluated with recurrence quantification analysis (rqa). no significant alterations in any circadian feature within groups were found, except for amplitude. controls exhibited increased entry cbt amplitude ( . ± . ) compared to groups a ( . ± . , p < . ) and b ( . ± . , p < . ). higher entry cbt amplitude in groups b and c was related with lower saps ii (r = - . and - . , p < . ) and apache ii scores (r = - . and - . , p < . ) respectively, reduced icu and hospital stay in group b (r = - . and - . , p < . ) and entry sofa score in group c (r = - . , p < . ). recovery cbt time series appeared more periodic in relation with icu entry, for all groups. a more random cbt signals pattern upon results: among . . individuals, . received inpatient treatment for sepsis. % had severe sepsis. % of sepsis and % of severe sepsis patients had an explicitly coded hai. the proportion of hai was higher in patients that received icu-treatment than in patients without icu-treatment ( % in icu/ % in non-icu sepsis, % in icu/ % in non-icu severe sepsis patients). tab. shows the foci of explicitly coded hai. nosocomial pneumonia was the most common hai in all patient groups. clabsi occurred more frequently in icutreated patients; % were affected. cauti and c. diff infections were more common among non-icu-treated sepsis patients. more than one quarter of non-icu-treated sepsis patients had a c. diff infection. hai are common causes of sepsis and pose a significant healthcare burden. the proportion of patients affected and the distribution of foci differ between non-icu-and icu-treated sepsis patients with important implications for sepsis management within hospitals. impact of sepsis protocol triggered by ramathibodi early warning score (rews) in ipd sepsis on clinical outcomes s matupumanon , y sutherasan , d junhasawasdikul , p theerawit sepsis is now early identified and managed during triage in the emergency department. however, there is less focus on the effect of patients' management at the ward level. we aim to evaluate the impact of the implementation of the sepsis protocol on clinical outcomes in in-patients with new-onset sepsis. we conducted a prospective observational cohort study among adult medical patients admitted to the general wards in a university hospital. a -month pre-protocol period (august to august ) was assigned to a control group, and a -month protocol period (september to october ) was allocated to a protocol group. an in-patient sepsis protocol comprised nurse-initiated sepsis protocol by ramathibodi early warning score (rews)≥ plus suspected infection, prompt antibiotic, lactate measurement, and fluid resuscitation was implemented. (table ) . the implementation of in-hospital sepsis protocol was associated with significant improvement in patients' outcomes, namely lactate measurement, starting antibiotic within hr, fluid management, and the shorter length of icu stay. icu routine nursing procedures interfere with cerebral hemodynamics in a prolonged porcine fecal peritonitis model sl liu , dc casoni , w z'graggen , d bervini , d berger , sj jakob routine nursing procedures (np) can interfere with blood pressure and cardiac output and may therefore alter cerebral hemodynamics in critical illness. this may be risk factor of sepsis-associated encephalopathy. methods: sedated and mechanically ventilated pigs were randomized to fecal peritonitis or controls (n= , each). after hours of untreated peritonitis, the animals were resuscitated for hours (resuscitation period). np [assessment of sedation (as), tracheal suctioning (ts), change in body position (cp), lung recruitment maneuver (rm)] were performed at baseline and h, h, h and h after start of rp. systemic and cerebral hemodynamics and o saturations were recorded continuously. shock is the most common cause of death in the postsurgical icu, including septic shock and hypovolemic shock, reaching the - % mortality in septic shock. the inadequate response of the immune system to the infection triggers a potent inflammatory cascade, where the c-reactive protein (crp) is an essential key in the amplification and maintenance of this cascade. the gene encoding to crp is located on the proximal long arm of human chromosome ( q ). the gt polymorphism in the promoter sequence of crp gene (rs ) has been associated with invasive pneumococcal disease. thus, we analyze the relationship between rs polymorphism and the risk of developing septic shock in postsurgical patients. an observational, retrospective and single-center study was conducted on a sample of caucasian patients undergoing major abdominal surgery, of which one part developed septic shock and another part developed systemic inflammatory response syndrome, who were used as control. the rs polymorphism was analyzed by vasoactive medications are commonly used in sepsis treatment but may correlate with peripheral ischemia and the well-publicized complication of limb and digit loss. yet, the association between limb and digit threat and the intensity, duration, and pattern of vasopressor exposure are unknown. we studied adults ( - ) at hospitals in an integrated health system who met criteria for sepsis- . we identified the time to clinically apparent limb or digit threat using clinical adjudication among those with vasopressor-dependent sepsis (i.e. > hour of vasopressors at sepsis onset) who had a surgical evaluation within -days of sepsis onset. we defined daily vasopressor intensity as to vasopressors administered. then, we created a time-dependent model for threat with mortality as a competing risk with a weight function to estimates the varying contribution of vasopressors over time. we determined the subdistribution hazard (sh) ratio of threat for various patterns of vasopressor exposure and intensity, adjusted for age, baseline risk factors, and sequential organ failure assessment (sofa) score at sepsis onset. of , adults with sepsis, , ( %) were vasopressordependent (age, [iqr, - ]; , [ %] males; max sofa score, [sd ] ). of these, , ( %) died and ( . %) had evaluations for limb or digit threat [iqr, - ] days after sepsis onset. the model-based weight function showed the contribution of vasopressors to threat was stable over time ( fig a) . overall, a unit increase in cumulative vasopressor exposure was associated with risk of threat (sh ratio, . [ %ci, . - . ], p<. ). for various patterns of vasopressor exposure, greater intensity associated with increased risk of threat ( fig b) . compared to constant exposure, an increasing and peak pattern associated with the greatest sh (fig c) . cumulative vasopressor exposure was associated with an increased risk-adjusted hazard of limb or digit threat following sepsis. fig. (abstract p ) . relationship between vasopressor exposure and limb or digit threat following vasopressor-dependent sepsis. panel a demonstrates the estimated contribution of daily vasopressor intensity prior to surgical evaluation for limb or digit threat, with mortality as a competing risk. panel b and c explore the relationship between threat and both cumulative vasopressor exposure and the pattern of exposure following sepsis onset. (b) the maximum cumulative vasopressor exposure was associated with the highest risk of limb or digit threat (shr . ) when compared to reference exposure pattern (shr . , reference). (c) increasing (shr . ) and peak (shr . ) patterns of cumulative exposure were associate with an increased sh of limb threat, while a decreasing pattern was associated with a lower risk (shr . ) when compared to constant intensity (shr . , reference). abbreviations: shr: subdistribution hazard ratio proportion of encounters transitioning from phenotype at presentation within hrs, by arrival phenotype assignment and probability of membership. (c) tsne plots for α-type, ß-type, y-type, and ∂-type, with core (dark), marginal (light), and non-members (grey) in plots on the left and core, marginal, non members, and transitioning members (black) on the right fig. (abstract p ). isolated microorganisms critical care references: . wertz et al. critical care explorations : e the process investigators choosing wisely guidelines for the provision of intensive care services, version . ics structured patient handovers references: . care of the critically ill woman in childbirth the proqol manual: the professional quality of life scale:compassion satisfaction, burnout & compassion fatigue/secondary trauma scales references: . shimabukuro-vornhagen a et al. ca the code: professional standards of practice and behaviour for nurses, midwives and nursing associates p introduction: the aim of this study was to compare factors associated with the icu mortality for vap due to multidrug-resistant (mdr) klebsiella spp. in case of monobacterial (mo) vs polibacterial (po) origin. methods: retrospective data analysis of patients treated in icu with mdr klebsiella spp. strains as pathogens of vap during three year period was carried out. results: data of patients were evaluated. mo vs po of mdr klebsiella spp. vap cases was found to be ( . %) vs ( . %), p = . . the icu mortality was / ( . %) in mo, and / ( . %) in po one, p = . . statistical significant differences of survivors vs non-survivors in mo and po vap due to mdr klebsiella spp. were found in medians of neutrophilosis p introduction: we study the population structure and resistome of mdr enterobacterales and pseudomonas aeruginosa isolates, c/t-susceptible or -resistant, recovered from low respiratory, intraabdominal and urinary tract infections of icu patients of portuguese hospitals (step study results: in e. coli, two vim- producers were found (st -b -h -o :h -ctx-m- and st -c-h -o :h ) (c/t-mic= . / - / mg/l). a kpc- -st -cladev-h -o :h ( / mg/l) was also detected. the most frequent esbl-e. coli clone was st cpr klebsiella pneumoniae ( patients), candida spp. ( patients). the comparison subgroup consisted of patients with bacteremia caused by non-escape pathogens. we evaluated the days of mechanical ventilation, duration of antibiotic therapy (amt), icu length of stay (los), hospital los and mortality (table ). results: mortality in patients with bacteremia caused by non-eskape pathogens was . %, candida spp vancomycin mass removal over minutes of hemoperfusion using ha . bars refer to vancomycin mass (mg): blue (experiment ) and red (experiment ) bars using blood while green (experiment ) bar using balanced solution. yellow dashes are mean mass values of the three experiments (with standard deviations) and yellow line represents the reduction curve over time table (abstract p ). results. * p-value versus non-eskape subgroup mechanical ventilation p translational value of the microbial profile in experimental sepsis studies sp tallósy , a rutai , l juhász , mz poles , k burián , d Érces , a szabó , m boros invasive hemodynamic monitoring and blood gas analyses were performed on anesthetized animals between - h of sepsis. the respiratory, cardiovascular, renal, hepatic and metabolic dysfunctions were evaluated with the species-specific sequential organ failure assessment (sssofa) score, the microbial profile was determined with selective media and maldi-tof ms in the initial inoculum and in the abdominal fluid taken h after sepsis induction. results: strong correlation was found between the initial dose of the inoculum (cfu) and the sssofa scores for organ dysfunction (rats: r = . , p= . ; pigs: r= . , p = . ) p introduction: pancreatic stone protein (psp) has shown promise as a biomarker of infection however, its diagnostic potential has not been systematically evaluated. we performed a systematic review and meta-analysis of available data on psp to evaluate its value for detecting infection in adults and determining a plasma or serum threshold value. methods: the pubmed and cochrane library database were searched for studies on psp in adult patients and their raw data were analyzed to estimate the best psp cut-off value that could detect infected patients using the youden's index. the cut-off sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) were computed and compared to those for procalcitonin (pct) and c-reactive protein (crp). finally, we explored the potential value of a model combining all three biomarkers to detect infection. results: from a total of potentially eligible published studies, containing patients were included in quantitative analysis. among them, patients suffered from a clinically confirmed infection. the median appropriate statistical tests were used using spss . cd was expressed as % age of neutrophils expressing positivity. results: sixty patients were analyzed. all parameters were compared between survivors and non survivors. demographics were comparable. most common source of sepsis was lungs and majority were admitted due to medical reason. non-survivors had significantly increased number of days with septic shock. at day median values of all the biomarkers and the sofa score were significantly higher in the nonsurvivor group (p< . ). there was a decreasing trend of all biomarkers and sofa score amongst survivors. on multivariate logistic regression analysis, increased cd and crp levels between baseline and day , increased days with septic shock and increased sofa references: introduction: we characterized the association of c-reactive protein (crp) with extracellular vesicles (evs) in plasma from sepsis patients and assessed a commercial crp adsorbent (pentrasorb, pentracor, hennigsdorf, germany) to deplete free and ev-associated crp. in addition, we characterized the potential pro-inflammatory effects of ev-bound crp on monocytes and endothelial cells monocytes and human umbilical vein endothelial cells (huvecs) were stimulated with isolated evs ( , g, min) monocyte il- secretion was quantified by elisa; the activation of huvecs was assessed by their expression of icam- and e-selectin using confocal microscopy. results: septic plasma (n= ) contained . ± . mg/l crp vs. . ± . mg/ l for healthy controls (n= ). both, total evs and crp + evs were significantly elevated in septic plasma as incubation of septic plasma with pentrasorb resulted in depletion of free crp ( . ± . mg/l before vs. . ± . mg/l after adsorption) as well as in a significant reduction in crp evs from crp-depleted septic plasma induced significantly lower il- levels. huvec icam- or e-selectin expression, however, did not increase upon stimulation with septic evs. conclusions: treatment of septic plasma with pentrasorb efficiently removes free crp and detaches crp from the ev surface, resulting in reduced proinflammatory effects flow cytometry confirmed the association of monocytes with platelets and platelet-derived evs as well as the uptake of evs by monocytes. conclusions: storage of isolated monocytes induces a shift towards cd expressing proinflammatory monocytes, which seems to be mediated by residual platelets and platelet-derived evs. it remains to be clarified whether evs released from activated platelets can also trigger a shift towards proinflammatory, intermediate monocytes in vivo ethical approval was provided by ucl research ethics committee ( / ). paired parametric analyses were performed and data displayed as mean +/- % ci. results: plasma calprotectin concentration began to increase . hours after endotoxin administration, was significantly higher than baseline by hours ( . ng/ml vs. ng/ml, p < . ), peaked at hours (mean ng/ml, figure ) and normalized by hrs. calprotectin peaked earlier than comparator soluble mediators (procalcitonin hrs, crp, hrs) and exhibited % sensitivity; all participants demonstrating a minimum -fold increase from baseline (mean . x). calprotectin displayed greater baseline variability (sd . ng/ml) than either crp or procalcitonin. conclusions: our results indicate the potential of plasma calprotectin as a biomarker for bacterial infection. it increases earlier and peaks more rapidly than standard biomarkers. whilst higher baseline variability was observed p a multicenter randomized controlled study on landiolol for the treatment of sepsis-related tachyarrhythmia: subanalysis of the j-land s study o nishida kagoshima university graduate school of medical and dental sciences, department of emergency and intensive care medicine methods: we analyzed a retrospective cohort of electronic health records from adult sepsis patients at upmc hospitals from to . we defined sepsis- by i.) suspected infection (e.g., administration of antibiotics or body fluid culture) & ii.) organ dysfunction (e.g., or more sofa points) in the first hours of care. data were organized by hour and included vital signs, lab values, and treatments (e.g., total hourly iv fluids (ml) and norepinephrine equivalent dose). for each hour we describe, i.) available data elements, ii.) presence of sepsis- , and iii by hour , most patients had vital signs ( %; n= , ), basic labs ( %; n= , ), fluid cultures ( %, n= , ), while serum lactate was completed in % (n= , ) conclusions: early sepsis care patterns are variable. iv fluids were given during early hours, when uncertainty about sepsis was greatest, while vasopressors were administered after sepsis- elements were present. p effects of abdominal negative pressure treatment on splanchnic hemodynamics and liver and kidney function in a porcine fecal peritonitis model sl liu department of intensive care medicine splanchnic hemodynamics and laboratory parameters were measured at baseline (bl, start of rp), and h, h and h after start of rp. two/three-way rm-anova or mixed-effects analysis, and student t tests were performed. results: npt in controls had no effect. after sepsis induction, mean arterial pressure (map) decreased by ( - ) mmhg, cardiac output (co) by . ( . - . ) l/min, and arterial lactate increased by . ( . - . ) mmol/l. sepsis and resuscitation was associated with increasing hepatic and renal arterial flows (p≤ . , both), and increasing prothrombin time npt in sepsis resulted in numerically less noradrenaline administration ( . ± . ug/ min/kg in sepsis with npt vs. . ± . ug/min/kg without npt, p= . ) and positive fluid balance ( . ± . ml/h/kg with npt vs. . ± . ml/h/kg without, p= . ). conclusions: in our experimental fecal peritonitis model, npt did neither impair splanchnic hemodynamics nor abdominal organ function. whether npt helps to reduce noradrenaline and volume administration in abdominal sepsis should be evaluated in further studies. p association between a c-reactive protein gene polymorphism (rs ) with the risk of develop septic shock in postsurgical patients of major abdominal surgery p martínez-paz valladolid, spain; hospital of medina del campo notably, the three groups received a comparable pro kg dose of acetaminophen. no difference was found between groups in term of toxic effects. patients carrying the cyp a p showed a more pronounced effect on body temperature in respect of wt and ugt a p °c respectively, but it does not reach statistical significance (fig. b). only % of the patients reach a temperature < °c at t and only % < . °c. conclusions: polymorphisms in enzymes involved in the metabolism of acetaminophen are relatively common. cyp a p seems to lead to higher peak plasmatic concentration and a slightly increased efficacy in fever control panel a: variations of acetaminophen plasmatic levels after minutes (t ) and hours (t ) after administration of an iv dose of g of paracetamol in wt patients and patients carrying mutation; panel b: body temperature variations in wt patients and patients carrying mutations clinical research, investigation, and systems modeling of acute illness (crisma) center, department of biostatistics we determined phenotype cohesiveness using probability of assignment at presentation, defining core members as ≥ % and marginal as < % probability. we determined how members transitioned to other phenotypes over hrs using t-distributed stochastic neighbor embedding (tsne) plots and determined the odds ( %ci) of transition. results: we studied , adult sepsis encounters (median age c) the odds of ever transitioning from presenting phenotype increased significantly for marginal members vs publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank the department of education of the basque government (piba - ) and the university of the basque country upv/ehu (ppg / , giu / ) for their financial support. a great disaster affects the family-and friend-performance of bcpr by diminishing the willingness of family and friend bystanders to follow the instruction provided by dispatchers. the experimental method ifitem could be an alternative of fibtem in cases when internal coagulation pathways assessment is prioritized (i.e. heparinized patients on extracorporeal supports). patients undergoing limitation of life-sustaining therapy had lower karnofsky scale scores. therefore, this scale may be useful to guide end-of-life decisions in the future, but further studies with larger number of patients are needed. readmission after discharge home from critical care: a qualitative study c robinson , f nicolson , p mactavish , t quasim , jm mcpeake nhs greater glasgow and clyde, nhs greater glasgow and clyde, glasgow, united kingdom; university of glasgow, nhs greater glasgow and clyde, glasgow, united kingdom critical care , (suppl ):p readmissions to acute care occur in a high number of critically ill patients within days of hospital discharge [ ] . biomedical drivers such as frailty and pre-existing co-morbidities have been identified as drivers for readmission. however at present there is limited data on the influence of social problems on readmission. this study, using a grounded theory approach, sought to understand from a patient/caregiver perspective what the drivers for readmission to acute care were. ethical approval was granted from the west of scotland research ethics service ( /ws/ ). a grounded theory approach was used to explore from a patient and caregiver perspective what the drivers for readmission are [ ] . using a clinical database, we identified those patients who had an icu admission ≥ days who were readmitted to acute care within days of hospital discharge. the researcher attended the ward and after discussion with the direct care team conducted a semi-structured interview with patient and/or caregiver. the interview was recorded and transcribed verbatim. the transcripts were analysed to generate initial codes, followed by the development categories and sub-categories. theoretical sampling was undertaken. results: participants were interviewed. ( . %) were patients and ( . %) were caregivers. the themes that have emerged from the data were: pain and polypharmacy; lack of social support and/or isolation; strained relationships with primary care providers and information provision across the patient journey. subsequent theory development is underway to understand how this learning could help reduce readmissions in future. in conclusion, both social and biomedical drivers are likely to contribute to acute care readmission in this group. future interventional work is required in order to identify modifiable factors to reduce this burden for patients and the healthcare service. frailty has shown to have prognostic relevance for patients with critical illness. since a wide range of tools has been described to screen for frailty, we aimed to describe the association of two frailty screening tools, the clinical frailty scale (cfs) score and the modified frailty index (mfi) in critically ill patients. we performed a post-hoc analysis of a multicenter cohort of patients admitted to six canadian intensive care units (icu) between february and july . frailty was identified using the clinical frailty scale (cfs) and the modified frailty index (mfi). concordance of the frailty screening tools was evaluated with partial spearman rank correlation and intraclass correlation (icc). discrimination and predictive ability of the tools for hospital mortality, -year mortality, hospital readmission and adverse events were compared using concordance statistic (c-statistic) and calibration plot adjusting for age, sex, sequential organ failure assessment (sofa) score and icu admission source, respectively. the cohort included patients. prevalence of frailty was . % ( % confidence interval [ci] . %- . %) with the cfs and . % ( % ci . %- . %) with the mfi. concordance between the two tools was low [(icc of . ; % ci . - . ) and partial correlation coefficient of . ( % ci . - . )], even after adjustment. hospital and -year mortality were greater for frail compared to non-frail patients using of both tools. similarly, both tools found frail patients were less likely to be living independently after hospital discharge, and more likely to be rehospitalized when compared to non-frail patients. while the cfs and mfi show low concordance, both showed good discrimination and predictive validity for hospital mortality. both tools identify a subgroup of patients more likely to have worse clinical outcomes. the post-intensive care syndrome (pics) is a myriad of physical, psychiatric and cognitive disorders secondary to critical illness, leading to a decreased quality of life and an important socioeconomic burden. this study aimed to identify if the conformity to a pics prevention bundle was able to reduce the incidence of the syndrome at icu discharge. all patients admitted to the icu from january st to december st were included. the conformity to each of the ten components of the pics prevention bundle was assessed daily, and the patients were evaluated for anxiety, depression, cognitive dysfunction, muscular weakness, mobility impairment and nutritional risk at icu discharge and at a -to- -months follow-up consultation. the patient cohort was divided in terciles according to bundle conformity for the analysis. results: from the enrolled patients, ( %) were evaluated at icu discharge, and ( %) attended to the follow-up consultation. there was no difference in baseline characteristics between the cohorts. there was no correlation between the prevalence of pics at discharge and bundle conformity during icu stay ( % vs. % vs %, p . ), though there was a decrease in nutritional risk and days in mechanical ventilation (table ) . after to months there was a reduction on the prevalence of any kind of pics, mobility impairment, muscular weakness and nutritional risk. the patients that developed pics were older and had a higher simplified acute physiology score iii at icu admission. a higher adhesion to a pics prevention bundle was not able to prevent the occurrence of the syndrome. post intensive care syndrome (pics) is well recognized following general icu care [ ] . intensive care syndrome:promoting independence and return to employment (ins:pire) is a multidisciplinary complex intervention designed to address pics [ ] . with a paucity of evidence on pics after cardiothoracic intensive care, we aim to evaluate pics and the feasibility of the ins:pire intervention in this population. those attending the clinic received weeks of intervention including individual appointments with icm nurse, physician, pharmacist, and physiotherapist. a café area facilitated peer support alongside psychology group sessions. primary outcome was quality of life measured by eq- d- l. further surveys included: pain, mental health, and selfefficacy. questionnaires were taken at baseline, and months. results: over cohorts, patients attended, % male, median age years (iqr - ), median apache score of (iqr - . ), and median icu length of stay was days (iqr - ). a total of ( %) patients completed surveys at one year. scheduled admissions represented % of those attending. mean euroqol eq-vas score was / (sd +/- ) at baseline increasing to / (sd +/- ) by year (table ) . those with problems in at least one domain of eq- d- l fell from % at baseline to % at -year with the breakdown shown in table . severe problems were seen in % falling to % at year. hads demonstrated an anxiety or depression rate of %. brief pain inventory identified patients ( %) with ongoing chronic pain. mean self-efficacy was / (sd +/- ) at baseline and / (sd +/- ) at year. cardiothoracic intensive care patients have ongoing and persistent features of pics with significant effects on health-related quality of life. further, the ins:pire multi-professional complex intervention is feasible within this specialist group. screening approach might be implemented whenever screening of the total icu population is not deemed feasible. influenza is an acute viral illness with a significant financial burden. point of care testing for influenza is available and has demonstrated accuracy [ , ] , the current gap in knowledge is the question around the opportunity cost of influenza testing. if poct is financially a less costly test this could free up scarce resource. the study adopts a cost minimisation approach. the point of care test is the roche cobas® liat® machine which can detect flu a/b and is compared with the west of scotland specialist virology centre's established in house multiplex real time pcr assay.the model was developed using microsoft excel and has arms comparing analysis of the above mentioned tests. the model estimates that the total cost of poct per patient tested is £ . compared with £ . for lab testing ( figure ). this is a saving of £ . per patient when poct is used. the result swings in favour of the lab test when poct specificity falls to . %. if the lab could provide the result of influenza testing within hours the result would swing in favour of lab testing. zanamivir which will potentially be used increasingly in the intensive care setting can more than double the difference between the tests in favour of poct. this research suggests that poct offers potential cost savings in the icu setting. this is the case as long as poct specificity is higher than a threshold of . % and the lab take longer that hours to return the result. the sensitivity analysis should allow for external validity given the usual variations in icu practice. the aim of the present study is to describe the demographic, clinical, microbiological aspects and the outcome of patients with intensive care unit-related (icu-related) bacteremia. moreover, we aimed to study the patient outcome in association with colistin susceptibility. retrospective, single-center study in a -bed icu for months, from / / to / / . icu-related bacteremia was defined as bacteremia in patients with icu stay > hours or icu readmission (first admission ≥ month before). only the first episode of bacteremia was considered. the primary outcome was -day mortality. data regarding clinical, demographic and outcome characteristics were retrieved from the patient files. the hospital's ethics committee approved the present protocol. moreover, the patients with bacteremia due to colistin-resistant pathogens were compared with the patients affected by colistin sensitive microbes. forty episodes of gram-negative icu bacteremia were collected during the aforementioned period in patients ( . % male) with a mean age and apache ii of . ± . years and ± . , respectively. the event had taken place at an average of . days. the responsible isolates were resistant to carbapenems in . % of the episodes. the majority of the events were due to a single isolate ( %). acinetobacter baumannii and klebsiella pneumoniae presented the majority of the implicated microbes ( % and . %, respectively). the crude -day mortality was %. finally, we could not detect any difference in mortality between the colistin sensitive and the colistin-resistant pathogens ( figure ). the present study denotes that, in a setting of extremely drugresistant pathogens with limited treatment options, gram-negative bacteremia in the icu is associated with increased mortality. image : characterization of resistance mechanisms affecting ceftolozane/ tazobactam in enterobacterales and pseudomonas aeruginosa icu isolates using whole genome sequencing (step study) m hernández-garcia , cc chaves , jm melo-cristino , ds silva , ar vieira , mp f. pinto , jd diogo , eg gonçalves , jr romano , rc cantón hospital ramón y cajal-irycis, microbiology department, madrid, spain; introduction: clostridium difficile infection (cdi) is the main cause of hospital acquired diarrhoea [ ] . the aim of this study was to compare characteristics of cdi during yr and . a retrospective observational study was carried out in lithuanian university of health sciences hospital -the largest teaching facility of tertiary care in country. according to department of infection control records, patients (pt) with (w.) diarrhoea and the first positive stool test for c.difficile toxin a/b were included. age, charlson comorbidity index (cci) score, profile of hospital department (medical (md), surgical or icu) where cdi was diagnosed, type of cdi (healthcare-associated (ha), hospital or community-acquired) and rate of risk factors (rf) have been estimated in both and . ibm spss . ; pearson's chi-square, fisher's exact tests were used for statistics. p < . was statistically significant. results: in total pt from , from were enrolled. in n= ( %) pt were ≥ yr old, in -n= ( %), (p= . ). in cci> was estimated in n= ( %) pt in comparison of n= ( %) in , (p= . ). in n= ( %) of cdi cases were ha, in -n= ( %), (p= . ). in n= ( %) of cdi were diagnosed in md in comparison of n= ( %) in , (p= . ). in weeks prior to cdi n= ( %) pt have been admitted to hospitals, n= ( %) have been treated w. antibiotics, n= ( %) -w. ppis, n= ( %) -w. h antagonists, n= ( %) -w. immunosupressants in comparison of n= ( %), n= ( %), n= ( %), n= ( %) and n= ( %) in , respectively, (p> . ). overall rate of cdi cases among in-hospital patients increased tenfold by yr and . in , more elderly patients had cdi and severe comorbidities were less frequent in comparison with . in , more cases of cdi were hospital-acquired and have occured in medical departments. rate of risk factors of cdi remained unchanged.these results indicate a possible relationship between ttv dna count and immunological alteration. the ttv quantitative determination could be useful as a proinflammatory marker in sepsis, with some benefits: low cost, easy determination and good correlation with immune system functionalit. it will be necessary to perform a larger study to check our hypothesis and to establish a ttv level threshold that may allow to anticípate the disease prognosis. introduction: acute kidney injury (aki) is a serious complication in sepsis and associated with high morbidity and mortality. the combination antimicrobial regimens with vancomycin (vcm) and broad-spectrum betalactams (bsbl), such as piperacillin tazobactam and cefepime, have been identified as potentially nephrotoxic combinations, but existing studies have not provided sufficient evidence. the aim of this study was to evaluate detailed association between the combination antimicrobial therapy and the risk of aki in septic patients. this investigation was a post hoc analysis of prospective nationwide cohorts enrolling consecutive adult patients with sepsis in intensive care units in japan. in this study, progression of aki was defined as one or more elevation of renal sub-score in sequential organ failure assessment score from day to day . we regarded anti-pseudomonal penicillins, fourth generation cephalosporines, and carbapenems as bsbl. multivariable logistic regression analysis including a two-way interaction term (vcm x bsbl) was performed to assess the add-on effects of each antimicrobial agent on the progression of aki. the final study cohort comprised patients with sepsis. among them, received vcm without bsbl, received bsbl without vcm, received both vcm and bsbl, and received other type of antimicrobials. the administration of vcm was associated with an increased risk of aki in patients with bsbl [odds ratio (or), . ( . - . ); p= . ]. however, the tendency was not evident in patients without bsbl [or, . ( . - . ); p= . ]. the interaction effect on the progression of aki between vcm and bsbl were statistically significant (p for interaction= . ). the regression model including two-way interaction term suggested that the combination of vcm and bsbl might synergistically increase the risk of aki in patients with sepsis. increasing resistance to carbapenems due to carbapenemase productionone of main actual problems of antibacterial resistance in burn icu. production of several types of carbapenemases (kpc, ndm and oxa- ) is common in k. pneumoniae strains. carbapemenase production is a marker of extreme antibacterial resistance. the aim of our study was to investigate the epidemiology of nosocomial infections caused by producing kpc, ndm and oxa- k. pneumonia strains in burn icu. total of patients with nosocomial infections caused by carbapenem resistance strains of k. pneumoniae were included in the study, from whom had lower respiratory tract infection, had skin and skin structure infection. initial identification of isolates was performed in laboratory by automatic microbiological analyzer. for all of k. pneumoniae isolates presence of bla ndm , bla oxa- and bla kpcgenes were examined by pcr method. baseline characteristics of patients: me (iqr) of age - ( ; ) years, me (iqr) of tbsa - ( ; ) percent, me (iqr) of icu los - ( ; ) days. inhalation injury was diagnosed in ( . %) patients. total of patients died, mortality rate was . %. all patients were diagnosed with nosocomial infection caused by k. pneumoniae. from k. pneumonia strains ( . %) were found to be producing kpc, ( . %)producing ndm and ( . %) -producing oxa . only ( . %) carbapenem resistance k. pneumoniae isolates were not producing carbapenemases. from patients infected by oxa producing k. pneumoniae patients died, mortality rate was %. from patients infected by oxa or ndm producing k. pneumoniae patients died, mortality rate was . %. from patients infected by non-carbapenemase producing k. pneumonia no one died. carbapenemase producing strains are widely spread among carbapenem resistance strains of k. pneumoniae in burn icu. mortality of patients infected by producing oxa or ndm k. pneumoniae strains reaches . %. the rationale for blood purification as adjunctive therapy during sepsis involved the capacity in removing endogenous and exogenous toxins, but currently no recommendations exists [ ] . a critical point may be the potential interaction with antimicrobial therapy, which remains the mainstay of sepsis treatment. the aim of our study was to investigate the vancomycin (van) removal during blood purification using an in vitro model of hemoperfusion (hp) with ha cartridge (jafron, zhuhai city, china), most widely used in china and actually available in europe. this is an experimental study. three independent experiments were performed: we injected mg of van in ml of whole blood from healthy donors (experiment and ) or in ml of balanced solution (experiment ) in order to assess membrane saturation. a closed-circuit (blood flow of ml/min) simulating hp ran using ha . samples were collected from arterial line at , , , , , , , , minutes; van plasma concentrations were measured and removal was evaluated using mass balance analysis. differences in mass removal was assessed using kruskal-wallis test. results: figure shows van mass at each timepoints. we observed no difference between in blood and in balanced solution experiments (p- the aim of this study is to determine if routine bbv testing in the icu contributes to the discovery of undiagnosed bbv infections. icu patients may require renal replacement therapy (rrt). sharing rrt equipment carries a risk of bbv transmission, which mainly relates to hepatitis b (hbv), hepatitis c (hcv) and hiv. since , all glasgow royal infirmary icu patients undergo routine bbv screening, with rrt machines allocated for patients with specific bbv statuses. routine bbv testing is beneficial to both the individual and society. hcv is a pertinent health issue in scotland. the scottish government aims to eliminate hcv by and is researching innovative and costeffective methods to identify undiagnosed infections. this single-centre retrospective observational study examined prospectively collected clinical data from icu admissions. proportions were compared using a two-proportion z-test and a logistic regression model was carried out to determine if deprivation quintile was independently associated with the seroprevalence of bbvs. the bbv seroprevalence in the cohort studied: . % (hbv), . % (hcv), . % (hiv). the seroprevalence of hbv in the cohort studied was similar to that of scotland (p= . ), but the seroprevalence of hcv (p< . ) and hiv (p= . ) were statistically significantly higher than that of scotland. due to the small number of reactive test results for hbv and hiv, the relationship between deprivation and bbv seroprevalence was explored for hcv only. the only independent variable associated with a reactive anti-hcv test result was "current or previous illicit drug use" (adjusted odds ratio of . ; % confidence interval of . - . ; p< . ). this study shows that routine bbv testing in the icu is useful in discovering new bbv infections. this is the first observational study focusing on the value of routine bbv testing in an icu setting to our knowledge. continuous infusion vancomycin protocol is a safe, acceptable and effective alternative to intermittent dosing of vancomycin in critical care. ceftaroline is an efficacious treatment in patients with severe cap, admitted in icu. it relates to earlier resolution of respiratory failure and less rescue antibiotics. we need an adequately pragmatic trial to confirm our findings organ dysfunction in scrub typhus, incidence and risk factor a sarkar , a guha , r dey [ , , , , ] . its preads by bite of larval stageof thromboculid mites or chigger [ ] . clinical features may include fever, headache, myalgia, lymphadenopathy, eschar, skinrash. it may also cause pneumonia, renal failure, shock, meningoencephalitis, multiple organ failure [ , ] . our study aims to discuss the incidence of organ dysfunction in a comprehensive way taking the overall population of patients with identified scrub typhus infection. there is lack of data in eastern india regarding the incidence and risk factors of developing multiorgan dysfunction syndrome (mods) in scrub typhus. in this retrospective study we studied the incidence of various organ involvement and the risk factors associated with the development of mods in scrub typhus. we collected data from december to november in tertiary care hospital at kolkata. we have included all patients who are having fever, scrub typhus igm antibody positive, age more than years. sofa score was used in evaluating patients with mods. exclusion criteria involves patient who are having coinfectional ong with scrub typhus. in a cohort (n= ), patients with multiorgan dysfunction syndrome was seen in patients ( . %), the mean age in group of patients with mods was . +/- . years (mean+/-sd). in group of patients with mods, fever duration in days was of +/- . days (mean+/-sd), interval from treatment to defervescenc in days was . +/- . days (mean +/-sd). among patients with mods, hematologic involvement was seen in patients ( . %), hepatic involvement was seen in patients ( . %), renal involvement was seen in patients ( . %), neurologic involvement was seen in patients ( %), respiratory involvement was seen in patients ( . %), cardiovascular was seen in patients ( . %), icu shifting was necessary in patients ( . %), mechanical intubation was needed in patients ( . %) in multiorgan dysfunction syndrome patients. hospital mortality in patients with mods was patients ( . %). no mortality was seen in patients without mods. other parameters were evaluated among patients with mods. they include eschar in patient ( . %), seizure in patients ( . %), hepatoslenomegaly in patients ( . %), leucopenia in patients ( . %), leucocytosis in patients ( . %), thromnbocytopenia in patients ( . %),decreased hemoglobin in patients ( . %), transaminitis in patients ( . %). the risk factors associated with the development of mods are platelet counts, bilirubin, transaminitis, glasgow coma scale, time interval from treatment to defervescence, hemoglobin, total leucocyte count and fever duration. scrub typhus is an important cause of acute febrile illness in this part of the country and is frequently associated with organ dysfunction. however, the overall mortality is low which is similar to other studies done before [ ] . score at baseline were significant (p< . ) predictors of mortality.highest area under the roc curve was obtained for number of days with septic shock ( . ) followed by increased cd between baseline and day ( . ). though serial pct levels significantly increased amongst non-survivors, it did not predict mortality. serial level of biomarkers in icu patients may predict mortality. larger trials are needed to confirm the results. plasma strem- levels were retrospectively measured at day - , - and - in septic shock patients from the immunosepsis cohort (nct ), included between / and / , using a validated elisa method. the associations between strem- , mhla-dr, -day survival status, and occurrence of icu-acquired nosocomial infection (ni) were assessed. neither strem- nor mhla-dr levels at d / were associated with the occurrence of icu-acquired ni. however, -day mortality was significantly higher in patients with d - strem- value superior to the median ( . % vs . %, p= . ; median= pg/ml). a significant inverse correlation was found between mhla-dr at d - and strem- at d - (sp - . , p< . ) and at d - (sp - . , p< . ). at d - , when stratifying patients based on strem- ( pg/ml) and mhla-dr ( ab/c), patients combining elevated strem- and low mhla-dr presented with significantly higher day mortality ( . % vs . %, p = . , chi-squared test) and ni incidence ( . vs %, p= . ) compared with patients with low strem- / high mhla-dr. this study shows for the first time that trem- pathway activation is associated with septic shock-induced immunosuppression, as shown by an inverse correlation between strem- at baseline and mhla-dr expression at d - . persisting high strem- values and low mhla-dr expression in septic shock patients are significantly associated with higher rate of icu-acquired infection and mortality. introduction: sepsis mortality remains high [ ] . the surviving sepsis campaign (ssc) recommends to guide resuscitation on normalization of lactate levels [ ] , however this is debated [ ] . we have shown that plasma levels of bio-adrenomedullin (bio-adm) were associated with patient outcome during sepsis [ ] . we therefore aimed to evaluate the added value of bio-adm to lactate measurement in the adrenoss cohort. this is a post-hoc analysis of the adrenomedullin and outcome in severe sepsis and septic shock (adrenoss) cohort study. the adre-noss study is a prospective observational study conducted in twenty-four centers and included septic patients [ ] . we studied the relationship between the association of initial evolution of lactate plasma levels and bio-adm level at h and outcome in patients for whom both markers were available at admission and one day later (" h"). bio-adm levels below pg/ml were considered as low, and high if greater than pg/ml [ ] . in patients with high lactate levels (> mmol/l) at admission (n= ), lactate normalization (< mmol/l) at h was associated with better outcome than in patients with persistently high lactate at h ( day mortality . % vs . % respectively, hr . [ . - . ], p< . ) ( figure ). among patients with decreasing lactate, high and low bio-adm levels at h identified patients with different outcomes ( day mortality % vs % for low vs high bio-adm respectively, hr . [ . - . ], p< . ). high and low bio-adm levels at h also differentiated outcome of patients with persistently elevated lactate (hr . [ . - . ], p< . ). in patients with low initial lactate, neither lactate or bio-adm had no added prognostic. our data suggest that measurement of bio-adm in addition to lactate may help physicians to refine risk stratification and therefore to guide resuscitation during sepsis. the effect of fluid replacement in sepsis, severe sepsis and septic shock in first hrs in clot quality and microstructure s pillai , g davies the inflammatory response in sepsis can lead to a spectrum of coagulation system defects [ ] . sepsis and severe sepsis is associated with a hypercoagulable state where the clot microstructure is known to be a tight and highly elastic clot, which is potentially resistant to fibrinolysis ( figure ). conversely, septic shock is associated with a hypocoagulable state where the clot microstructure is loose and structurally weak. the study aim to investigate the effect of fluid resuscitation and replacement in clot microstructure over hours. methods: patients ( sepsis, severe sepsis and septic shock) were included in the study. all these patients received standard fluid replacement therapy with crystalloids. blood samples were collected at hours, hours and hours. clot microstructure, standard markers of coagulation and inflammatory markers were measured. in sepsis group following fluid administration, the d f reduced initially and then remained stable ( . - hours, . - hours, . - hours, normal d f range . ± . ). in severe sepsis group, the d f reduced initially, then increased ( . - hours, . - hours, . - hours) and in septic shock, the df was very low to start with and there were only slight increase with fluid administration ( . - hours, . - hours, . - hours). the hypercoagulable state and clot quality in both sepsis and severe sepsis group improved with fluid resuscitation, however despite an early improvement in clot quality, ongoing fluid resuscitation resulted in markedly reduced functional clot with very low clot strength and functionality. this study demonstrates that d f as a marker of clot quality and function may have potential in fluid and component replacement in critical illness and injury. this study analyses the prognostic ability of white blood cell count (wbc), neutrophil:lymphocyte ratio (nlr) and c-reactive protein (crp). hypo-and hyperimmune responses have been associated with increased mortality from septic shock [ ] . patients with septic shock (sepsis . ) admitted to queen elizabeth hospital birmingham, between december and july were included. the primary outcome was -day mortality. data was tested for normality and presented as median (iqr) and analysed using a mann whitney u test. categorical data was presented as % and analysed using a chi-squared test. a p value of < . was used to determine significance. a multivariate binary logistic regression analysis was conducted using age, apache ii, charlson comorbidity index, performance status, and initial lactate as covariates. a hosmer lemeshow test of > . indicated good fit. results: patients were admitted with septic shock. the majority ( %) were male, with a median age of ( - ) and a -day mortality of %. on day , wbc was lower in patients who died compared to patients who survived ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] patients who died of septic shock had a lower wbc, nlr and crp response early on compared to survivors. this may represent early immunoparesis that allows infection to propagate unchecked. however, this was not independently associated with mortality when confounding factors were accounted for. a specific metabolite of mitochondriaitaconic acid is formed upon proinflammatory activation. the attempts of various researches to find the itaconic acid in peripherical blood of patients with sepsis were unsuccessful [ ] . some phenylcarboxylic acids (phcas) are known to be microbial metabolites and sepsis biomarkers; they also affect the mitochondrial functions [ ] . concentrations of phcas (phenyllactic, p-hydroxyphenylacetic, phydroxyphenyllactic acids) and mitochondrial metabolites (succinic, itaconic acids) in serum samples from patients on the st day of diagnosis of sepsis and serum samples from patients with late stages of sepsis (sepsis- ) were measured by gas chromatographymass spectrometry; control group - donors. results: itaconic acid was found in low concentrations ( . - . μm) only at early stage of sepsis. the multiple increase in levels of phcas and mitochondrial metabolites were detected in patients with late stage of sepsis in comparison with early stage and donors, p< . . increased succinic acid (up to - μm) concentration is the result of succinate dehydrogenase inhibition by microbial metabolism intermediates (phcas), which was confirmed by in vitro experiments in isolated mitochondria (fig. ) . itaconic acid may be a promising marker in early stage of sepsis, which needs to be proved. prediction of severe events in clinical sepsis is challenging. for such prediction we aimed to compare the novel biomarker calprotectin in plasma, with routine biomarkers. in a prospective study, blood samples were collected from consecutive patients who triggered the sepsis alert in the emergency department in our hospital. c-reactive protein (crp), procalcitonin, neutrophils, and lymphocytes were analysed according to routine practice. p-calprotectin was analysed using a specific particle enhanced turbidimetric assay (gentian diagnostics as). the composite endpoint, which was termed severe event, was defined as death or admission to the intensive care unit (icu)/high dependency unit (hdu) within hours from arrival. the study included patients with written informed consent, of whom were considered to have infection (defined as obtained blood culture and subsequent antibiotic therapy for at least days or until discharge or death), and had no infection. seventy-four patients ( %) with infection developed a severe event. mean pcalprotectin was . mg/l (standard deviation (sd) . ) among patients with infection and . mg/l (sd . ) among patients without infection (p= . ). in patients with infection mean p-calprotectin was . mg/l (sd . ) among those with and . mg/l (sd . ) among those without a severe event (p= . ). analysis of area under the receiver-operating characteristic (roc) curve for prediction of severe events showed superiority for p-calprotectin compared with procalcitonin and neutrophil-lymphocyte-ratio, both regarding all sepsis alert cases and regarding the patients with infection (p< . for all comparisons), fig . in addition, there was a trend toward superior performance compared to crp (p= . and . ). in sepsis alert patients, p-calprotectin was elevated in those who subsequently developed severe events. p-calprotectin was superior to traditional biomarkers for prediction of severe events. introduction: rapid diagnosis of acute infections and sepsis is critical in emergency departments (eds). current tests have slow turnaround times, low sensitivities, and/or signals from contaminant or commensal organisms. empirical antimicrobial treatment may result in severe adverse events and contributes to antimicrobial resistance. diagnostics to distinguish bacterial from viral infections and noninfectious etiologies support clinicians in efforts toward antimicrobial stewardship. in a prospective, non-interventional study in the eds of sites in greece (prompt study nct ), we evaluated hostdx sepsis, a host response test for suspected acute infections and suspected sepsis. hostdx sepsis measures human mrna targets and employs advanced machine learning to differentiate patients with bacterial and viral infections, and noninfectious etiologies. adult patients presenting with suspected acute infection and at least one vital sign change were enrolled. whole blood rna was quantified using nano-string ncounter. predicted probabilities of bacterial and viral infection were calculated (bvn- algorithm). patients were adjudicated in a retrospective chart review by independent infectious disease specialists blinded to hostdx sepsis results. among patients adjudicated as bacterial ( ), viral ( ), noninfected ( ), or indeterminate ( ) the area under the receiver operating characteristics (auroc) of hostdx sepsis for predicting bacterial vs. viral/non-infected patients was . , and auroc for viral vs. bacterial/non-infected patients was . (fig. ) . our results indicate that hostdx sepsis distinguishes bacterial from viral infections and other etiologies with high accuracy. hostdx sepsis is currently developed as a rapid point-of-care device with a turnaround-time of less than minutes. hostdx sepsis may therefore assist ed doctors in making appropriate treatment decisions earlier, towards the ultimate goal of antimicrobial stewardship. we studied the diagnostic value of a leukocyte deformability assay that rapidly quantifies the immune activation signatures of sepsis in an undifferentiated population of adults presenting to the ed. ed clinicians must balance the benefits of early intervention against the risks of indiscriminate use of resource-intensive interventions. there are no currently available rapid diagnostics with acceptable performance to achieve this balance. we prospectively enrolled adult patients within hours of presentation with signs of suspicion of infection in two eds in the usa. edta-anticoagulated blood was drawn and analyzed using deformability cytometry [ ] . procalcitonin (pct) levels were also measured. patients were retrospectively adjudicated for sepsis- by physician committee using the entire medical record. diagnostic performance characteristics and receiver operating curves were used to examine the diagnostic performance of the assay as well as pct. of the patients enrolled, . % were adjudicated as septic. the leukocyte deformability assay demonstrated % sensitivity, % specificity, and % negative predictive value for a single cutoff. the auc was . ( figure ). pct with a cutoff of . ng/ml had % sensitivity, % specificity, and % negative predictive value. the auc for pct (as continuous variable) was . . the leukocyte deformability assay of immune activation signatures demonstrated superior diagnostic performance for sepsis when compared to pct. the assay's diagnostic performance and rapid turnaround time of minutes may positively impact patient outcomes while minimizing indiscriminate use of valuable resources in the ed. it is already known in literature that high levels of midregional proadrenomedullin (mrproadm) are related with organ disfunction in infections despite of source and pathogens [ ] . similarly, microcirculatory impairment has been reported in sepsis. we examine the correlation between microcirculatory disfunction and mrproadm as a sign of early organ failure. we included consecutive adult patients with suspected infection, sepsis or septic shock admitted to our intensive care unit (icu) as first hospital admission with an expected icu stay of > hours. mrproadm was measured daily during the first five consecutive days and sublingual microcirculation was assessed with incident dark field (idf) technology at t , t , and t . we collected information on saps ii, apache scores, and sofa score for each timepoint. results: ten patients had septic shock, sepsis and infection. three patients died during icu stay. a mrproadm clearance of % or more between t and t was found associated with the improvement of mfi (mann-whitney u test, median increase . % versus . %, p= . ) (figure ) . a mrproadm > . nmol/l at the icu admission was associated with a worse sofa score at all the timepoint. moreover, mrproadm levels at admission was found significantly related with icu mortality (auc . [ . - ]; p= . ). mrproadm shown no relation with absolute value of mfi. the study shows a good correlation between the clearance of the biomarker and the improvement in mfi. moreover, our results support previous findings on the prognostic value of mrproadm in terms of sofa and icu-mortality. clinical performance of a rapid sepsis test on a near-patient molecular testing platform r brandon , j kirk , t yager , s cermelli , r davis , d sampson , p sillekens , i keuleers , t vanhoey immunexpress, seattle, united states; immunexpress, immunexpress, seattle, united states; biocartis nv, biocartis, mechelen, belgium critical care , (suppl ):p the purpose of this study was to clinically validate a new, rapid version of the septicyte™ assay on a near-patient testing platform (biocartis idylla™). septicyte™ lab is the first-in-class sepsis diagnostic to gain fda-clearance but has a complex workflow and a turnaround time (tat) of~ hours. the assay in idylla™ cartridge format is called septicyte™ rapid. septicyte™ lab was translated to the biocartis idylla™ near-patient testing platform and analytically validated. for this study, . ml of peripheral blood paxgene tm solution from previously collected patient samples was pipetted directly into the cartridge and inserted into the idylla™ reader. patients were part of an independent cohort (n= ) from intensive care units located in the usa and europe. septicyte™ rapid results were reported as a septiscore™ between and with higher scores representing higher probability of sepsis. assay performance determined included technician hands-on-time (hot), assay tat, failure rates, and area under roc curve based on comparison to retrospective physician diagnosis. average hot was minutes, and average tat was minutes. clinical samples could be processed immediately with septicyte™ rapid and did not require hour pre-incubation of paxgene blood, greatly improving tat. correlation of septiscore™ values between lab and rapid, based upon a subset of samples run on both platforms, was very high (r > . ). estimated roc auc performance for discriminating sepsis from non-infectious systemic inflammation (nisi/sirs) was similar to that previously reported for septicyte™ lab. this is the first demonstration of a validated, fully-integrated, rapid, reproducible, near-patient, immune-response sepsis diagnostic, providing actionable results~ hr, to differentiate sepsis from non-infectious systemic inflammation / sirs. accuracy of septicyte™ for diagnosis of sepsis across a broad range of patients r brandon , k navalkar , d sampson , r davis , t yager immunexpress, seattle, united states; immunexpress, immunexpress, seattle, united states critical care , (suppl ):p the purpose of the study was to demonstrate sepsis diagnostic performance of the biomarkers of septicyte™ in subjects other than critically ill adults, and in hospital locations other than icu. septicyte™ lab was the first immune-response sepsis diagnostic assay to gain fda-clearance (k ) and, as part of gaining this clearance, clinical validation was performed on adult patients admitted to intensive care (icu) only [ ] . we therefore performed an in silico analysis across a broad range of patients using the septicyte™ host immune response biomarkers and algorithm. peripheral blood gene expression data, including public and private datasets, were chosen based on quality, annotation, and clinical context for the intended use of septicyte™. multiple comparisons were performed within datasets to better understand the diagnostic performance in certain cohorts including healthy subjects. diagnostic performance was determined using area under curve (auc). results: table shows some characteristics of the selected datasets and patients, including number of datasets (n= ) and comparisons (n= ), number of cases (n= ) and controls (n= ) used in comparisons, patient category and hospital location. septicyte™ aucs for the three groups of adults, adult / pediatric and pediatric / neonates were . , . , and . respectively, which is similar to that previously reported ( . - . ) [ ] . these results suggest that the septicyte™ signature has diagnostic utility beyond adults suspected of sepsis and admitted to icu. this signature has now been translated to the near-patient testing platform biocartis idylla™ (as septicyte™ rapid) which promises rapid (~ hour) diagnosis of sepsis in a broad patient population following further validation. introduction: especially extracorporeal cardio pulmonary bypass (cpb) is known to induce severe inflammation. postoperative inflammation is associated with a sepsis like syndrome including endothelial barrier disruption, volume depletion and hypotension. sphingosine- -phosphate (s p) is a signaling lipid regulating permeability and vascular tone. in septic humans decreased serum-s p levels could be identified as marker for sepsis severity. we addressed three main issues: ( ) are serum-s p levels affected by cardiac surgery? ( ) are potential alterations of serum-s p levels related to changes of acute-phase proteins, s p sources or carrier? ( ) is the invasiveness of the surgery a factor that may influence serum-s p levels? methods: elective major cardiac surgery patients were prospectively enrolled in this study. serum samples were drawn pre-, post-procedure and on day and day after surgery. we analyzed s pand its potential sources: red blood cells (rbc) and platelets. we further quantified levels of other inflammatory markers and documented other clinical parameters. median serum-s p levels in all patients before the procedure were . (iqr . - . ) nmol/ml. serum-s p levels decrease after surgery, whereas all other inflammatory markers increase. serum-s p levels dropped by % in the on-pump and % in the off-pump group. changes of serum-s p levels are associated with s p sources and carriers: albumin, hdl and vwf:ag activity. patients with a full recovery of their serum-s p levels after surgery compared to their individual baseline presented with a lower sofa score (p> . ) and shorter icu stay (p< . ). serum-s p levels are disrupted by open heart surgery and levels might be negatively affected by endothelial injury or loss of s p sources. low serum-s p levels may contribute to prolonged icu stay and worse clinical status. future studies may investigate the beneficial effects of s p administration during cardiac surgery. the aim of study is to measure and correlate the expression of ncd , mhla-dr, pct (procalcitonin) and qcrp (quantitative creactive protein) to predict development of sepsis and its outcome. in this tertiary centre based longitudinal cohort study, a total patients were enrolled in whom sepsis was suspected on the basis of clinical diagnosis and supported by lab investigations. they were divided into two groups sepsis/case and non-sepsis/control. disease severity in icu was assessed by sequential organ failure score (sofa). blood samples for routine lab investigations and biomarkers were taken at the time of admission in icu before administration of first dose of antibiotics at time d /d . assessment of biomarkers was done simultaneously with tlc at d /d , d and during follow up of patients till their final outcome. there was no significant (p> . ) mean change in pct, qcrp, sofa, ncd , mhla-dr from day to day , however, mean change was higher among cases than controls.on comparison of mhla-dr between the groups across time periods, mhla-dr was significantly (p= . ) lower among septic patients than controls at both day and day . all biomarker correctly predicted cases among different percentage of patients with different sensitivity and specificity. there was no significant (p> . ) association of mortality with the study biomarkers except for pct. in our study, diagnostic value of pct in differentiating sepsis from non-sepsis was similar to ncd among all biomarkers studied. no advantage of ncd or mhla-dr was found over pct in diagnosis and correlation with disease progression and mortality. introduction: aqp is a water channel protein contributing to astrocyte and immune cells migration, blood-brain barrier maintenance and cell survival [ ] [ ] . aqp genetic variants represent biomarkers associating with outcome after traumatic brain injury and intracerebral hemorrhage [ ] [ ] . linking aqp genetic polymorphism to the course of sepsis has not been studied. methods: study cohort included icu patients diagnosed according to sepsis- consensus. aqp rs polymorphism was studied by analyzing pcr products in a % agarose gel using an aqp specific polynucleotide tetraprimer set. data were analyzed by log rank test (medcalc . . ), and odds ratios/hazard ratios were computed. statistical significance was determined by fisher test (ft) or mann-whitney test. results: of sepsis patients had the minor mutation a for snp rs located within the regulatory ' region of the aqp gene. septic shock occurred more frequently in homozygotic carriers of aqp c allele vs. patients with aa or ca genotype: or= . ( %ci: . - . ), p= . (ft). lethality in septic shock patients, n= , significantly increased compared to sepsis patients with no shock, n= ( % vs. %, p= . , ft). maximum sofa values were significantly lower in patients with minor allele a compared to cc carriers of ( . vs. . , respectively, p= . ). in post-surgery group of patients, carriers of ac or aa genotypes had significantly increased survival compared to patients with cc genotypes: chi-square= . ; hr= . ( %ci: . - . ) for lethality; p= . (figure ) . association of minor allele a of aqp snp rs with survival in sepsis patients seems secondary to linking the snp to decreased development of multiorgan failure and septic shock that contribute to mortality. validation of presepsin as a biomarker of sepsis in comparison to procalcitonin, il- and il- v chantziara , f kaminari , c sklavou , s fortis , p kogionou , s perez , a efthymiou saint savvas hospital, icu, athens, greece; saint savvas hospital, cancer immunology and immunotherapy center, athens, greece critical care , (suppl ):p sepsis is an everyday challenge for the intensivist and biomarkers are useful tools for identification and treatment of this syndrome. we sought to validate presepsin as a biomarker of sepsis in comparison to pct(procalcitonin) and interleukins (il- ,il- ). we enrolled patients, men and women average age ( . - ) years old, apache ii ( . - . ), saps ii ( . - . ), sofa ( . - ). patients were septic on admission (according to surviving sepsis campaign: international guidelines for management of sepsis and septic shock: ), had a septic episode during their hospitalization in the icu while patients never endured sepsis. we measured presepsin, procalcitonin, il- , il- during sepsis and on remission. results: all septic patients had increased values of presepsin, pct, il- and il- during sepsis with a cutoff value for presepsin pg/ml, while the values of these biomarkers were significantly decreased during remission or in comparison to non-septic patients(presepsin p = . , pct p≤ . , il- p≤ . , il- p= . . all patients who were not septic survived while among septic patients died ( % mortality). presepsin correlated significantly with pct, il- and il- (p< . ). presepsin is a valid biomarker of sepsis and correlates significantly with all the other values of pct, il- and il- . clinical sepsis phenotypes are proposed at hospital presentation. these phenotypes, biomarker profiles, and outcomes are not yet reproduced in prospective data. even less is known about the biologic mechanism the drives these distinct groups. thus, we sought to validate clinical phenotypes and to determine markers of innate immunity, coagulation, tolerance and tissue damage in a prospective cohort. we prospectively studied patients with sepsis- criteria within hours of presentation at hospitals in pennsylvania ( - ) using automated electronic alerts. using clinical variables, we predicted phenotypes (α, β, γ, δ) for each patient using euclidean distance anchored to published seneca phenotype centroids. discarded blood was analyzed in a subset (n= ) for markers of innate immunity (e.g. il- , il- ), coagulation (e.g antithrombin iii, eselectin), tolerance (e.g. ho- , igfbp ), and tissue damage (e.g. serum lactate, bicarbonate) results: among patients, α-type was present in ( %), β-type in ( %), γ-type in ( %) and δ-type in ( %, figure a ). on average, β-type was older and more comorbid (mean , sd yrs; mean elixhauser . , sd . ) with renal dysfunction (median creatinine . [iqr . - . ] mg/dl, p< . all). the δ-type had more acidosis (mean hco - . , sd . meq/l), higher serum lactate (median . [iqr . - . ] mmol/l, p < . both) and inpatient mortality ( %, figure b) . the γand δ-type had greater markers of innate immunity and abnormal coagulation (e.g il- , icam p< . both), while markers of increased tissue damage (lactate) and poor tolerance (ho- ) were present in δ-type, compared to α-type (figure c) . the distribution and characteristics of clinical sepsis phenotypes were reproduced in a prospective validation cohort. similar to the seneca study, distinct biomarker profiles of tissue damage, innate immunity and poor tolerance were present for the δ-type. the effect that neoadjuvant chemotherapy and hyperthermic intraperitoneal chemotherapy (hipec) may have in the postoperative kinetics of biomarkers remains unknow. some studies demonstrate that neoadjuvant chemotherapy and hipec do not invalidate the use of inflammatory markers in postoperative patient monitoring, but none have compared biomarkers kinetics between patients who underwent hipec or only cytoreduction surgery. our main purpose was to identify a difference pattern in c-reactive protein (crp). we conducted a single-center observational study from january to november , including all patients who underwent cytoreductive surgery with or without hipec. crp was measured daily until seven post-operative day. we compared patients with and without hipec. a total of patients were included, were female. mean age was yrs ( - ). no clinical and demographical differences were observed between groups. no documented infection was found. after surgery crp increased markedly in both groups. crp time-course from the day of surgery onwards was significantly different in hipec patients ( . ± . mg/dl vs . ± . mg/dl; p= . ). multiple comparisons between hipec and non hipec patients were performed and crp concentration was significantly different on the th and th pod (figure ). no differences were found in other biomarkers (leucocytes and platelets) neither in body temperature. after a major elective surgical insult crp levels markedly increase independently of hipec. serum crp time-course showed a higher pattern in hipec patients despite no infection detected. decreased thrombin generation potential is associated with increased thrombin generation markers in sepsis associated coagulopathy d hoppensteadt , f siddiqui , e bontekoe , r laddu , r matthew , e brailovsky , j fareed. introduction: sepsis associated coagulopathy (sac) is commonly seen in patients which leads to dysfunctional hemostasis in which uncontrolled protease generation results in the consumption of clotting factors. the purpose of this study is to determine the thrombin generation potential of baseline blood samples obtained from sac patients and demonstrate their relevance to thrombin generation markers. baseline citrated blood samples were prospectively collected from patients with sac at the university of utah clinic. citrated normal controls (n= ) were obtained from george king biomedical (overland park, ks). thrombin generation studies were carried out using a flourogenic substrate method. tat and f . were measured using elisa methods (seimens, indianapolis, in) . functional antithrombin levels were measured using a chromogenic substrate method. the peak thrombin levels and auc levels were lower in the sac patients in comparison to higher levels observed in the normal plasma ( table ). the sac group showed much longer lag time in comparison to the normal group. wide variations in the results were observed in these parameters in the sac group. the f . and tat levels in the sac group were much higher in comparison to the normal. the functional antithrombin levels were decreased in the sac group. these results validate that thrombin generation markers such as f . and tat are elevated in patients with sac. however, thrombin generation parameters are significantly decreased in this group in comparison to normal. this may be due to the consumption of prothrombin due to the activation of the coagulation system. thus, persistent thrombin generation with simultaneous consumption of clotting factors such as prothrombin contributes to the consumption coagulopathy observed in sepsis patients. introduction: procalcitonin (pct) is used in the icu as an inflammatory marker to monitor bacterial infections and guide antibiotic therapy. whether pct can predict bacteremia and therefore could prevent expenses attached to bloodcultures is unknown . we investigated whether pct can predict the outcome of blood cultures in the icu and reduce expences. a single centre observational cohort study was performed in a dutch community teaching hospital . adult patients who were staying in the icu and were suspected of bacteremia were included. simultaneously with drawing of blood cultures, samples for pct measurement were obtained. expenses for pct measurement and bloodcultures were calculated. in the study period of one year, a total of patients were included. three patients were excluded because of incomplete data. out of the included patients, ten patients had positive blood cultures. there was a significant difference in pct levels between patients who had positive bloodcultures versus patients with negative bloodcultures ( . ng/ml vs . ng/ml) ( figure ). the negative predictive value for negative blood cultures is % when pct is below ng/ml, there was no difference in crp levels between the two groups ( mg/l vs mg/l, p= . ).a set of negative blood cultures in our centre costs euros. positive blood cultures however costs significantly more depending on the micro-organisms found. pct only costs . euros per measurement. so when blood cultures are omitted when the pct level is below ng/ml, a cost reduction of % can be achieved. a pct value below ng/ml is a good predictor of a negative blood cultures in icu patients suspected of bacteremia. pct guided bloodculture management in these patients could lead to a significant cost reduction introduction: level of cfdna in plasma is a promising prognostic candidate biomarker in critical illness [ ] . oxidized cfdna (ocfdna) have not been studied as a biomarker although its functional role in cellular stress have attracted attention of researches [ ] . the goal of our study was to assess the early prognostic value of plasma cfdna/ocfdna for sepsis in a nicu setting. the cohort included nicu patients diagnosed with stroke, intracerebral hemorrhage (ich), anoxia, encephalopathy. cfdna was isolated from day plasma and stained with picogreen. oxidized dna was determined using dna immunoblotting with anti- -oxo-desoxiguanosine antibodies. genotyping of allelic variants of the tlr rs gene was performed using a pcr and designed allele-specific tetraprimers followed by electrophoretic separation of the products statistics was performed by the fisher test and mann-whitney test. results: sepsis was diagnosed by sepsis- criteria in patients ( . %). average nisu staying was , ± , days. circulating dna plasma levels on day predicted the future sepsis development (figure ): or for cfdna was . ( %ci: . - . ), p< . ; or for ocfdna was . ( %ci: . - . ), p= . . power of both performed tests with alpha= . : . . log rank test demonstrated better predictive value of cfdna vs. ocfdna (figure) . concentrations of cfdna, but not ocfdna, on day significantly positively correlated with maximum sofa values during hospitalization, day and pre-outcome leukocyte count and neutrophil-to-lymphocyte ratios in a limited cohort of nisu patients with tlr rs cc genotype and not in other patients with genotype tlr ct+tt. increased level of plasma cfdna better then ocfdna predicts sepsis development in nisu. further studies are warranted to clarify the fig. (abstract p ) . pct values in patients with positive blood cultures and patients with negative blood cultures possible utility of tlr rs polymorphism determining for sepsis risk stratification early on nisu admittance. admission was related with higher severity of illness and extension of icu stay for all groups. reduced cbt fluctuations upon icu admission was found to more severely ill patients with worse clinical outcomes, while the more periodic cbt patterns were correlated with high cbt rhythmicity and better outcome. the impact of sex on sepsis incidence and mortality have been elucidated in previous studies, and sex is increasingly recognized as one key factor in sepsis [ ] . some studies indicate that women have better immunologic responses to infections [ ] . later investigations assume this advantage is linked to immune modulating genes located on the x-chromosome [ ] . the purpose of this study is to reveal sex differences in incidence of and mortality of sepsis in a large population-based cohort. methods: adult participants in the hunt study ( - ) were followed from inclusion through end of . incident bloodstream infections (bsi) from all local and regional hospitals in nord-trøndelag county were identified through linkage with the mid-norway sepsis register, which includes prospectively registered information on bsi used as a specific indicator of sepsis. we estimated age-adjusted cumulative incidence of first-time bsi and compared the risk of a first-time bsi and bsi mortality in men and women using age-adjusted cox proportional hazard regression. during a median follow-up of . years individuals experienced at least one episode of bsi, and died within days after a bsi. cumulative incidence and cumulative mortality curves are shown in fig. a introduction:the proportion of hospital-acquired infections (hai) among sepsis patients is unknown in germany. systematic differences in hai foci between sepsis patients with and without icu treatment are insufficiently described. retrospective cohort study based on nationwide health claims data of the german statutory health insurance aok. incident inpatient sepsis cases were identified in / among insured persons > y without preceding sepsis in months prior to index hospitalization. sepsis was defined according to explicit sepsis icd- -codes (incl. severe sepsis/septic shock). hai were defined based on specific icd- -codes for surgical site infection, catheter- introduction: elevated renin is associated with an increased risk of death in patients with vasodilatory shock (vs). recent data show that patients with vs and elevated renin levels have improved survival when treated with angiotensin ii (ang ii) + standard care (sc) vs placebo + sc. patients with acute respiratory distress syndrome (ards) can develop angiotensin-converting enzyme (ace) defects that can lead to elevated renin levels and insufficient endogenous ang ii production. we hypothesized that patients with severe ards and elevated renin shock would have improved survival when treated with ang ii + sc vs placebo + sc. in the randomized, placebo-controlled, double-blind athos- study, patients with severe vs receiving > . μg/kg/min of norepinephrine or the equivalent were randomized to intravenous ang ii (n= ) or placebo (n= ). in a post hoc analysis, we assessed the subset of patients with elevated renin (defined as a renin level greater than the median value of the overall athos- population) and ards (defined by a pao /fio ratio < ) at the time of randomization. survival to days was compared between the ang ii group (n= ) and the placebo group (n= ). in patients with elevated renin and ards, baseline age, acute physiology and chronic health evaluation ii score, and blood pressure were similar in the ang ii and placebo groups. the median serum renin level was . pg/ml (iqr: . - . ) compared to the normal range for serum renin: - pg/ml. a significantly higher proportion of patients receiving ang ii survived to day compared to those in the placebo group ( % vs %; p= . ). elevated renin identified patients with vs and ards who were most likely to gain a survival benefit from ang ii. elevated renin is likely caused by an ace defect and may describe an important subset of patients with a biotype that responds well to ang ii therapy. introduction: elevated renin levels have been shown to be associated with an increased risk of death and more severe acute kidney injury (aki) in patients with vasodilatory shock (vs). recent data show that patients with vs and elevated renin levels have improved survival when treated with angiotensin ii (ang ii) + standard care (sc) vs placebo (pbo) + sc. we hypothesized that vs patients with severe aki and elevated renin levels would have improved survival and enhanced renal recovery with ang ii treatment. in the randomized, pbo-controlled, double-blind athos- study, patients with severe vs received > . μg/kg/min of norepinephrine or the equivalent and were randomized to intravenous ang ii + sc (n= ) or pbo + sc (n= ). in a post hoc analysis, we assessed the subset of patients with elevated renin (defined as a renin level greater than the median value of the overall athos- population) and severe aki (defined as those with aki requiring renal replacement therapy [rrt] at baseline). survival and renal recovery were assessed in patients treated with ang ii + sc (n= ) and pbo + sc (n= ). in patients with elevated renin and severe aki, baseline age, acute physiology and chronic health evaluation ii score, and blood pressure were similar between ang ii + sc vs pbo + sc. the median baseline serum renin level in the whole group was . pg/ml (iqr: . - . ; normal range for serum renin: - pg/ml). a significantly higher proportion of patients receiving ang ii + sc vs pbo + sc survived to day ( % vs %, respectively; p= . ). ang ii recipients also had a higher rate of discontinuation from rrt by day ( % vs %; p= . ). in this study, elevated-renin shock patients with aki treated with ang ii + sc gained a survival benefit and earlier discontinuation from rrt compared to those receiving pbo + sc. elevated renin is likely caused by an angiotensin-converting enzyme defect and may identify those patients with a biotype that responds well to ang ii therapy. most clinical trials conclude the ineffective use of anticoagulation for sepsis-induced coagulopathy [ ] . however, post hoc analyses of randomized control trials report positive results [ ] , suggesting anticoagulation is effective in specific populations exhibiting coagulopathy. further, anticoagulants should be administered in the early phase [ ] ; however, methods for precisely predicting the progression of sepsis-induced coagulopathy are not established. this study aimed to create and evaluate a prediction model of coagulopathy progression using machine-learning techniques. we performed a subgroup analysis of data from a retrospective cohort study involving adult septic patients in japanese institutions from january to december and used the japanese association for acute medicine disseminated intravascular coagulation (dic) score as a dic severity index test. the predictive ability of Δdic ([dic score on day ] -[dic score on day ]) was evaluated using various statistical methods. using variables available at the outset, we compared the predictive ability of random forest (rf) and support vector machine (svm) with that of multiple linear regression analysis. a total of adults with sepsis were included in the analysis. the root mean square error in Δdic score for the multiple linear regression analysis model was . compared with values of . and . for rf and svm, respectively. thus, the rf method predicted the progression of sepsis-induced coagulopathy more accurately than multiple linear regression analysis. conclusions: rf, a machine-learning technique, was superior to multiple linear regression analysis in predicting the progression of sepsis-induced coagulopathy. this prediction model might enable us to use anticoagulation in an early phase. this study examined the efficacy and safety of landiolol, an ultrashort-acting β -blocker, for treating sepsis-related tachyarrhythmia, according to patient background characteristics. the j-land s study (japiccti- ) was conducted in patients with sepsis, diagnosed according to the sepsis- criteria, and tachyarrhythmia (atrial fibrillation, atrial flutter, or sinus tachyarrhythmia). the patients had a mean heart rate of ≥ beats/min and required catecholamine administration to maintain a mean blood pressure of ≥ mmhg. the efficacy endpoint was the percentage of patients whose heart rate could be controlled within - beats/min at h of registration. the safety endpoint was the incidence of adverse events within h of registration. subgroup analyses of efficacy and safety were performed after stratifying the patients according to various patient background characteristics. a total of patients were randomized, to landiolol and to the control group. the efficacy endpoint, percentage of patients with a heart rate of - beats/min at h of registration, was significantly higher in the landiolol group ( . % vs . %; mantel-haenszel test: p = . ). the incidence of adverse events was . % and . % in the landiolol and control groups, respectively, and there was no difference between the two groups. most adverse events were related to sepsis or septic shock. the subgroup analyses showed that no patient background characteristic clearly affected the efficacy and safety of landiolol. landiolol is a well tolerated and effective therapeutic agent for controlling heart rate in patients with sepsis-related tachyarrhythmias; its safety and efficacy were not affected by the patient background characteristics investigated. tissue oxygenation monitoring in sepsis r marinova, at temelkov umhat alexandrovska, anesthesiology and intensive care, sofia, bulgaria critical care , (suppl ):p near-infrared spectroscopy (nirs) was proposed as a concept in the end of th century. this method offers noninvasive monitoring of oxy-and deoxyhemoglobin in tissues.nirs could be measured on the thenar or forehead within few santimeters of the skin. it was first applied as a monitoring in cardiovascular surgery. patients with sepsis have changes in the microcirculation which are important target for therapy. invasive monitoring of oxygen delivery and consumption has been used in patients with sepsis but as every invasive technique such a monitoring hides risks. nirs offers a noninvasive method for tissue oxygenation monitoring (sto ) and could be useful in patients with sepsis and septic shock. the aim of the study is to compare noninvasive tissue oxygenation monitoring with hemodinamic monitoring and lactate values in patients with sepsis methods:the study includes critically ill patients in icu of umhat alexandrovska, sofia. of the patients fullfil the criteria for septic state. the other patients do not have sepsis. in both group of patients are measured tissue oxygenation with invios monitor, mean arterial pressure, oxygen saturation in mixed venous blood and lactate values during h after icu admission. patients with sepsis are reported with significantly lower values of tissue oxygenation, compared to patients without sepsis. the values of tissue oxygenation correlate well with the mixed venous blood oxygenation, mean arterial pressure and lactate values but not significantly with apache scores. conclusions: nirs when used for tissue oxygenation monitoring correlates well with the hemodinamic monitoring and lacate values in patients with sepsis and could be used as an noninvasive monitoring for guiding teurapeutic strategies. tissue oxygenation monitoring has no linear correlation with the severity of illness in patients with sepsis and could not be reccomended as a guidance in the early ressuscitating stage of sepsis. further investiganions in these field are needed.the sequenom´s massarray platform and a recessive inheritance model was selected (cc vs tt/ct). the possible association between the cc recessive form of the rs polymorphism and the septic shock risk was analyzed, demonstrating a statistically significant relationship (p= . ) between both conditions. among patients who developed septic shock, . % presented a recessive inheritance pattern while . % showed the ct/tt genotype. on the other hand, those patients with the recessive form of the rs polymorphism were selected and a statistical analysis was performed comparing those patients who developed septic shock from those who did not develop it, obtaining a statistically significant relationship (p= . ) between the presence of the recessive form of polymorphism and the likelihood of developing septic shock. the recessive form of rs polymorphism is a risk factor for septic shock in post-operative patients of major abdominal surgery. introduction: sepsis remains one of the major causes of morbidity with mortality rates as high as % worldwide, representing significant clinical challenge to confront highly intangible therapeutic needs. rnabased structures are emerging as versatile tools encompassing a variety of functions capable to bypass the current protein-and cellbased therapies. rna aptamers act as disease-associated protein antagonists. here, the effects of an aptamer, apta- , were evaluated in animal models that mimic systemic inflammation in humans. high dose of lps endotoxin was used to induce systemic inflammation in mice and in non-human primate animal models. apta- was administered intravenously in two doses post lps infection. animals were monitored and blood samples collected up to hours after apta- administration. healthy-and lps-only treated animals served as control groups. complex analyses of clinical parameters, hematology, serum biochemistry, inflammation and tissue damage markers were performed. results: apta- increased survival of endotoxin challenged animals up to % in a dose-dependent manner and exerted profound effects on wellbeing and recovery of healthy eating habits. administration of apta- led to delayed coagulation and enhanced fibrinolysis; maintained the complement cascade activated while preventing it from further amplification. expression of pro-inflammatory cytokines was reduced while anti-inflammatory increased. endogenous pro-inflammatory molecules (damps), secreted from injured cells, were preserved at healthy level in animals treated with apta- . systemic inflammation and sepsis lead to severe dysregulation of several arms/axis of innate immune response. our studies showed that apta- affects various components of this system and restores the organism's control over its dysregulated immune response. thus, apta- might be a promising potential therapeutic candidate to treat life-threatening conditions such sepsis. several preclinical studies demonstrated beneficial effects for methane (ch ) administration in various inflammatory conditions. our aim was to investigate the consequences of post-treatment with inhaled ch in a clinically relevant intra-abdominal sepsis model. anesthetized minipigs were subjected to fecal peritonitis ( . g/kg, - x cfu i.p.; n= ) or sham-operation (sterile saline i.p; n= ). invasive hemodynamic monitoring with blood gas analyses was started between - hours, organ dysfunction parameters (pao /fio ratio; mean arterial pressure; lactate, bilirubin, creatinine; urine output and platelet counts) were determined according to a modified porcinespecific sequential organ failure assessment (ps-sofa) score system, the perfusion rate (pr) of sublingual microcirculation was measured by incident dark field illumination imaging. the animals were divided into non-treated septic or septic shock groups (n= - ) and ch treated septic or septic shock (n= - ) subgroups, ch inhalation started from the th hr ( . % ch in normoxic air; ml/min). despite the standardized induction, heterogeneous severity of organ damage was evolved. in septic and septic shock groups the median values of ps-sofa score reached ( . - . ) and ( . - ), respectively. septic shock was characterized by significant elevations of creatinine and bilirubin levels, while the platelet count decreased (from to * /l). inhalation of ch increased the sublingual pr by % in the septic group, the creatinine and bilirubin levels were decreased by % and %, respectively. ch post-treatment significantly decreased the ps-sofa score (to ; . - . ) and resulted in lower values in septic shock group (to ; . - . ). methane post-treatment effectively influences sepsis-related end organ dysfunction. up to a severity threshold it may be a promising additional organ protective tool. evaluation of sepsis awareness among various groups in turkey: a survey study s erel, o ermis, Ö nadastepe, l karabıyık gazi university school of medicine, anesthesiology and intensive care, ankara, turkey critical care , (suppl ):p introduction: sepsis is a common life-threatening condition in critically ill patients [ ] . public awareness is important for early recognition of sepsis and improvement of outcomes [ ] . we aimed to evaluate sepsis awareness among different groups of people. methods: prospective paper-based surveys were issued between st july and st august to patients, the relatives of the patiens, hospital staff and general public who gave consent to participate in the study. the questionnaire included ten questions about demographic informations, occupational informations of hospital stuff and sepsis awareness. a total of participated in the survey. of these participants, ( . %) were patients, ( . %) were relatives of patients, ( . %) were physicians, ( . %) were medical students, ( . %) were nurses, ( . %) were other hospital stuff and (% . ) were other people. of these participants, ( . %) had heard of the word "sepsis". ( . %) responded correctly regarding the definition of sepsis. ( . %) of the participants heard the word "sepsis" during their education, but only ( %) heard it through the media. in the groups of high school graduates, university graduates and postgraduates, the rate of hearing the word sepsis and correctly identifying sepsis is significantly higher than the primary school graduates or illiterate groups. (p< . ). physicians, nurses and medical students were heard of the word "sepsis" significantly more than other groups (p< . ). physicians and medical students responded more accurately to the definition of sepsis than other groups (p< . ). public awareness of sepsis is limited compared to healthcare workers. increasing public knowledge of sepsis through education and through media may contribute to raising public awareness and improving outcomes. the association between clinical phenotype cohesiveness and sepsis transitions after presentation jn kennedy , eb brant , km demerle , ch chang , s wang , dc angus , cw seymour key: cord- -li pwigg authors: nan title: esicm monday sessions october date: - - journal: intensive care med doi: . /s - - -x sha: doc_id: cord_uid: li pwigg nan methods. for the present investigation, healthy male volunteers with a mean age of ± . years were recruited for a cardiovascular screening exercise stress test prior to inclusion for the study. during the lbnp protocol, the subjects were exposed to sequential increasing negative pressures of - , - , and - mmhg while resting in a supine position with their legs sealed in the lbnp chamber at the level of the iliac crest. in addition to continuous registration of cardiac output (co) and mean arterial pressure (map), sublingual perfused vessel density (pvd) ( ) and microvascular flow indices (mfi) ( ) were measured using sidestream dark-field (sdf) imaging before (t ), during (t ; - mmhg), and after (t ) lbnp. results. there were no significant differences in mean co and map in our subjects. introduction. fever management remains controversial in sepsis. control of thermal balance might improve vascular tone but fever could play a role in host defence. objectives. the aim of this multicentre randomised controlled trial was to determine primarily whether external cooling might accelerate the weaning of vasopressors in patients with septic shock. patients with septic shock treated with epi/norepinephrine infusion and fever over . °c were enrolled in centres when also requiring mechanical ventilation and sedation. patients received external cooling to reach normothermia ( . - °c) during h (n = ) or had fever respected (n = ). a goal of mmhg for mean arterial pressure was used in the two groups. a similar algorithm was used for weaning of vasopressors. the main end point was the number of patients achieving a % decrease in the initial dose of vasopressor in the two groups. shock reversal was defined by vasopressor withdrawal for at least h. at inclusion the two groups (cooling/respect of fever) were similar for age ± versus ± years, saps iii ( ± vs. ± ), sofa score ( ± vs. ± ), and body core temperature ( . ± . vs. . ± . °c). a similar number of patients received steroids and a pc before enrolment. body temperature became significantly lower in the cooling group within the h of treatment: . ± . vs. . ± . at h and . ± . vs. . ± . °c at h (p \ . ). the decrease in vasopressor was more rapid in the cooling group (fig. ). shock reversal was vs. %, p = . and in-hospital mortality was vs. % in the cooling and the respect of fever groups respectively. conclusions. these preliminary results show that treating fever using external cooling in septic shock patients allows a more rapid decrease in the dose of vasopressor without apparent adverse effect. grant acknowledgment. aphp-scr . we set up to describe the antibiotic treatment regimens prescribed for patients with severe sepsis in spanish icus and to analyze the potential therapeutic benefit of combination therapy. methods. edusepsis subanalysis, including all patients with severe sepsis admitted to the participating icus during months, in three periods between november and june . there was analyzed the time between the presentation of sepsis and the initiation of antibiotic treatment and empirical antibiotic used in terms of focus and origin of sepsis (community/nosocomial). we also studied the combination therapy compared to monotherapy, assessing the impact on outcomes of combination therapy in particular. the results are presented as frequencies (percentage) or mean ± standard deviation. results. there were included , patients with severe sepsis (age . conclusions. combination therapy is not associated with a better outcome in this large cohort of patients with severe sepsis. nevertheless, there is room for improvement since % of patients did not receive antibiotic therapy within the first h from admission, as recommended by the ssc. introduction. tracheostomies are increasingly common in hospital wards and can lead to significant patient harm. this is partly due to bed pressures in uk critical care units and the increasing use of percutaneous and surgical tracheostomies for critical care patients. commonly, hospital wards lack the infrastructure to care for tracheostomies safely. objectives. analyse tracheostomy-related critical incidents reported in the uk over a year period. we wished to identify themes and make recommendations to improve patient safety. methods. the search was conducted from st october to th september and was conducted in february to allow time for incidents to be submitted. the selected incidents were then incorporated into an access database (microsoft office ) and the description of each incident was read and reviewed. we analysed tracheostomy-related critical incidents reported to the uk national patient safety agency over a year period, identified by key letter searches. we categorized the records to identify recurring themes and then performed root cause analysis where possible. results. we identified , incidents from the npsa incident database originating from hospital wards during the study period having the defined letter sequences. of these incidents, were associated with tracheostomies; directly affecting patients with the remaining not directly affecting individual patients. in the incidents where patients were directly affected ( %) were associated with some identifiable patient harm of which ( %) were associated with more than temporary harm. in incidents ( %) some intervention was required to maintain life and in cases the incident may have contributed to the patient's death. there were cardiac arrests and respiratory arrests described in these incidents. of the incidents, involved equipment and there were blocked or displaced tracheostomy tubes described. note: an individual incident could be classified in multiple fields conclusions. we were able to identify themes in incident reports associated with tracheostomies and identify areas where care could be improved to reduce risks to patients. there were a number of recurrent problems that contributed to incident evolution or severity that would be potentially avoidable. these include: introduction. the study of computerized thoracic tomography patterns can be of great help in the diagnosis of the causes of acute respiratory failure in the icu patients. we hypothesized that the consecutive analysis of a series of thoracic cts will contribute to the management of these critically ill patients. objectives. to study, over a three-month period, the thoracic cts performed in the adult icu in the albert einstein hospital in são paulo, brazil. methods. from may st to august st, , all the thoracic cts were analyzed by two radiologists from the albert einstein hospital staff according to a pre-established protocol: ( ) presence of parenchymal consolidations; ( ) ground-glass opacities; ( ) septal thickening; ( ) atelectasis ( ) pleural effusions; ( ) pneumothorax ( ) pneumomediastinum; ( ) subcutaneous emphysema; ( ) presence of nodules; ( ) presence of masses; ( ) presence of cysts; ( ) emphysema; ( ) bronchial thickening. results. hundred and sixteen thoracic cts were performed and analyzed over the study period, from ( . %) males and ( . %) females. the mean age of the patients was . ± . years. thoracic ct analysis revealed: ( ) parenchyma consolidations: ( . %); ( ) ground-glass opacities: ( %); ( ) septal thickening: ( . %); ( ) atelectasis: ( . %); ( ) pleural effusions: ( %) ( ) presence of pneumothorax: ( . %); ( ) pneumomediastinum: ( . %); ( ) subcutaneous emphysema: ( . %); ( ) nodules: ( . %); ( ) presence of masses: ( . %); ( ) presence of cysts: ( . %); ( ) emphysema: ( . %); ( ) bronchial thickening: ( . %). conclusions. thoracic ct is a useful tool for a detailed analysis of the lung parenchyma, specially in the detection of ground-glass opacities, consolidations and atelectasis, improving the diagnostic possibilities and management of acute respiratory failure. s. wolf , , a. rieß , j.f. landscheidt , c.b. lumenta , l. schürer , p. friederich charite campus virchow, department of neurosurgery, berlin, germany, klinikum bogenhausen, neurosurgery, muenchen, germany, klinikum bogenhausen, anesthesiology, muenchen, germany introduction. extravascular lung water index (evlwi) may present a valuable marker for the severity and treatment of acute lung injury and acute respiratory distress syndrome. measured by single indicator transpulmonary thermodilution and indexed to predicted body weight, a threshold of ml/kg is currently regarded as the upper limit of normality. however, so far only critically ill patients were studied and data from subjects with normal cardiovascular function is lacking. objectives. to prospectively investigate evlwi in patients without cardiopulmonary compromise. methods. patients requiring elective brain tumor surgery were equipped with a transpulmonary thermodilution device (picco . , pulsion medical systems ag, munich, germany). triplicate evlwi measurements were performed after induction of anesthesia (time point ), before (time point ), during (time points and ) and after surgery (time point ) as well as after extubation (time point ) and before discharge from the neurosurgical icu (time point ) . data were recorded electronically and investigated with a random effect model to cope for multiple measurements per individual. results. valid measurements were performed in patients ( female/ male, fig. ). no patient showed clinical signs of over-hydration or cardiopulmonary failure and all were discharged regularly from the icu on postoperative day one. indexed to predicted body weight, females had a mean evlwi of . (sd . , range - ) ml/kg and males had a mean evlwi of . (sd . , range - ) ml/kg (p \ . ). % of the measurements in females and % in males exceeded the threshold of ml/kg. no significant differences were between the different time points of measurement (p = . ) or during anesthesia and after extubation (p = . ). conclusions. measured with single indicator transpulmonary thermodilution and indexed to predicted body weight, evlwi frequently shows values above the previously established normality threshold of ml/kg in patients without cardiopulmonary compromise. females present significantly higher values than male patients. as we are not aware of any abnormal hemodynamic profile for brain tumor patients, we propose our findings as a close approximation to normal values for evlwi. introduction. cardiovascular dysfunction is though to be common during weaning from mechanical ventilation. however, its precise incidence is unknown in this setting. in addition, the respective impact of systolic and diastolic dysfunctions on the weaning process have not been studied. objectives and methods. this is an ancillary study of the ''bnp for the management of weaning'' clinical trial. patients were ventilated with an automated weaning system as soon as they tolerated pressure support ventilation with an fio b %, a peep level b cmh o, and a total inspiratory pressure b cmh o. a total of patients underwent transthoracic echocardiography (tte) at day (initiation of weaning). in addition, serial tte were performed in a subgroup of patients to explore left ventricle filling pressures variations during daily weaning trials (low-pressure support with zero end-expiratory pressure). filling pressures were assessed using the ratio of early transmitral peak velocity (e) over early diastolic mitral annular velocity (e ). results. day tte revealed a systolic (ejection fraction \ %) or diastolic dysfunction (defined as e \ . cm/s) in half of patients. treatment during weaning included diuretics ( % of patients), vasodilators ( %) , dobutamine ( %), amiodarone ( %) and betablockers ( %). diastolic dysfunction was more prevalent in patients with difficult or prolonged weaning as compared to those with simple weaning (weaning duration \ days). serial tte revealed a greater increase in e/e ratio during failed weaning trials as compared to successful trials. conclusions. when treated, systolic dysfunction does not seem to jeopardize weaning. in contrast, diastolic dysfunction is associated with difficult/prolonged weaning. during failed weaning trials, there is a more pronounced increase in filling pressures as compared to successful trials. introduction. monitoring and determination of fluid responsiveness in a critically ill patient who presents with circulatory compromise and septic shock is essential but often, challenging and difficult. continuous haemodynamic monitoring using arterial pulse contour analysis is less invasive compared to the thermodilution method using the pulmonary artery catheter. objectives. we aim to assess the utility of stroke volume variation as measured by the flotrac Ò device (edwards lifesciences, irwine, usa) as a predictor of fluid responsiveness in patients with septic shock. we studied mechanically ventilated adult patients with septic shock in the medical intensive care unit (icu) of a university hospital. haemodynamic parameters including stroke volume variation (svv) and stroke volume (sv) were recorded using radial arterial pulse contour analysis (flotrac Ò pressure sensor versions . and . ) before and after a crystalloid fluid challenge. fluid responsiveness was defined as an increase of c % in sv after the fluid challenge. results. the sensitivity, specificity, positive predictive value and negative predictive value of a svv of c % to predict fluid responsiveness were respectively . , . , . and . %. the area under the receiver operator characteristic curve for the prediction of fluid responsiveness using svv (pre) was only . . similarly, there was no correlation between svv (pre) and the absolute change in stroke volume (spearman's rho - . , p = . ). conclusions. our study's findings call for caution with the use of svv measured via versions . and . of the flotrac Ò device to predict fluid responsiveness in patients with septic shock. further studies are now required to assess if recent software upgrades may provide more accurate svv measurements in severely septic patients. objective. our objective was to assess the recent literature with respect to cco monitor validation. in particular we wished to determine if study protocols reflected the dimension of time. we looked at four different cco monitors: vigileo tm , picco tm , pulseco tm , and oesophageal doppler (odm). human validation studies of cco monitors were sought through the ovid interface, generating over , hits. manufacturers' websites were also searched. case reports were excluded, as were abstract-only publications, letters, and studies over years old. ultimately, studies were included. a full reference list and search strategy is available from the authors. a recent article provided suggested criteria for assessment of cco monitors [ ] : this was used to generate a proforma. to check for interobserver bias, a subselection of five studies was assessed by the three authors independently; no differences were found. the authors summarised the remaining studies individually. results. results are summarised in table . w rows do not add up because some studies evaluated more than one monitor researchers have yet to address the necessity of validating cco monitors with respect to their realtime functionality. while most studies give an assessment of bias based on essentially static measurements, fewer than half document sampling time or directional change reliability. response time and response amplitude to a step change in cardiac output are important variables which may influence patient treatment; in the vast majority of studies, these have not been assessed. in this respect, all four monitors have yet to be validated. this study offers two perspectives: one, for clinicians to realise that the cco monitor in their intensive care unit may not have been as extensively validated as they think; another, for researchers, to realise that work is still to be done. initial distribution volume of glucose rather than right ventricular end-diastolic volume is correlated with cardiac output following cardiac surgery j. saito , h. ishihara , e. hashiba , h. okawa , t. tsubo , k. hirota hirosaki university graduate school of medicine, anesthesiology, hirosaki, japan, hirosaki university graduate school of medicine, division of intensive care, hirosaki, japan introduction and objectives. rational decision making for cardiovascular and fluid management in critically ill patients requires reliable assessment of cardiac preload. we have reported that initial distribution volume of glucose (idvg) measures the central extracellular fluid volume and has potential as an alternative preload variable ) . idvg can be approximated rapidly and simply in any icu using a conventional blood glucose analyzer ) . right ventricular end-diastolic volume (rvedv) has been shown to be a better indicator of cardiac preload than cardiac filling pressure ) . this study was intended to determine whether idvg, rvedv, pulmonary artery wedge pressure (pawp) or central venous pressure (cvp) are correlated with cardiac output (co) during the early postoperative days following cardiac surgery in the absence of apparent congestive heart failure. methods. twenty-nine consecutive patients who underwent cardiac surgery such as coronary artery bypass grafting (either off-pump or on-pump: n = ), valve surgery (n = ) and aortic arch replacement (either hemi or total: n = ) were studied. patients associated with excess hyperglycemia ([ mmol/l), arrhythmias or mechanical cardiovascular support were excluded from the study. a volumetric thermodilution pulmonary artery catheter for continuous monitoring of co and rvedv was placed in the operating room. immediately after cardiovascular variables were recorded, idvg was determined using the incremental plasma concentration at min after administration of glucose ( g) as described previously ) . three sets of measurements were performed; on admission to the icu and daily at a.m. on the first postoperative days. the relationship between either volumetric or static variables and cardiac index (ci) was evaluated throughout the study period. a p value. was considered statistically significant. results. all but one patients required vasoactive drugs during study period. indexed idvg (idvgi) had a moderate correlation with ci (r = . , n = , p \ . ), even though indexed rvedv (rvedvi) had a slight correlation with ci (r = . , n = , p = . ). a linear correlation was also obtained between changes in idvgi and those in ci (r = . , n = , p \ . ). however, changes in rvedvi had not a correlation with those in ci (r = . , n = , p = . ). neither pawp nor cvp had a correlation with ci (r = - . , n = and r = - . , n = , respectively). although cardiac dysfunction has a significant impact on determining co early after cardiac surgery, our results demonstrate that idvg rather than rvedv is correlated with co. idvg has potential as being an alternative indicator of cardiac preload following cardiac surgery. (spv) are reliable predictors of fluid responsiveness in controlled mechanically ventilated patients [ ] . ppv and spv are calculated using an intra-arterial catheter. it is unknown whether an arterial pressure signal obtained with the nexfin tm system [ ] using only a finger cuff can be used to calculate ppv and spv. objectives. to validate ppv and spv measured with a finger cuff. methods. after their arrival on the icu, sedated and mechanically ventilated patients after coronary artery bypass graft surgery (cabg) were included. intra arterial pressure (iap) was measured using an arterial catheter inserted in the radial artery, and non-invasively, using the finger cuff of the nexfin tm monitor (bmeye, the netherlands). we took the mean value of ppv and svv in a -min time interval before and after the administration of a fluid challenge. agreement of the ppv and spv measured by the finger cuff and from the iap signal were assessed using the method described by bland and altman. results. nineteen patients were included and twenty-eight volume challenges were analyzed, resulting in simultaneous measurements. ppv and spv measured by the finger cuff correlated with ppv and spv from iap (r = . , p \ . and r = . , p \ . , respectively), see figure . the mean bias was - . and - . % for ppv and spv respectively, and limits of agreement were - . and . % for ppv and - . and . % for spv (see figure ). there was no correlation between the bias and the mean value of the two measurement methods. the correlation between changes in ppv and spv measured by the two different methods was r = . (p \ . ) for ppv and r = . (p \ . ) for spv. conclusions. in ventilated icu patients, ppv and spv can be reliably calculated using the nexfin tm monitor. reference(s). ( ) kramer, a., et al., chest, . ( ) . ( ) eeftinck schattenkerk, d.w., et al., am j hypertens, . ( ) . introduction. the transpulmonary thermodilution (tptd) technique with integrated pulse contour analysis (picco Ò -system) enables continuous monitoring of cardiac index (ci) after calibration by tptd [ ] . this monitoring technique is applied in patients with lung failure who undergo prone positioning (pp) which has been shown to potentially improve pulmonary gas exchange [ ] . objective. we sought to determine the influence of a modified pp ( °) on the accuracy of pulse contour derived ci (pcci) without recalibration by tptd. patients: after approval by our institutional review board and written informed consent by a legal surrogate we studied critically ill patients ( #, $, age - years) who were mechanically ventilated due to acute lung injury following lung contusions or acute respiratory distress syndrome. methods. all patients were prone positioned and had received an extended haemodynamic monitoring (picco Ò , pulsion medical systems ag, munich, germany). before turning from supine position (sp) to pp, ci was measured by tptd (tptdci) and pcci was calibrated. ten minutes after positioning, pcci was read from the monitor and then recalibrated by tptd. after - h, pp was ended and measurements were performed analogously to prone positioning. volume management between the respective time points remained unchanged. linear regression analysis and bland-altman plots were used for statistical analysis. all data are given as mean ± standard deviation, range in brackets. results. the tptdci in sp was . ± . ( . - . ) l/min/m . after proning, a pcci of . ± . ( . - . ) l/min/m and a tptdci of . ± . ( . - . ) l/min/m were measured. linear regression analysis revealed a correlation coefficient of r = . (p \ . ). mean bias (tptdci-pcci) was . ± . l/min/m . immediately prior to turning back to sp, tptdci was . ± . ( . - . ) l/min/m . after re-positioning, the pcci was . ± . ( . - . ) l/min/m and tptdci was . ± . ( . - . ) l/min/m , with a mean bias of . ± . l/min/m . the correlation coefficient was r = . (p \ . ). conclusion. pcci is only marginally influenced by prone positioning and is reliable without recalibration by tptd. however, in case of greater differences a recalibration by tptd is nevertheless recommended. objectives. the aim of this study was to analyze the clinical agreement between the intermittent bolus thermodilution technique (tdco) and apco in patients with non-traumatic intracranial hemorrhage requiring intensive care. methods. this was a prospective observational clinical study in a university level icu. we studied adult patients with non-traumatic intracranial hemorrhage, who for clinical indication underwent co monitoring by the tdco (pac, . fr, criticath tm sp h td catheter, becton-dickinson, singapore). in parallel, arterial pressure waveform was applied using the radial arterial pressure curve (flotrac/vigileo tm , version . and . , edwards lifesciences, ca, usa). tdco measurements were done approximately every h and when needed. the length of data recording was depending on the need for tdco monitoring and icu stays but was no longer than days. every tdco measurements and the simultaneous apco values were recorded and included into the analysis. results. data pairs were obtained. overall, mean co was . (sd . ) l/min for tdco and . (sd . ) l/min for apco. mean bias between tdco and apco was . l/min ( fig. ), % limits of agreement . to . l/min and the percentage error %. there was a large interindividual variation in mean bias and percentage error (minimum to maximum, - . to . l/min and - %, respectively). the bias was significantly greater if patient received norepinephrine ( . vs. . l/min, p = . ) but not if patient received dobutamine ( . vs. . l/min, p = . ) . only a small correlation between the bias and the rate of norepinephrine infusion was detected (q = . ). when cardiac index of . (l/min/m ) was used as a cut off value for need for intervention, the sensitivity and specificity for apco were . ( % ci . to . ) and . ( % ci . - . ), respectively. conclusions. according to our results the second generation of flotrac Ò /vigileo Ò monitoring system underestimates the tpco and the sensitivity is poor. there is also a large interindividual variation in bias. the use of norepinephrine may provoke the error. objectives. to compare cardiac output techniques to the reference tte method, which allows accurate measurement of the aortic flow section and of velocity time integral of aortic pulsed wave doppler signal to measure co. methods. monocentric prospective study included patients requiring invasive blood pressure and hemodynamic therapeutic intervention. tte co measurement was performed with aortic diameter measured in parasternal long axis view at the the aortic leflets, and velocity time integral measured using five apical view averaged on cardiac cycles. tod co was measured only when the pac insertion was decided. tte, uscom Ò , mostcare Ò and vigileo Ò were performed in all patients. each value was the average of successive cardiac cycles with consecutive measurements. each patient could have several measures. results. mechanically ventilated patients ( ± years; sofa ± . ) were investigated allowing to obtain measurements ( under norephinephrine). diagnostics: brain injury (n = ), sepsis(n = ) and others (n = ). patient had the methods ( measurements), patients had techniques ( measurements), patients had techniques ( measurements), conclusions. all methods correlated more or less with tte co, with a slope close to identity, and a low intercept. the best correlation was obtained between mostcare Ò and tod. agreement for almost all methods was large, within an acceptable range. for the pulse contour method, mostcare is correlated better than vigileo with tte co. the arterial signal has to be accurate as possible and requires a high quality chain for measurement avoiding overdamping or underdamping to allow effective signal digitalization. introduction. the lithium indicator dilution technique is attractive in paediatric intensive care because it is non-invasive. however, it requires calibration. the reliability of cardiac output measurement data rests on the reproducibility of the calibration factor (cf). objectives. to establish the number of calibrations (= x) that are required in a paediatric patient material, if the coefficient of variation for the calibration factor does not increase by % or more by (x + ) calibrations. to establish x it is also required that % of the patients do not show an increase in cv by % or more and that % of the patients show an increase in cv by % or more at (x + ). hemodynamically stable sedated and ventilator treated children under intensive care with a body weight of - kg were included. to perform calibration, . mmol/kg of lithium chloride was injected intravenously and the concentration of lithium ions in arterial blood was analyzed by a lithium selective electrode. the calibration process was repeated times and the cf as well as lithium indicator cardiac output (lidco) were calculated. results. results from children with a mean body weight of . kg are presented below. cv was below % throughout the investigation. introduction. stroke volume variation has been shown to be a better indicator of fluid responsiveness than static indices such as cvp or paop. a limitation of dynamic parameters is arrhythmias which produces abnormal svv. beat-to-beat variations reflect altered cardiac filling times not the effects of mechanical ventilation in fluid responsive conditions. a recently developed enhanced algorithm (newsvv) helps eliminate this limitation. newsvv rejects ectopic beats using multi-parameter signal recognition and restores the respiratory variation of the signal using spline-based interpolation. objectives. to evaluate the performance of the new arrhythmia rejection svv algorithm to predict fluid responsive from patient data with frequent arrhythmias. methods. newsvv was developed from data collected in a porcine model to limit the impact arrhythmias had on svv. comparing the current standard svv (svvstd) algorithm (flotrac-vigileo system edwards lifesciences, usa) with the newsvv showed a significantly improved sensitivity and specificity. ( ) in this preliminary study sets of patient data with frequent pvcs and atrial fibrillation (afib) were ran through the new algorithm and compared to the data from svvstd. in one patient fluid boluses ( - cc platelets and packed red blood) during a period of afib caused newsvv to decrease from to % and co to increase from . to . l/min, while svvstd algorithm did not show a significant change (varying randomly between and %). a second patient had non-paroxysmal afib. svvstd showed abnormally high values ranging between and %. patient was a non-responder to fluid and had a co ranging between and l/min. newsvv showed more realistic value of % depicting a non-responder range. the third patient had periods of afib followed by normal sinus rhythm (nsr). svvstd algorithm had abnormally high svv values ([ %) during the afib. during nsr, both algorithms correlated well with svv of %. (fig. .) conclusions. the newsvv algorithm improved svv with ectopics and afib and shows promise in eliminating a limitation of svv in those conditions. further studies are needed to fully evaluate the performance in patients with arrhythmia receiving fluid challenges. rd esicm annual congress -barcelona, spain - - october s methods. mechanically ventilated pigs (median weight kg) under general anesthesia were investigated. after instrumentation, baseline values were obtained after at least h of stabilization. ''shock'' phase (simulation of aaa rupture): ( - ) ml/kg of blood was gradually withdrawn and hemorrhagic shock maintained for h. abdominal cavity was filled with warmed saline to abdominal pressure of mmhg. ''clamp'' phase: infrarenal aorta was cross clamped for min and hemodynamics was resuscitated with shed blood and fluids. ''post-surgery'' phase lasted h and pigs were subsequently sacrificed. hemodynamics was obtained at baseline, every min for first h of hemorrhage, every h until postoperative phase and every h till the end of the study. data are presented as median (iqr), appropriate non-parametric tests were used for statistical analysis. results. baseline co measured by pac was ( - ) ml/kg/min. both vigileo ( - ) ml/kg/min (p = . ) and lidco ( - ) ml/kg/min (p = . ) differed significantly. the course of co is shown in fig. , all values are presented as a difference to baseline. the median difference between pac and vigileo was ( - )% and for lidco ( - )%. study limitations: both devices were designed for co estimation in humans but we do not expect huge differences in arterial system properties in pigs. young pigs reacted to hemorrhage by severe sinus tachycardia which caused failure in some co measurements but at least pigs are presented at every timepoint. conclusions. absolute co values obtained by both vigileo and lidco differ significantly from pac. unlike lidco rapid, flotrac/vigileo was able to track changes in co during severe hemorrhage. grant acknowledgment. iga mzcr ns - and vz msm . introduction. most important role of postoperative sedation is suppressing stress of the patients in icu. urinary -hydroxy- -deoxyguanosine ( -ohdg) can be a good biomarker for oxidative stress in clinical research. the aim of this study is to assess the free radical production under sedation in icu and compare the production between with midazolam and dexmedetomidine. subjects and methods. subjects were twenty-five patients with sedation after neck malignant tumor operation and ventilated for h in icu. patients with renal failure were excluded from this study. all patients received fentanyl ( lg/kg/day), fifteen patients were with midazolam ( . mg/kg/h: m-group) and ten patients were with dexmedetomidine ( . - . lg/kg/h: d-group) we examined the concentration of urinary -ohdg by high performance liquid chromatography (hplc) method with coolaray system every morning in icu. results. the average value of urinary -ohdg of healthy human volunteer is ng/ml. the values of urinary -ohdg were less than ng/ml in the both groups and no significant differences were observed between the groups in this study. conclusions. postoperative sedation with both midazolam and dexmedetomidine were effective in suppressing oxidative stress in icu patients. poorly controlled pain in the postoperative period can lead to slow recovery and life threatening complications, especially in elderly patients. it has also been suggested that the quality of postoperative analgesia could decrease delirium incidence and reduce duration of hospital stay in the elderly patients. however, the ideal postoperative analgesia management of elderly surgical patients in intensive care units remains to be determined. since, continuous epidural analgesia provides the required level of analgesia to support early mobilization and significant reduction in pulmonary and cardiovascular morbidity in the early postoperative period, we postulated that the use of low dose of continuous epidural morphine might improve postoperative analgesia and reduce undesirable side effects in elderly patientstherefore, the present study was designed to evaluate the effects of morphine administered via epidural patients controlled analgesia and intravenous tramadol + metamizol on postoperative pain control and side effects in elderly patients after major abdominal surgery. objectives. the purpose of this study was to compare the analgesic efficacy of morphine administered via epidural patients controlled analgesia (epca) with our standard analgesic for postoperative pain treatment, intravenous tramadol + metamizol in eldery patients undergoing major abdominal surgery. methods. forty patients older than years undergoing major abdominal surgery were randomly assigned to two groups. group i received epidural morphine mg at the end of surgery and used a patients controlled analgesia device programmed to deliver morphine . mg/h, . mg per bolus. group ii received intravenous infusion of mg tramadol plus mg metamizol in ml electrolyte infusion. the patients in group ii received ml of the infusion solution as a loading dose over min (corresponding to mg tramadol plus . mg metamizol) postoperative analgesia was tested at rest on a visual analogue pain scale ( = no pain, = worst possible pain) at , , , and h after surgery. patients' satisfaction, arterial oxygen saturation, respiratory rate, episodes of nausea, vomiting, pruritus and dizziness were also noted. results. both groups obtained adequate pain relief, and there were no between-group differences in pain scores. there were no significant respiratory differences but the patients in the epidural group were more sedated. in the tramadol metamizol group patients were treated for ponv while of the patients in the morphine group showed ponv. we conclude that combination of tramadol and metamizole provided postoperative analgesia equivalent to that provided by epidural morphine in early postoperative period. the both analgesic regimens were safe and suitable for the management of postoperative pain in elderly patients. h. poon , j. hulme sandwell and west birmingham hospitals nhs trust, birmingham, uk, sandwell and west birmingham hospitals nhs trust, intensive care medicine and anaesthesia, birmingham, uk a substantial amount of patients in intensive care units (itu) receive an inappropriate level of sedation with a tendency for over-sedation. although the ideal itu sedation practice is not known, many units use a protocol-based approach incorporating best practice consensus. the use of daily interruption of sedation infusions can reduce oversedation and is included in our current guidelines. objectives. the audit assesses compliance to our current protocols for sedation scoring and adjustment of sedation infusions. provision of sedation breaks in patients sedated more than -day is evaluated. methods. retrospective review of itu inpatients' daily record charts during june and july at sandwell and west birmingham hospitals nhs trust in two -bedded itu. charts were reviewed. results. our guidelines recommend hourly sedation scoring from h to midnight and hourly scoring from midnight till h; at , and h. % of the reviewed charts did not have a recorded hourly score. % did not have hourly scores overnight. % of the charts contain ramsay score - or - ; % of the charts contain ramsay score or . per protocol, sedation infusion is stopped at ramsay score - or - but in % of cases this did not occur. a sedation bolus should be given at a score of or . % did not receive a recorded bolus. our guidelines advocate restarting a sedation infusion at a lower rate after it has stopped and the patient is less sedated and increasing the rate after a bolus is given. however, correct infusion rate adjustments were only performed in % of cases. often, rates were changed but without first stopping, or administering a drug bolus. out of sedation days, there were only true daily breaks. conclusions. there is a tendency to over-sedation in our itu; less so under-sedation. common practice deviates from protocol and there is poor documentation. scores are recorded less often than protocol: there may continuous assessment by nursing staff that is not recorded. boluses are given more often than documented on patient charts. review of the current guidance is required to address appropriate frequency of formal scoring, nurse-led compulsory sedation breaks and pharmacokinetic education about the necessity to stop or bolus before infusion rate alterations. introduction. daily interruption of sedation has been shown to decrease length of stay in icu . recent national guidance in scotland promotes dis as part of a care bundle to decrease ventilator associated pneumonia. a week retrospective first round audit was completed prior to the introduction of dis and demonstrated % of patient hours where sedation could be improved. a second round audit of current practice was therefore undertaken to assess the impact of dis on sedation levels. our aim was to identify the frequency of periods where sedation levels were undesirable and investigate any clinical reason behind these. objectives. to assess whether dis would improve sedations levels of our patients already managed with a simple sedation algorithm (sa) aiming at a ramsay sedation score level - . methods. six months following the introduction of dis, a second period of weeks was studied retrospectively where the icu daily charts were examined to look at: demographic data, sedation score, and whether dis had been successfully carried out. results. cases were identified: males and females with an average age years and similar illness severity scores to the first group. dis was carried out on patient days, omitted on days and contraindicated on a further . , patient hours were examined. ( %) were excluded due to contraindications such as refractory hypoxia, drug overdose, and end of life care. the remaining patient hours were compared to the first round group [ , patient hours with contraindications ( %)] using the mann-whitney test as shown in fig. . conclusions. we could not demonstrate any difference in sedation levels following introduction of dis on our unit. we found a large proportion of patients where dis was unsuitable. introduction. delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients, occurring in up to % of ventilated patients in the united kingdom . delirium is independently associated with more deaths, longer hospital stay, and higher overall cost . hypoactive delirium is much more common, is easily missed and is associated with a worse prognosis than hyperactive delirium . objectives. the aim of our project was to quantify the presence of delirium on our critical care unit and to survey the practice of delirium assessment within our region. we conducted a prospective audit at the critical care unit, birmingham city hospital, uk. we used the confusion assessment method for the intensive care unit (cam-icu) to assess for delirium daily on all our patients for a period of weeks. simultaneously, we conducted a telephone survey to elicit the delirium assessment practice of the other units within the west midlands region of the unite kingdom. results. we carried out our assessment on patients over a -week period, which resulted in assessments ( were on non ventilated patients and on ventilated patients). assessments could not be completed because of deep sedation or language barrier. in total we had assessments positive for delirium giving an incidence of % for those patients we could fully assess. all of the patients with a positive assessment had hypoactive delirium. the telephone survey revealed only three of the twenty units in our region routinely assessed for delirium. none of the units had a formal management protocol/guideline for delirium. conclusions. delirium is a significant problem on our critical care unit. the incidence was lower than that reported in the literature this might be because firstly we were unable to assess a number of patients due to the patients being deeply sedated, and secondly we noted many of the patients during the assessment period were high dependency patients with minimal organ dysfunction. despite a large number of recent publications on delirium and increasing awareness amongst critical care professionals most of the units in our region do not routinely assess for delirium. without regular assessment most delirium will go unrecognised and thus opportunities to instigate preventative measures and early management will be missed. methods. six patients aged - years old ( females) who all sustained brain injury with cerebral oedema alongside other traumatic damage (i.e., fractures, abdominal trauma) are hereby presented. upon admission to the icu all patients received large propofol doses ( - ml/h of propofol infusion %), in an attempt to lower cerebral metabolic demand along with vasopressors to maintain a normal mean arterial pressure. three to days following admission all patients developed metabolic acidosis (base deficit ranged from - to - mmol/l), hyperkalemia (potassium concentration ranged from . to . mmol/l), evidence of muscle cell degradation (creatine kinase and myoglobin concentrations ranged from , to , u/l and from , to , lg/l, respectively) and lipaemia (triglyceride concentrations ranged from to . mmol/l). at that time all patients were clinically stable and usual laboratory tests as well as cultures were inconclusive, hence a diagnosis of pris was suggested. results. three out of six patients developed global left ventricular dysfunction, which was documented by echocardiographic evaluation, with normal cardiac enzymes, while all patients developed acute renal failure. cardiac and renal failure were observed within - h following the manifestation of the above abnormal laboratory findings. continuous hemofiltration was initiated promptly on a daily basis in all cases, while the administration of propofol was discontinued. abnormal laboratory findings normalized within - days, while cardiac and renal function gradually ameliorated within a week, following therapy in all cases. no deaths were recorded. conclusions. the initiation of continuous hemofiltration therapy is a crucial therapeutic tool for the elimination of propofol and its potentially toxic metabolites in cases of pris and may have a beneficial effect upon survival in these cases. l. zurong , w. yichun intensive care unit of hunan province tumor hospital, changsha, china objectives. our purpose was to compare the analgesic properties, effect, and side effects of intravenous butorphanol and fentanyl during chest tube removal in cardiac surgery patients. seventy-four patients with cardiac surgery were enrolled before chest tube removal. each patient received standard doses of either fentanyl ( lg) or butorphanol ( mg) before chest tube removal in a double-blind manner. pain intensity and pain distress were measured before analgesic administration, immediately after chest tube removal, and min later pain quality was measured immediately after chest tube removal. level of sedation was measured before and min after chest tube removal. results. the fentanyl (n = ) and butorphanol (n = ) groups were identical with respect to age, race, sex, and weight. pain intensity, pain distress, and sedation levels did not differ significantly between groups. however, procedural pain intensity (mean . , sd . ) and pain distress (mean . , sd . ) scores for all were low. patients remained alert, regardless of which analgesic was administered. conclusions. if used correctly, either fentanyl or butorphanol can substantially reduce pain during chest tube removal without causing adverse sedative effects. thus, clinicians may choose either safe and effective analgesic interventions during chest tube removal. introduction. delirium is defined as an acute alteration of mental status, with either a disturbance of consciousness or a change in cognition which develops over a short period of time and fluctuates during the course of the day. reported prevalence of delirium in critical care varies widely from to %. despite this, delirium remains grossly under-recognised and is often thought to be temporary and of little consequence in critical care. it is however one of the most frequent complications and, after adjusting for age, gender and severity of illness is an independent risk factor for prolonged length of stay and mortality ( ) . current recommendations are for the assessment and diagnosis of delirium using simple validated tools ( ) . pharmacological intervention should be considered when reversible precipitating factors have been corrected. haloperidol is considered the drug of choice. objectives. the purpose of this study was to detect knowledge and awareness of delirium, attitudes and behaviours towards its assessment and pharmacological management in critical care units of two large uk teaching hospitals a -point survey was distributed to all senior medical and nursing staff employed in critical care at the leeds general infirmary and the james cook university hospital, middlesbrough. a total of questionnaires were collected after four follow up rounds via web-based survey tool ''survey monkey''. results. the survey detected a significant awareness of the problem delirium poses in icu. the vast majority ( %) of practitioners did not screen for delirium routinely. of the % who screened only in used screening tools that were appropriate, the majority lacked the knowledge of suitable methods to do so. % of respondents felt that they required tools to aid diagnosis of delirium in their unit. the pharmacological management of delirium varied significantly, with a wide range of drugs used, suggesting the need for guidance. the majority of respondents ( %) felt that they needed guidelines for treatment of delirium, % felt that guidelines would change their practice. despite an awareness of the problem delirium poses in icu, data from this survey shows a lack of knowledge of assessment and treatment. given that most respondents needed guidelines, we have developed a delirium treatment protocol and implemented the confusion assessment method for icu (cam-icu) training package for all staff in the james cook icu. following its implementation we plan to re-evaluate in the hope that the awareness of delirium can be met with the appropriate knowledge to implement a sustained change in practice. results. patients were included, male ( %), mean apache ii score ± . midazolam was suspended in % after h. maximum dose of sufentanyl was mcg/kg/h. bilirrubin and creatinin did not change from initial values and there was no effect in enteral nutrition tolerance. bis values improved % from ± to ± (p = ns) and there were less hemodynamic effects as well as less necessity of amines and sedatives. results are shown in table . conclusions. sufentanyl is an efficient and safe sedative that reduces necessity of more sedatives, amines and generates adequate sedation without renal or hepatic effects. a.s. puxty , j. kinsella , k. anderson glasgow royal infirmary, department of anaesthetics, glasgow, uk etomidate is a sedative agent often used for the induction of critically ill patients. it is, however, a controversial drug with effects on the steroid axis that have been suggested may lead to a poor outcome. so far this has only been proven in infusions of the drug. despite this some have called for its withdrawal altogether objectives. to determine the attitude of anaesthetists and icu consultants in five hospitals in a major uk city towards the use of etomidate. methods. an online questionnaire was constructed using surveymonkey (portland, oregon, usa). this was then sent out to all anaesthetists in glasgow via an e-mail link. a reminder was sent after weeks. trainees from one of the hospitals were unable to be contacted via e-mail and so hard copies of the questionnaire were sent to them. of a total of anaesthetists in glasgow (trainees and consultants), ( %) completed the questionnaire successfully. of those answering the questionnaire, . % were sho level, . % spr, . % consultants and . % sas grade. these respondents sub-specialities/specialist interest were: general ( %), pain ( %), icu ( . %), obstetrics ( . %) and cardiac ( . %). overall ( % ci - )% of respondents were concerned about etomidate's effect on steroid synthesis, although when asked about induction of an emergency laparotomy ( - )% would still use it [with ( - )% avoiding it and ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) % responding that they were never involved in emergency laparotomies]. of those using etomidate, ( - )% would avoid it in a septic patient, and a further ( - )% would give steroid cover. the most common reason for using etomidate was cardiovascular stability [ ( - )%]. other reasons given were simple dosing ( [ - ] )% and habit ( [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] )%. more than one reason was allowed. looking for differences between groups the following was found: while icu consultants reported more concern over etomidate ( vs. %, p = . ), there was no difference in etomidate usage in emergency laparotomy ( % of general vs. % of icu consultants, p = . ). trainees were more likely to have their habit changed by the recent literature on etomidate ( vs. %, p = . ). conclusions. there is concern among anaesthetists and icu consultants regarding the use of etomidate but usage has not changed markedly by most. further evidence of harm would likely need to be demonstrated before abandonment of the drug. introduction. nociception and requirement of additional analgesia before painful procedures in icu are difficult to anticipate. under anaesthesia, the direct pupil light reflex reflects the sympatho-vagal balance and remains altered by pain and sedative drugs. the pupillometry is a reproductive, non invasive method based on automated flash light device assessing pupillary variations [ ] . to study pupillometric parameters to anticipate the tolerance to painful stimuli (surgical debridement). methods. eligibility criteria: sedated patients (morphinomimetics + benzodiazepines, bps = ) in days after invasive surgery for cervical necrotizing fasciitis (cnf), complicated or not with mediastinitis, requiring a surgical debridement three times a day. clinical evaluation performed before and during debridement: heart rate (hr), mean arterial pressure (map) and behavioral pain score (bps) [ ] . pupillometric test before debridement (calibrated bright flash of one-second at lux, (neurolight, id med) with recording of pupillary parameters: minimum and maximum diameter, variation rate, latency, velocity. noxious procedure was defined as an increase of at least one point of the bps (change in facial expression, upper limb movement or ventilator synchrony). the additional analgesia was decided blindly from pupillometric values. analysis compared two groups defined on bps variation induced by the procedure: group with dbps c and group with dbps = . comparison of pupillometric parameters before procedure between the groups. results expressed as median (interquartile range, iqr), mann-whitney test, significance at p \ . . . patients with cervical cellulitis of which complicated by mediastinitis, h/ fratio = / , age years ( ), igs ( ). in this population, during the procedure, hr and map were unchanged, the bps increased significantly [from ( ) to ( ) , p = . ] but remained unchanged in patients ( %) (group = high tolerance). pupillometric parameters before procedure before procedure group (n = ) group (n = ) p conclusions. all pupillometric parameters, except latency, were discriminant for subsequent debridement tolerance with significantly lower values in the group without pain experience. the pupillometric test seemed adapted to this clinical practice for evaluation of nociception status and may help for rationalizing analgesia for short noxious procedures. introduction. delirium is an acute and fluctuating change in mental status, with inattention and altered levels of consciousness. the incidence of delirium in orthopedic patients was ranges from . to %. delirium may present before or after the patient undergoing surgical procedure and has demonstrate increasing risk, including mortality. objectives. the purpose of this study was to compare the effectiveness and tolerability of intravenous propofol versus midazolam infusions in postoperative agitation/delirium therapy with using an epidural infusion for postoperative analgesia after major orthopedic surgeries in high-risk patients with chronic renal failure. with the institutional ethic committee approval; eighty-two high-risk chronic renal failure patients (asa iii, bun [ mg/dl and serum creatinin value [ ) after a major hip or knee operations with a diagnosis of agitation/delirium were eligible for the study in the postoperative period. richmond agitation sedation scale (rass) or confusion assessment method for the icu (cam-icu) were used for sedation/orientation levels. all agitated patients had an lumbar epidural catheter was inserted preoperatively in combination with spinal anesthesia intraoperatively. after the surgery the catheter was loaded with . % mg bupivacaine at the t to l sensory levels and a continuous infusion of . % bupivacaine was commenced at - ml/h in combination with patient controlled analgesia of meperidine ( mg/bolus). for agitation/delirium therapy in group p (n = ) propofol was used with intravenous loading dose of - mg/kg in a bolus and followed by continuous infusion at - mg/kg/h and group m (n = ) midazolam was used with intravenous loading dose of . - . mg/kg in a bolus and followed by continuous infusion at . - . mg/kg/h to ensure a target of rass in + and - values. hemodynamic parameters (heart rates, systolic and diastolic blood pressures), oxygen saturation with sedation-agitation scales were monitored periodically for h. adverse events were recorded. p \ . showed statistically significant. results. the groups were demographical comparable (p [ . ). group p patients reached the target rass scores earlier in group p (p \ . ). hemodynamic values were significantly higher in group m (p \ . ). the epidural bupivacaine consumption was significantly lower in group p with a limited analgesic requirement (p \ . ) and n treatment required adverse events was seen in group p (p [ . ). conclusions. intravenous propofol infusion may be an effective and safe approach adjunct to epidural analgesia for possible postoperative agitation/delirium treatment after major orthopedic surgeries in high-risk patients with chronic renal failure. introduction. ventilator-associated pneumonia (vap) is the most common nosocomial infection among the critically ill patients admitted in the intensive care units (icus). implementation of the available international evidence-based guidelines and recommendations to prevent and manage vap into the clinical setting may not be adequate leading to suboptimal patient care and increased vap rates. objectives. to assess the implementation of selected vap prevention strategies, and to learn how vap is managed by the intensivists practicing in the indian subcontinent. methods. three hundred -point questionnaires were distributed during an international critical care conference. ( . %) were returned and ( %) questionnaires of delegates from india, nepal and sri lanka were analyzed. most of the intensivists ( . %), reported using vap bundles in their icus with a high proportion including head elevation ( . %), chlorhexidine mouthcare ( . %), stress ulcer prophylaxis ( . %), heat and moisture exchangers (hme, . %), early weaning ( . %), and hand washing ( . %) as part of their vap bundle. use of subglottic secretion drainage (ssd, . %) and closed suction systems (css, . %) was also reported by many intensivists, whereas, use of selective gut decontamination was reported by only . % of respondents. most common method for sampling used for diagnosis of vap was endotracheal suction by ( . %) intensivists, and only . % intensivists reported using protectedsample brush. gram negative organisms (pseudomonas, acinetobacter) were reported to be the most commonly isolated organisms. majority of respondents ( . %) reported using proton pump inhibitors for stress ulcer prophylaxis. majority ( . %) believed that vap contributed to increased mortality in their icus with . % treating vap with an antibiotic course lasting for - days. de-escalating therapy was considered, in patients responding to treatment, by . and . % considered adding empirical mrsa coverage and . % considered adding nebulised antibiotics in certain high risk patients. overall there was good concordance regarding vap prophylaxis among the intensivists with a majority adhering to evidence based recommendations and guidelines. even though the gap between recommended guidelines and the actual clinical practice is closing, we could identify certain issues like the choice of agent for stress ulcer prophylaxis, use of hme, ssd and css, where there still exists some practice variability and opportunities for improvement to provide better patient care. objectives. to reassess the value of individual levels and dynamic alteration of procalcitonin (pct) in predicting the outcome of ventilator-associated pneumonia(vap) patient. methods. forty adult patients with vap were studied and divided into two groups according to their outcome at day after diagnosis of vap: death and survival. serum pct levels were measured on days , and (d , d , and d , respectively) and their alteration between different days (kinetics, pct) were calculated. to control the study, acute physiology and chronic health evaluation ii (apache ii), sequential organ failure assessment (sofa), and clinical pulmonary infection score (cpis) and c-reactive protein (crp) were also recorded and analyzed. all parameters have been investigated as independent variables in relation to -day death as dependent variable. results. the increase of pct levels on day , and were significantly predictive of death in univariate analysis with area under curve (auc) and % ci of . ( . , . ), . ( . , . ) and . ( . , . ), respectively. however, kinetics of pct levels among day , and did not show a significant difference between favorable and unfavorable outcomes (p [ . ). multivariate analysis revealed that only sofa ( ) conclusions. neither pct individual levels nor their kinetics during vap course can predict patient outcome. comprehensive evaluation of patients with multiple methods, in combination with pct levels, may increase predictive accuracy in the future. grant acknowledgment. we have no competing interests. introduction. the presence of new or progressive radiological infiltrates, pyrexia, leukopenia or leukocytosis, and the presence of purulent tracheal aspirates are key features defining the presence or absence of vap. the incidence of vap is dependent upon the number of diagnostic criteria applied, and the demographics of the critical care population to which it refers. a uk government directed ''patient safety first'' campaign in the uk, has highlighted vap as a complication related to mechanical ventilation that can be reduced through the introduction of a ''care bundle''. however, benchmarking between different units has practical limitations. objectives. selective data presentation can distort the perceived occurrence of critical events in order to deliver performance targets. we compared the incidence of vap between a neurosurgical and general intensive care unit in the same hospital. a variety of denominators were applied to explore the potential for data manipulation to realise performance targets a local database of neurosurgical and general intensive care admissions, covering a month period, was analysed retrospectively results. and subjects were admitted to gitu and nitu respectively in the month period. ( %) and ( %) subjects were ventilated for more than days. table summarises the demographics and measures of performance between the two units. a p value . was considered significant. parametric and non-parametric tests were applied as appropriate. . vap is associated with not only mortality but also considerable morbidity, prolonged duration of ventilation and increased cost of hospitalisation. to determine the incidence of vap in patients ventilated at the qensiu, to calculate mv resource utilisation, and to ascertain whether vap relates to outcome in acute sci. we undertook a retrospective case note review of all patients ventilated at the qensiu during a year period. patients were identified using a local computerised database. the qensiu receives referral of patients with sci from the whole country (pop * . m). vap was defined pragmatically as deteriorating gas exchange more than h following mv, coupled with a raised crp or wcc, together with either a positive sputum sample or new infiltrates on cxr. statistics: descriptive, median (range); analytical, mann-whitney u and fisher's exact test as appropriate. death occurred in % of patients, and was significantly greater in the group who were retrospectively assigned to the vap cohort: vap vs survival of the deaths, occurred following discharge from the unit ( of whom developed a subsequent vap). conclusions. vap incidence was apparently high in this patient population ( %), particularly in comparison to the reported general icu population incidence ( - %) . this may partially reflect our pragmatic diagnostic criteria, applied retrospectively. vap was also associated with an increase in mortality following discharge in patients with sci. a modified vap bundle adapted to sci patients is being developed locally, based on recent recommendations . introduction. the implementation of a prevention programme with feedback to nurses and healthcare workers (hcw) was associated with better outcomes and increased compliance [ ] . to assess the effects of feed-back in a study based on implementing a variables care bundle to prevent vap. a multicenter and prospective study was carried out in icus. the element care bundle consisted in hands hygiene, oral hygiene, monitoring cuff pressure, sedation vacation/adjustment and avoid ventilator circuits changing. beweekly feed-back displaying posters with information was carried out to update hcw in the compliance of the prevention measures and vap incidence. a questions with open answer questionnaire was performed months after the implementation of the feed-back in all icus to assess the knowledge of the compliance measures, vap incidence, opinion of the study and improvement suggestions. results. questionnaires were obtained. the median experience in intensive care was . years (sd . - . ). % of the staff was aware of the study: . % agree that was useful, . % disagree and . % didn't know. regarding if they thought that in their units they had a high vap incidence, . % answered that they did, . % answered negatively and . % didn't know. asking about the knowledge of the prevention measures' compliance . % answered right, . % said they knew but didn't specify the percentage, . % didn't know and . % didn't answer the question. finally, about the vap incidence, . % answered right, . % said they knew but didn't specify it, . % didn't know and . % didn't answer the question. . % added comments, the most relevant was: . % of the respondents wanted more verbal information. conclusions. poster feed-back failed to improve compliance on vap care bundle due to lack of information. our survey suggests to implement other communication strategies based on direct verbal interaction to improve implementation. objectives. to compare the effectiveness of two different methods of oral dental hygiene on ventilator-associated pneumonia (vap) prevention using the cpis (clinical pulmonary infection score). methods. twenty-seven critically ill patients, aged - years were studied. patients were randomly separated in groups: group (n = ) received oral care with tooth brushing using the bass technique followed by lavage with chlorhexidine . % (chx) solution in nacl . % (chx:nacl . % = : ). hexetidine . % (hex) was used for oral lavage alone in group (n = ). demographics, sofa, apache ii, gcs and cpis scores were recorded upon patient admission. on days , , and , bal and tongue surface cultures were obtained. the endpoints taken into account were the cpis on days , , , and as well as the number and species of bacteria cultivated. a cpis c was considered positive for vap. two-way anova, t test for independent samples, mann-whitney u, pearson correlation and kruskal-wallis tests were used for statistical analysis. p \ . was considered statistically significant. patient data analysis showed that both groups were homogeneous. on days , and there were more negative tongue surface cultures in the chx group than in the hex group (p = . ). even though the cpis did not differ significantly between the groups, a strong tendency of faster and greater reduction in the chx group was observed. moreover, a continuous gradual improvement of the cpis score was recorded in both groups on days , and . the overall incidence of vap was similar in both groups: group , . % (n = ) and group , . % (n = ). the same bacteria (p \ . ) developed in both bal and tongue cultures on days (p \ . ) and (p \ . ). nevertheless, the cpis was positive for vap only in the above patients on day , while day was totally free of vap. conclusions. even though the cpis improvement was more remarkable in group , both group scores showed parallel improvement overtime, the chx group being in a slightly more propitious position. diligence in patient oral care seems to be an additional effective practice for vap prevention, independently of the method used. introduction. specific patterns of cytokine gene expression are reported to be associated with the occurrence of infection in humans [ , ] . it is unclear whether these characteristic profiles are a consequence of an established disease process or precede the infective process. objectives. our primary endpoint was to determine whether hospital acquired pneumonia was associated with differential gene expression of ifn-c, tnf a and il- family of cytokines. secondary endpoint was to identify whether alteration in gene expression preceded the clinical onset of infection. methods. consecutive patients undergoing elective thoracic surgery were recruited. hospital acquired pneumonia was diagnosed as per nnis guidelines, independent of study investigators. mrna and protein levels were analysed pre operatively, h and days post operatively. . patients had an uncomplicated recovery. patients developed hospital acquired pneumonia. il- , il- , il -p , il- -p , il- -p , tnf-a, and ifn-c mrna and protein levels of il- , il- , and ifn-c in peripheral blood were analysed before surgery, h and day post surgery. il- p mrna levels were reduced in the pneumonia group ( , ; , - , ) compared to non pneumonia group ( , ; , - , ) day post surgery (p = . ). ifn-c mrna levels were reduced in the pneumonia group ( ; - , ) compared to non pneumonia group ( ; - , ) (p = . ) day post surgery. absolute copy numbers of mrna per million copy numbers of b-actin are quoted. all values are quotes as median and th to th centile range. patients with postoperative hospital acquired pneumonia exhibit distinct patterns of cytokine gene expression. these distinctive patterns manifest before the clinical onset of pneumonia. objectives. the aim of this study was to evaluate the impact of the implementation of a ventilator bundle on the incidence of vap in our intensive care unit (icu). methods. prospective, observational study. during a year period (january - ) a ventilator care bundle based on the cdc and canadian guidelines , was applied to each patient requiring more than h of mechanical ventilation (mv). the ventilator care bundle consisted in:hand hygiene. use of barrier precautions. preference of noninvasive ventilation (niv). orotracheal intubation. semirecumbent position. continuous aspiration of subglottic secretions. manteinance of the endotracheal cuff pressure. oral care with chlorhexidine. daily sedation vacation and assessment of readiness for weaning. no scheduled ventilator circuit changes. ventilation circuit maintenance. stress bleeding profilaxis. we followed general measures for infection control:single patient room. microbiologic surveillance. monitoring and early removal of invasive devices. program to reduce antimicrobial prescriptions. for each ventilated patient the following data was registered:age, apache ii, the reason of admission, risk factors, use niv, mv duration, timing of tracheostomy, time of diagnosis of vap, microbiological data, length of stay and mortality in icu. the compliance with the bundle was registered in a check list. the application of the ventilator care bundle impact was compared with historical data. . ventilated patients were included. the median age was years. the mean apache ii was . ± . . the reason of admission was in a % medical and % surgical. the most frequent risk factors were: age [ years, emergency surgery, pulmonary disease and immunosuppression. niv was used in %. the median duration of mv was days. tracheostomy was done in . % patients with a delay of ± days. there were late-onset vap episodes and the rate of vap per , ventilator days was . . the vap were caused by candida albicans, enterobacter aerogenes and pseudomona aeruginosa. the length of icu stay was . days. mortality was % (only one patient with vap). the rate of compliance with ventilator care bundle was %. the rate of vap per , ventilator days after implementation of the bundle decreased significantly (table ) . there is currently no consensus on the diagnostic criteria for ventilator associated pneumonia (vap) which has led to significant variation in the reported incidence ( - %) . icus need a reliable and accurate diagnostic system so that the efficacy of measures to reduce the incidence of vap can be assessed, and if vap is to be considered as a quality indicator of performance. objective. to establish a process to diagnose vap that can be used for continuous surveillance and to assess the effect of new therapeutic interventions. method. potential diagnoses of vap were identified prospectively by a senior intensive care doctor and clinical data was collected to calculate a modified clinical pulmonary infection score (cpis) . each case was subsequently reviewed at a multidisciplinary team (mdt) review forum with intensive care and microbiology clinicians. the case details, modified cpis and semiquantitative microbiological culture results were used to reach a consensus view on the diagnosis. a pilot audit performed over a week period in , gave a vap incidence of % ( vaps; ventilated patients; ventilator days) . a change to our ventilator care bundle was subsequently instigated, with the addition of chlorhexidine paste to daily mouth care before repeat surveillance. result: patients were admitted to the critical care unit over days. patients were ventilated during a total ventilator days. patient episodes were identified as potential vap and discussed at the mdt forum. cases were diagnosed as vap (incidence . %) and patient diagnosed as tube associated pneumonia. the other cases were excluded either due to clinical circumstances (n = ) or absence of positive microbiology (n = ). conclusion. we have developed a process for identifying and diagnosing vap within our critical care unit that continues to be used for ongoing surveillance. collaboration between the intensive care team and the microbiology department, along with a mdt forum, has been fundamental to this process. our data highlights the difficulty in diagnosing vap and the need for multidisciplinary expertise. of the patient episodes prospectively identified as potential vap, were deemed not to be vap when clinical data and results were available for review at the mdt forum. the reduction of vap incidence between the pilot study and subsequent screening suggests benefit from the introduction of oral chlorhexidine, however we recognise other contributing factors. controversially, icus in the uk are increasingly being asked to provide data on vap incidence as a quality indicator. we believe that we have a process that is robust and allows us to accurately monitor the incidence of vap. introduction. bacterial biofilm within the internal surface of the endotracheal tube (ett) may contribute to ventilator-associated pneumonia. the gene expression pattern of those bacteria, embedded within biofilm matrix, greatly differs from their planktonic counterpart and allows survival benefits and increased virulence. to compare biofilm production capability of planktonic versus sessile methicillin-resistant staphylococcus aureus (mrsa) retrieved from within etts, and to assess whether antimicrobials can hinder those processes. ultimately, to study any change in planktonic versus sessile bacterial dna. we previously developed a model of pneumonia in pigs mechanically ventilated up to h and challenged into both lungs with mrsa. from those studies, etts of pigs, treated with placebo (n = ), linezolid (n = ) or vancomycin (n = ) were retrieved. distal and medial parts of each ett were processed ( samples). the planktonic mrsa strain, inoculated to the pigs, was compared with sessile mrsa strains, retrieved from the internal surface of the etts, in capability to form biofilm, assessed through the adhesion-to-aplaque method for gram-positive bacteria. the optical density of biofilm was measured using a microplate reader at wave length k = nm and results are proportional to the planktonic control strain (value = ). pulsed-field gel electrophoresis (pfge) was used to determine potential bacterial dna recombination. introduction. ventilator-associated pneumonia (vap) is a common complication in mechanically ventilated patients and is associated with increased morbidity, mortality and costs. treatment-related risk factors associated with vap, include prolonged duration of mechanical ventilation, lack of antiseptic techniques, improper patient's position, inappropriate cuff pressure, peptic ulcer prophylaxis, and deep sedation. objectives. the aim of this study is to evaluate the presence of these risk factors and their association with vap development in a multidisciplinary icu. one hundred and fifty-seven critically ill patients consecutively admitted to a multidisciplinary icu, were prospectively studied. forty-one of them, developed vap ( m/ f age: ± years, apache ii score on admission ± , sofa score on admission ± ). inclusion criteria were intubation \ h prior to icu admission or after h of admission. exclusion criteria included: prior hospitalization in another icu, icu stay\ h, brain death, age \ years old and pregnancy. bronchial secretions, samples from the pharynx and gastric secretions were collected from each patient times weekly (on days , and ). we also documented the known risk factors for vap; sedation depth (using the ramsay scale), cuff pressure, head-bed elevation, reintubation, ventilator circuit changes, tracheostomy, the presence of levin, deep venous thrombosis and stress ulcer prophylaxis, three times weekly per patient results. in this selected sample of patients, the incidence of vap was per , ventilation days. out of this sample, % underwent at least one endotracheal tube change, % had at least once their ventilator circuit changed, % underwent a tracheostomy, % had levin, % did not have head-bed elevation above °, % had ramsay scale or , % had cuff pressure b cmh o, % did not received deep venous thrombosis prophylaxis and all of them received h -receptors antagonists, as gastric ulcer prophylaxis. these results indicate that several risk factors for vap, do indeed apply for the cases under study and that the incidence of vap is relatively high. therefore, the implementation of preventive strategies and the reinforcement of vap bundles can result in beneficial effects on the appearance of vap, in the monitored icu. introduction. pulmonary inflammatory response and progressive ards may complicate posttraumatic ali. clrt by a motor-driven bed is used in trauma patients to improve gas exchange and to prevent from ventilation-associated complications. we investigated the effect of clrt on the inflammatory response in the posttraumatic course. to assess systemic and pulmonary cytokines (interleukin (il- , il- ), intercellular adhesion molecule- (icam- ) before and days after begin of clrt. conventionally positioned patients served as a control group. after approval by our institutional review board trauma patients presenting with ali (pao /fio \ ) were prospectively randomized in clrt (n = ) and control group (n = ). cytokines were assessed from serum (s) and broncho-alveolar lavage (bal) after admission at the icu and on day , respectively. results. the mean age was ± years and mean injury severity score was ± . pulmonary gas exchange improved significantly in clrt in comparison with conventional positioning on day . changes in cytokine levels are presented in table (median and / percentile values, * = p \ . within groups and $ = p \ . between groups, wilcoxon and mann-whitney-u test). serum il- and il- levels were reduced statistically significant on day in both groups, but this effect was significantly more pronounced in clrt-group. in bal cytokines tended to be increased in clrt and control group on day . icam- levels were increased in s and bal after days treatment. conclusions. the early use of clrt reduces the systemic inflammatory response (il- , il- ), but has no influence on regional pulmonary cytokine expression. clrt might be a helpful tool for stabilization in trauma patients with ali. objectives. the aim of this study was to compare the performance of adaptive support ventilation (asv) with and without closed loop control by end tidal co (etco ) (asvco ) to that of pressure control ventilation (pcv) and volume control ventilation (vcv) during simulated ards and to compare the ability of all modes to manage etco , tidal volume (v t ), and plateau pressure (pp) as respiratory mechanics, peep and minute volume changed. methods. asv and asvco were compared to a v t of ml/kg in vcv and pcv using the michigan instruments test lung set up with co titrated into one of the test lung chambers. the compliance of the system was set at and ml/cmh o and resistance at . cmh o/l/min. at baseline ventilation co was titrated to establish a co production of ml/kg pbw/min ( kg) or ml/min. after stabilization and data collection co production was increased to ml/ min and then to ml/min then decreased to ml/min. after each co adjustment and stabilization period data was collected. statistical analyses were performed by anova or kruskal-wallis tests where appropriate, a p value. was considered significant. overall etco level in asvco ( . ± . mmhg) was higher than in other modes (asv . ± . , vcv . ± . , pcv . ± . mmhg) (p \ . ). at the lowest compliance etco in asvco ( . ± . mmhg) was higher than in vcv ( . ± . mmhg) and pcv ( . ± . mmhg). overall v t was similar in all modes except that v t in asvco ( . ± . ml/kg) was lower than in vcv ( . ± . ml/kg) (p = . ). at the lowest compliance v t in asv ( . ± . ml/kg) and asvco ( . ± . ml/kg) were lower than in vcv ( . ± . ml/ kg) and pcv ( . ± . ml/kg) (p \ . ). overall, pp in asv ( ± . cmh o) and asvco ( . ± cmh o) were lower than in vcv ( conclusions. our high mortality in this group of patients despite improved oxygenation concurs with published data. however, potential improvements with adherence to ph and oxygenation targets could be made to ensure optimal use of hfov as a lung protective strategy. objectives. this randomized cross-over controlled study was designed to assess safety, gas exchanges, and ventilator outputs obtained with intellivent Ò as compared to adaptive support ventilation (asv) ( ) in icu ventilated patients with acute respiratory failure. methods. the study was approved by ethic committee and inform consents were obtained by next-of-kin. intubated, sedated and ventilated patients were included (age = ± years, saps ii = ± , and ali/ards and normal lungs patients, respectively). patients were ventilated using a g (hamilton medical, switzerland) with a dedicated software. asv and intellivent Ò were delivered in random order for two periods of h with half an hour of washout in between. tidal volume (v t ), peak pressure (ppeak), spo , and etco were continuously recorded. blood gas analysis and plateau pressure (pplat) were measured at the end of each period. a paired t test was used to compare ventilation and oxygenation parameters between asv and intellivent Ò period. no patient was removed from intellivent Ò for major safety issue. intellivent Ò delivered a lower mv ( . ± . vs. . ± . l/min, p = . ), peep ( ± vs. ± cmh o, p = . ), fio ( ± vs. ± %, p \ . ), vt/pbw ( . ± . vs. . ± . ml/kg pbw, p = . ), and pplat ( ± vs. ± cmh o, p = . ) than asv. static compliance, pao /fio ratio and paco were not different between asv and intellivent Ò . with both asv and intellivent Ò , v t was between and ml/kg pbw in all the patients. figure is showing the distribution of mean of individual breath by breath peak pressure during the two recording periods. conclusions. intellivent Ò delivered lower volumes and pressures than asv for equivalent results on gas exchange suggesting more efficient ventilation. introduction. during neurally adjusted ventilatory assist (nava) pressure applied to the airways by the ventilator is moment-by-moment proportional (according to a proportionality factor called ''nava gain'', unit: cmh o/lv) to the electrical activity of the diaphragm (eadi, unit: lv), as measured through a modified nasogastric tube with a multiple array of esophageal electrodes. independently from its physiological correlation with real diaphragm activity, eadi and its variations are the only variables through which different nava gains may affect patient respiratory pattern. objectives. we explored how eadi influence the effect of varying the nava gain on tidal volume and peak airway pressure. we included twelve patients recovering from acute respiratory failure. all patients, connected to a servo-i ventilator (maquet critical care, solna, sweden) able of delivering both psv and nava, underwent to a random application of increasing gains ( . - - . - - . - - cmh o/lv) during nava and increasing pressure support ( - - - cmh o) during psv. each level was maintained at least min. all changes in eadi, tidal volume (vt), and peak airway pressure (paw peak ) were referenced respect to their respective values at nava gain . . introduction. lung protective ventilation strategies is considered 'gold standard' for patients with acute respiratory distress syndrome (ards). high-frequency oscillation (hfo) has been used as a rescue measure and claimed to protect the lungs from ventilator induced lung injury ( ) . theoretically hfo should be considered early in the course of ards. objectives. we were interested to determine the time course to achieve optimal gas exchange with early hfo and its impact on the use of other adjunctive therapies; inhaled nitric oxide, prone positioning and extracorporeal oxygenation or carbon dioxide removal. after ethical approval, a total of adult patients with ards were enrolled in this prospective observational study. the oscillation (metran co. ltd, - , -chome, kawaguchi, saitama, japan) was started when fio [ . or level of peep [ cmh o were required on a conventional ventilator. hfo frequencies, cycle volume and bias flow were altered until optimal gas exchange achieved. the pattern of gas exchange was observed for the first h and other adjunctive therapies were used when required. the following parameters were recorded: duration of hfo, arterial blood gases during the first h, frequency of need for other therapies, incidence of barotraumas, and re-requirement of hfo once weaned from. a total of patients (age between - years, male:female ratio = : ) were ventilated - days with conventional ventilator before start of hfo. duration of hfo varied from to days ( median). there was a significant improvement in pao at - h (p = . ) following the onset of hfo (fig. ) . the number of patients requiring other therapies are very low; inhaled nitric oxide n = , prone positioning n = , both prone positioning and nitric oxide n = , ecmo/novalung n = . seven patients required re-hfo once weaned and another two developed pneumothoraces requiring chest drainage. conclusions. the data of this study demonstrates that significant improvement in gas exchange occurs in patients with ards following - h of hfo. early oscillation also appears to reduce the need for other adjunctive therapies. further studies of early hfo strategy are warranted. introduction. neurally adjusted ventilatory assist (nava) is a novel method for patient triggering of pressure support. instead of relying on conventional pressure or flow triggering, the peak diaphragmatic emg signal (edi) is used to precisely synchronise patient demand with ventilatory assist. although, the physiology and science underpinning nava has been described, less is known about its clinical application and efficacy ( ) . in particular, clinical superiority over conventional pressure support has not been established. objectives. here, we describe the clinical, nursing and operational lessons learnt from the introduction of nava platforms (servo-i, maquet) into a -bedded central london intensive care unit over years. in parallel we present some novel data from an observational cohort study examining the effect of nava on sedation use and ventilator days. a protocol for the safe measurement of edi in critically ill ventilated patients was developed through multidisciplinary review and discussion. a year registry of clinical lessons and adverse events from the introduction of nava was kept. in a parallel observational cohort study we examined three populations of ventilated patients (n = ) matched for apache ii, oxygenation index and compliance. group had no nava catheter; group had edi signal measured during conventional pressure support; and group utilised the edi signal to act as a neural trigger to drive ventilatory support. results. the measurement of edi was not associated with a difference in hospital mortality. there was a significant reduction in sedation use, muscle relaxation, ventilator days and icu days in patients with a nava catheter (fig. ) . however, there was no significant difference in any of these parameters with edi measurement guiding conventional pressure support versus nava. ventilator days in nava versus pressure support conclusions. in this study we show that neurally adjusted ventilatory assist can be safely and effectively be introduced into a 'non-expert' intensive care unit. we further show that reductions in sedation use and ventilator days appear to be related to the earlier introduction of sedation holds and reductions in ventilatory assist (with consequent earlier spontaneous breathing trials) in order to acquire an edi signal rather than due to an intrinsic advantage gained by improved patient-ventilator synchronisation with nava. the causes of the respiratory failure were: infections n = ; . % (immunodeficiency n = , tuberculosis n = , aplastic anemia n = , congenital cardiomyopathy n = , sepsis n = ), rsv infection-bronchiolitis n = ; . %, bronchopulmonary dysplasias n = ; . %, leukemias n = ; . %, burn-ards n = ; . %. the mean duration of hfov was . days ( h to days). the parameters of ventillation ranged: fio : - %, mean pressure: - cmh o, dp: - cmh o. the i time and hertzs ranged within the acceptable for age limits. closed suction circuit was used. we didn't notice any side effects from cardiovascular system or distension of the thorax. eadi and respiratory effort indices decrease when assistance increases in nava. nava should also theoretically allow perfect synchronization between the patient and the ventilator, and no asynchrony has been described with this mode. nava level adjustment at bedside, however, is still a matter of research. we assessed breathing pattern, respiratory effort indices, and patient-ventilator synchronization throughout a titration of nava and of pressure support ventilation (psv). we assessed breathing pattern, respiratory effort indices, and patient-ventilator synchronization throughout a titration of nava and of pressure support ventilation (psv). methods. physiological study conducted in seven patients (preliminary results) during the weaning. airway pressure (paw) and flow, esophageal and gastric pressures and the eadi were continuously recorded. for each patient, the following levels of assistance were consecutively applied: in psv: - - - - cmh o; in nava: . - - . - - . - - - - cmh o/mvolt. results are given as median and [ th- th percentiles], and tidal volume (vt) in ml/kg of predicted body weight. results. the increase from the lower to the higher level of assistance was associated with an increase in vt from . [ . - . ] to . [ . - . ] ml/kg in psv and from . [ . - . ] to . [ . - . ] objectives. we describe technical possibilities, tolerance and gas exchange with combination of oscillation device with nimv. a specific oscillator device (sensor medics, vyasis) was selected to change conventional airflow to oscillatory airflow. connected by ''t'' piece with oscillatory devicerespiratory circuit-face mask. we selected bipap ventilator (vision resp inc), facial mask. bipap mode (iap/epap cmh o) to achieve stable mechanical ventilation (t ). a progressive increment in rate of oscillation (hz) and power oscillation to achieve airflow change (t ). to evaluate the differences of peepi during the release phase, referred to mechanical pressure release from p high to p low , and the inspiratory work of breathing (wob) during p high among currently available aprv ventilators, using a lung model (ttl , mi). methods. the six aprv ventilators were evaluated in this study: ) nellcor puritan-bennett (puritan-bennett), ) evita xl (drager), ) servo i (maquet), ) avea (viasys), ) g (hamilton) and ) engstrom (ge healthcare). ventilator settings in aprv ventilators were set as follows: p high /p low cmh o/ cmh o, t high /t low . s/ . s. when evaluated peepi during the release phase, t low was diminished by steps of . s from . to . s. the inspiratory pressure-time product (ptp), as an index of wob, was directly measured under with tidal volume/respiratory rate of ml and /min. measurement for each setting was performed in a random order. three breaths were analyzed and averaged for each measurement. the results are shown in fig. objectives. to perform bench study to test the hypothesis that ett or trach can reduce the insufflated (vti) and/or exsufflated (vte) volume as provided by coflator Ò . methods. coflator Ò is connected to a pneumatic model (ttl, michigan instruments) via ett mallinckrodt . , . , . , . , . ) or trach (mallinckrodt . , . , . ) . the set up is tested in conditions of compliance (c ml/cmh o) and resistance (r cmh o/l/s): c r , c r , c r , c r . the device is set in manual mode, at the highest inspiratory flow, inspiratory/expiratory time / , s pause after expiration. three pressures are used, , and cmh o in both inflation and deflation. a baseline condition without any tracheal prothesis nor r served as reference. airflow and pressure upstream ett or trach are measured (biopac mp ). five insufflations followed each by an exsufflation are performed in each condition. the data are analyzed by using a linear mixed effects model where ett or trach, and pressure have fixed effects and c or r a random effect. the dependent variable is vti and vte. the main end-point is the slope of the relationships between vti or vte and pressure. results. the vti-pressure slope was significantly lower with any ett than baseline at both c ( fig. a and b). the same was true for trach. even though these differences were statistically significant the reduction in vti from the baseline averaged ml with etts as a whole. the vte-pressure relationships were similar for ett and trach and showed no difference from baseline at c ( figure d ). however, at c , the relationships are scattered ( figure c ). moreover, expiratory pressure of - and - cmh o were not reached for ett . , . and . and trach . and . . conclusions. ett and trach slightly but significantly change the performance of the device. however, small sized ett or trach in c condition substantially modify the efficacy of the exsufflation. these findings desserves assessment in patients for relevance. rd esicm annual congress -barcelona, spain - - october s though humidified high flow nasal canula oxygen (hfnc) has been widely studied in pediatric population, few data in adult is available and its and its precise indications and actual benefits in these patients remains unknown. two studies have shown that hfnc generates a low level of positive airway pressure contributing to decrease the work of breathing. one study has reported a favourable effect on comfort and oxygenation of hfnc as compared to venturi mask and in another preliminary one, fewer patients using hfnc went on requiring non invasive ventilation. objectives. to evaluate the efficiency of hfnc (optiflow, fisher and paykel, auckland) in critical care patients with acute respiratory failure. methods. prospective single centre study in a university hospital intensive care unit. all patients exhibiting acute respiratory failure (arf) as defined by clinical signs and/or failure of haematosis, regardless of the aetiology, were eligible. hfnc was used at a mean output of ± l/min and a mean fio of ± % throughout the study period. results. thirty-five patients were included. the mean age was . ± . years old and mean saps ii is ± . pulmonary infection was the most common aetiology of arf. hfnc was used ± days. all but one patient were discharged alive from icu. optiflow significantly reduced respiratory rate (p \ . ), heart rate (p \ . ), dyspnea score (p = . ), sus clavicular recession and thoraco abdominal asynchrony, and improved pulse oxymetry (p = . ). there was no significant difference in ph, pao , paco on arterial blood gazes performed before and , and h after hfnc use. the pao /fio ratio at and h after hfnc initiation was higher than before use of hfnc (p = . ). patients ultimately intubated exhibited a higher respiratory rate min ( . ± . vs. . ± bpm, p = . ) and min ( with an incidence of up to % in routine sonography [ ] , pleural effusion is one of the most common complications in intensive care patients. the use of bedside d ultra-sound to detect pleural effusion is fast, practicable and minimises radiation exposure [ ] . however, sonographical volumetry tends to be imprecise, and ct imagingbased volumetry is the more accurate method to quantify pleural fluid in intensive care patients [ ] . objectives. the aim of this study was to compare the accuracy of d and d ultra-sound volumetry of pleural effusion in intensive care patients. methods. icu patients designated for thoracentesis because of radiological support for pleural effusion were examined both with d and d ultra-sound \ h before and after the intervention. effusion volume was calculated with the formula ''volume [ml] = sep [mm] '' [ ] for d measurements and compared to the d volumetry by the ge d view software. the difference of volumetry before and after intervention was compared to punctured volume (gold standard). the device used for u-sound measurements was the ge voluson i. . within the group under survey (n = ), eight patients were on the respirator. mean punctured volume was ml ( ml; ml). mean absolute value of deviation from punctured volume (gold standard) was ml ( . %) for the d measurements and ml ( %) for d measurements. biggest difference between methods was found between ml and ml punctured volume. none of the methods generally measures higher volumes than the other. conclusions. the size of deviations from gold standard in both directions in d measurements suggests that the method is not reliable in predicting pleural effusion volume. d measurements are more likely to predict the right effusion volume, making the method a better diagnostic tool than d u-sound measurements. although thoracocentesis was found to be safe for mechanically ventilated patients [ ] and d volumetry may not change the therapeutic decision, which depends on high-risk patients' overall clinical condition, it could nevertheless help to avoid unnecessary interventions and thus improve patient safety. ongoing work analyses results for a group of patients with ct imaging-based volumetry of pleural effusion as gold standard. we study the utility of deltacvp changes during pressure support ventilation (psv) as an indication of respiratory effort. patients after several t-trials failures were on psv. the level of ventilatory assistance was changed in order to set the psv. no aditional interventión was used in the management of these patients. we registered data from the ventilator and beside monitor (vt, rr, p , deltacvp) in two levels of ps. optimal-ps, as the lowest support without respiratory distress and with the middle of this level -psv. the inspiratory trigger was used with the highest sensibility without autotrigger, the inspiratory ramp was changed in every patient and expiratory was flow-cycled at % of the peak inspiratory flow. results. patients n, acute on chronic respiratory failure, n, heart failure, n, recovery of acute respiratory failure. age ± years, admission apache ii ± and they needed weaning with ps after ± days with control mechanical ventilation. the respiratory mechanics in this time were cst.rs ± ml/cmh o and raw.rs ± cmh o/l/s. the ramsay score was ± ( ) ( ) ( ) ( ) ( ) . when the optimal level of ps was decreased from ± to ± cmh o, all patients showed respiratory distress, and the variables studied changed significantly: p : . ± . to . ± . cmh o, deltacvp . ± . to . ± . cmh o, vt decreased from . ± . to . ± . l and rr increased from ± to ± bpm (p \ . ). the correlation between p and del-tacvp was . (p = . ). central venous pressure swing provided information about the respiratory effort and may be useful during pressure support ventilation. introduction. the use of a tidal volume of ml/kg of predicted body weight is part of the management of patients presenting with ards ( ) and prevents ventilator induced lung injury in icu patients undergoing mechanical ventilation ( ) . the setting of tidal volume is based on patient height. height seems to be more often estimated by the icu staff than actually measured ( ). objectives. our study aimed to assess the accuracy of the visual estimation of patient height and its impact on ventilator settings. thirty-two patients admitted to a surgical icu were prospectively included in this observational study. patients had their height visually estimated by icu staff members ( doctors, nurses and nurse-assistants) and then measured. we also measured the knee height from which height can be extrapolated. we then compared the mean estimated height for each patient to the actual measured height with the use of bland and altman plots and the consequences of the measurement error on the tidal volume setting. in most patients visual estimation overestimates the actual height. the measurement errors result in an increase in the tidal volume up to + ml/kg. this remains true whatever the subgroup studied: all patients (bias: . ± . , % ci: - . ; . ), male patients (bias: . ± . , % ci - . ; . ), female patients (bias: . ± . , % ci . - . ) and whatever the type of assessor. extrapolated height from knee height results invariably in an underestimation of actual height (bias - ± . , % ci - . ; . ). our results prove that neither visual estimation nor knee height measurement are reliable surrogates for measured height. therefore, measuring patient height should be mandatory in critically ill patients in order to minimise ventilator-induced lung injury. methods. , respiratory acts were recorded in icu patients selected because of severe asynchrony with the ventilator (g , hamilton medical) during psv. by visual analysis (va) of airway pressure and flow trajectory, ineffective efforts and inspiratory/expiratory delays were detected. the results of va were compared with those provided by a new algorithm based on the automatic analysis (aa) of flow trajectory. results. va identified ineffective efforts ( % of patients acts). among , assisted acts, average inspiratory and expiratory delay was ± ms and ± ms, respectively. significant inspiratory and expiratory delay ([ ms) occurred in , ( %) and in acts ( %), respectively. automatic analysis was able to identify , of , patients acts ( %). in , cases ( %), both inspiratory muscles contraction and relaxation were detected. in acts ( %) only relaxation was identified. compared with va, inspiratory and expiratory delay of aa was ± and ± ms, respectively. aa recognized the start and the end of patient's effort before the ventilator in , ( %) and , ( %) of assisted acts. sensitivity and specificity of aa in detecting ineffective efforts, inspiratory delays [ ms, expiratory delays [ ms were and %, and %, and % respectively. the new algorithm proved to be efficient as a real-time, continuous monitoring system of patient-ventilator interaction. the advantage over traditional flow and pressure based triggers has to be tested. introduction. mechanical ventilation remains as one of the most difficult safety issues in the icu, but parameters commonly monitored by ventilators only depict the most extreme risks for patients. new computerized approaches may manage exhaustive data and may include ''intelligent'' software that mirrors expert decision making. to test the clinical usefulness of a new computerized system as a herald for clinically significant alarms and its possible impact in outcome. methods. twenty-five mechanically ventilated patients were continuously monitored in a single mixed icu in a university-affiliated hospital. we recorded age, diagnosis, pao /fio , apache ii and sofa on admission. the computerized system grabs and process data from different devices, usually a monitor and a respirator, and evaluates the most relevant events in a ventilated patient. all the algorithms were designed and validated with the clinical staff. data of ventilated patients were recorded at the icu during months and a total of , , breaths from different patients, each of them with a register of at least % of total ventilation time, were collected. data include biomedical signals (waves and trends) as well as all the clinical events detected by the system, including trapped gas at end-expiration, presence of secretions, double-cycling, asynchronies during expiration, pulse pressure variation in patients not triggering the ventilator and stress index ([ . or . ) in those ventilated with square airflow. outcome variables were icu length of stay, hospital stay and mortality. statistical analysis included multiple regression models for length of stay and mortality. [ ] [ ] [ ] [ ] [ ] [ ] [ ] , icu length of stay . days [ . - ] , hospital length of stay days . the frequency of alarms were: trapped gas at end-expiration: . %, presence of secretions . %, double-cycling . %, asynchronies during expiration . %, stress index [ . . %, stress index . . %, and pulse pressure variation . %. multiple regression analysis found pao /fio associated with length of mv and close to significance with hospital stay and mortality, but any of the computerized alarms reached yet the level of significance. conclusions. the computerized system is able to detect and review more clinically significant problems than clinical routine. however, its impact to define patient outcomes warrants further investigation. objectives. we have assessed the ability of the ventilator t-bird vs and ltv- to deliver to a lung model with ards a set tidal volume (vt) at different simulated altitudes. we used a decompression chamber to mimic the hypobaric environment at a range of simulated cabin altitudes of , , , and , m ( , , , , , feet). ventilators were tested with realistic parameters. vt was set at and ml in an ards lung model. the positive end expiratory pressures (peep) were set at and cmh o. pressure drop across the pneumotachograph was measured by a differential pressure transducer (enertec tm ). the spirometer was checked at each altitude using a calibration syringe. the inspired oxygen content (fio ) was %. respiratory rate was breaths/min. the ratio inspiratory time/expiratory time was / . the protocol included three measurements for each simulated altitude. comparisons of preset to actual measured values were accomplished using a t test for each altitude. a significant difference was defined by p \ . . the standard deviation for the three measurements obtained at each altitude was consistently less than ml. respiratory rate delivered was breaths/min in all cases. variation of peep did not change the volume delivered. the t-bird vs showed a decrease in volume delivered. comparisons of actual delivered vt and set vt demonstrated a significant difference starting at , m for a vt set of ml, at , m for vt set of ml. at these altitudes, the variations between vt set and delivered were more than %. with decreasing barometric pressure, the ltv- showed mostly an increase in volume delivered. comparisons of actual delivered vt and set vt demonstrated a significant difference at , m for a vt set of ml, at , m for vt set of ml. the delivered tidal volume remained within % of the set vt. assuming that the patient is ventilated at sea level and gas exchange is normal, the movement to altitude would result in an increase in tidal volume which might in fact represent a clinical event. conclusions. the ltv- met the trial targets in all settings, whereas the t-bird-vso did not compensate well for altitude and progressively delivered lower volumes as barometric pressure decreased. such variations between delivered and set vt suggest lack of efficacy of altimetric correction in hypobaric conditions in some devices. the ltv showed a moderate increase in volume delivered for ards lung model with increasing altitude, but maintained the delivered volume within % of the set vt up to , m. the accuracy of the vt delivery was superior with the ltv- than with the t-birdvso . oxygen therapy is commonly used to correct residual oxygenation impairment in the post-extubation period. this is usually done through a venturi mask which allows to deliver predetermined fractions of oxygen humidified with bubble humidifiers. the low humidity delivered by such devices and the use of an oro-nasal mask may, however, reduce patient's comfort, possibly resulting in mask displacement or removal and consequent oxygen desaturations. nasal high-flow (nhf) oxygen therapy allows to deliver high-flow oxygen, humidified with heated humidifiers and delivered through nasal cannulae, with the potential to improve comfort and efficacy. objectives. in patients requiring oxygen therapy after extubation, we compared nhf vs. venturi mask in terms of oxygenation and comfort. patients who were mechanically ventilated for more than h, passed a spontaneous breathing trial, and had pao /fio \ at the end of the trial were randomized to receive oxygen with nhf or venturi mask after extubation. exclusion criteria were: tracheostomy, age \ , pregnancy, or anticipated need for noninvasive ventilation after extubation. in both groups, fio was set to obtain spo between and % ( - % in copd patients). with nhf, flow rate was set at l/min. arterial blood gases, respiratory rate, and discomfort were assessed at , , , , , , and h. discomfort was assessed by asking patients to rate their discomfort with the used device by using a numerical scale from (no discomfort) to (maximum imaginable discomfort). discomfort symptoms were also assessed for the dryness of the delivered oxygen (dryness of the mouth, throat, nose, difficulty to swallow and throat pain). incidence of desaturations and interface displacement was also assessed. objectives. to evaluate the optimal humidifier water temperature when using a helmet for noninvasive positive pressure ventilation. oxygen. each was sequentially tested in the following order: using the helmet without humidification at ambient temperature, with humidification with unheated chamber water, and with humidification with the chamber water at , , and °c. at each setting, after a min stabilization period, measurements were taken. comfort level at each setting was evaluated using a visual analog scale (vas) rated zero (most comfortable) to ten (least comfortable). temperature and relative and absolute humidity inside the helmet, and vas scores statistically significantly increased as the humidification chamber water temperature increased. the lowest vas, . ± . , was obtained when water in the humidifier chamber was at ambient temperature. conclusions. for patient comfort during cpap using a helmet, the most desirable conditions are likely to obtained by humidifying without heating, that is by leaving the water in the humidifier chamber at room temperature. introduction. the physiological and clinical effects of non-invasive ventilation (niv) on acute post-operative respiratory failure are relatively unknown. the aim of this study was to determine the prediction factors for failure in the use of niv with a helmet in this context. the use of niv was assessed for a period of years, in a post-operative intensive care unit (icu). demographic data was collected, as well as arf and arterial gas readings. haemodynamic changes were assessed using picco tm technology and the clinical development of patients was recorded. all patients who developed acute respiratory failure (arf) were treated using niv as their primary care, and the two groups for the study were determined in this way, depending on whether the technique was successful, or the patients required intubation. the risk factors that determined failure in the application of niv were subsequently determined. of the patients presenting with post-operative arf treated with niv using a helmet, did not require intubation ( . %). following a multivariate analysis using logistic regression, we determined that there are four independent risk factors for the failure of niv. the primary causes of respiratory failure are as follows: acute respiratory distress syndrome (ards) and pneumonia, and in second place, the high initial evlwi (extravascular lung water index) value, as a protective factor, is the increase in the po /fio ratio after the first hour of niv application. conclusions. niv using a helmet could provide an effective alternative to conventional ventilation in selected patients with post-operative arf. -jaber s, delay objectives. analyze niv practice in emergency departments. we have development an international epidemiology survey (march ) by electronic questionnaire to know niv organization, equipment and training in emergency departments (phase i). design. international multicenter prospective. we have enrolled information from hospitals: spain ( ); italy ( ); india ( ); usa ( ); slovakia ( ); turkey ( ); germany ( ); australia( ); chile ( ); singapore ( ); finland ( ) during to analyze noninvasive practice in prehospital and emergency medicine, equipment, interfase, ventilatory modes and common clinical applications. major results during month period analysis were: noninvasive mechanical ventilation were applied in prehospital: ( ) ( . %). nimv commonly was applied follow a objective pprotocol of nimv: ( ) ( ) ( . %). global rate indication of niv were copd exacerbation ( %) and cardiac pulmonary edema ( - %). all niv applications were successful applications in emergency departments (avoid eti %) with minor complications ( . %) (skin nose lesion). equipment more relavant were (cpap devices ( %) and facial mask ( %) was more frequent, follow total face( %); nasal mask ( %); helmet ( %); type ventilary mode: cpap ventilatory mode was frequent used as first line ( % ( ) suggest niv should be started within h of not responding to the maximal medical therapy for acute type respiratory failure patients. following an earlier audit presented as an abstract at esicm ( ) , which looked at possible delays in starting niv, protocols were implemented to start niv earlier at russells hall hospital acute admissions unit. objective. the aim was to assess the delays in starting the appropriate patients on niv at admission looking at impact on adverse outcomes. method. data was collected retrospectively using bts niv audit tool. cases admitted with type respiratory failure in our hospital between january and march who needed niv were included in the audit. delay was subdivided into a) door to first arterial blood gas (abg) sampling b) abg to decision for niv and c) from decision to actual starting of niv. results. the mean time to get an abg from admission was min. cases with delay more than h skewed the data. the median time, which was more representative of the usual delay between admission and first abg, was min. our audit showed that out of ( %) patients had abg within an hour compared to out of ( %) in the last audit. although noninvasive ventilation (niv) has been widely used in patients with acute on chronic respiratory failure (acrf) due to chronic obstructive pulmonary disease (copd), series studying patients with pulmonary restriction due to morbid obesity (mo) are rare ( ) , despite the disease is highly prevalent in our environment. objectives. the aim of our study is to analyze and compare the effectiveness of niv in patients with copd and om. we analyzed all patients admitted to icu for a period of years with diagnosis of acrf due to copd or mo and treated with noninvasive ventilation. niv success was defined as the avoidance of endotracheal intubation, survival in icu and at least h on a medical ward with no signs or symptoms of respiratory failure. variables are expressed as means ± standard deviation and percentages. comparison between variables by pearson's v test and student t. we analyzed survival and hospital readmission per year (log rank test). during the study period, patients were admitted with exacerbation of copd and with mo. all patients were treated with two levels of pressure. age differs between copd and om, ± and ± years, respectively (p = . ), as well as the percentage of men, . adaptive support ventilation (asv) Ò (hamilton galileo) has been shown to result in better patient synchrony, reduced weaning times and reduced work load for the icu staff ( , ) . but, data is lacking on its efficacy, especially as non invasive ventilation (niv) due to the concern of being closed loop ventilation. also, little is known about the risk factors of late niv failure in patients who improve initially ( objectives. to assess end tidal co monitoring in patients with hypercapnic exacerbations of copd requiring niv methods. simultaneous measurement of paco and petco was performed in groups of patients. paco was measured using arterial blood gas analysis and petco was measured using non-invasive capnography. the groups were; phase a: mechanically ventilated patients post coronary artery bypass graft, used to establish the reliability of the end tidal carbon dioxide monitor in a homogenous group of previously well patients. phase b: patients with copd who did not have symptoms associated with an exacerbation, used to assess the use of a non invasive sampling device and assess the sampling method in stable copd patients. phase : patients with a hypercapnic exacerbation of copd requiring niv. capnography was monitored continuously in this group and petco values were calculated based on a mean value min before and after the arterial blood gas sample. this was to avoid any sampling error as it was impossible to isolate the exact moment of arterial puncture. agreement between the sampling methods was assessed using the bland-altman method. phase a objectives. we aimed to evaluate the possible harm of niv failure in routine practice among spanish icus. methods. we extracted patients with acute respiratory failure requiring either invasive or noninvasive mechanical ventilation in spanish icus during the -month period of the validation of the sabadell score ( ). we recorded demographic parameters and treatments received during the icu stay. patients were followed until hospital discharge or death. results. we analyzed , patients, of whom , ( %) received only invasive mechanical ventilation (imv) and ( %) received niv. niv succeeded in % of patients, but the other % required intubation. niv failure was more common in neurologic ( %) and post operatory ( %) and less frequent in coronary patients ( %). mortality was lower than predicted in niv patients ( vs. %) and similar to predicted in imv patients ( vs. %). mortality was lower than predicted in patients in whom niv was successful ( vs. %) and (similar or slightly lower than to predicted) in those in whom niv failed ( vs. %). conclusions. routine use of niv seems to confer a benefit, even when it fails and intubation is needed. reference(s tables and shows the parameters on respiratory muscles. introduction. the effectiveness of non-invasive ventilation (niv) in the setting of hypoxemia de novo remains controversial. it has been detected that patients in whom niv fails and intubation is required have a high mortality. otherwise, in patients in whom niv avoids intubation, survival rate is also high. to identify the factors involved in success or failure of niv in critically ill patients with hypoxemia de novo. we retrospectively studied all the patients admitted in our -bed intensive care unit (icu) from january to december with the diagnosis of hypoxemia de novo. do-notintubate patients were excluded. the indication of niv was at medical discretion, as well as intubation criteria. we defined the hypoxemia de novo as acute non hypercapnic respiratory failure due to a different cause from cardiogenic pulmonary edema. we defined two groups of patients: ) niv failure, patients who required intubation, and ) niv success, patients who did not require intubation. we collected demographical variables (age and gender), etiology of the hypoxemia, severity scores on admission (saps ii and sofa), glasgow coma scale (gcs), respiratory rate (rr), pulsioximetry (spo ), ph and fio , before and h after starting niv, episodes of nosocomial respiratory infection, length of stay (los) in icu and icu mortality. we compared both groups using the mann-whitney non-parametric test. p \ . was statistically significant. we studied patients ( women and men) with a mean age of ± years. the etiology of respiratory failure was: ards (n = ), pneumonia (n = ) and others (n = ). there were patients in the niv failure group ( %), and in the niv success group ( %). niv failure rate was higher when hypoxemia was due to ards (p = \ . ). objectives. this retrospective analysis aimed to assess outcomes following instigations of niv in a variety of clinical conditions. outcome data for copd/apo and non-copd/apo groups were compared. we assessed whether outcomes differed between these groups. in addition we wished to assess how outcomes varied across non-copd, non-apo conditions. objectives. the aim of this study was to compare patient's respiratory effort with three different noninvasive ventilators currently used on critical care patients and selected from a bench study. six patients treated by niv to prevent respiratory failure after extubation were included. each subject was successively submitted to a randomly assigned min-period of ps-niv with three different ventilators: bipap vision (respironics), elisée (resmed) and oxylog (dräger medical). these ventilators have different performances in a bench comparison. ventilatory settings were adjusted for the first ventilator and maintained for the followings. ps level was increased in order to obtain a tidal volume of - ml/kg of body weight (ps ± cmh o). flow, airway and oesophageal pressures were recorded. the oesophageal pressure time product (ptpoes) and tidal oesophageal swing (dpoes) were measured to evaluate patient's respiratory effort. results. no significant differences in tidal volume, respiratory rate and autopeep were found between ventilators. the dpoes and ptpoes, however, were significantly higher with oxylog as compared to bipap vision and elisée , as expected from the bench comparison. there are limited data on niv s efficacy in hypoxic respiratory failure. objective. to investigate the epidemiology and outcomes of patients administered niv as first line respiratory support in a mixed medical-surgical icu over a year period (jan -dec ), in an academic medical center. methodology. data abstraction from icu database, clinical care manager and chart review. results. surgical patients (sp) and medical patients (mp) were administered niv. the sp were % male, and had a median age of years. the mp were % male, and had a median age of years. % of sp were admitted with type respiratory failure (t rf pao \ kpa), % were admitted with type respiratory failure (t rf paco [ kpa) and the remainder were admitted with respiratory distress (rd). % of mp were admitted with t rf (pao \ kpa), % were admitted with t rf (paco [ kpa) and the remainder were admitted with rd. the median length of stay (mlos) was days for sp (range - ); the mlos for mp was days (range - ). sp were commenced on niv on average . h after admission (range - h), and remained on niv for a median of . (range - ) h. % of surgical patients required intubation, and the mortality rate was . %. mp were commenced on niv on average h after admission (range - h), and remained on niv for a median of (range - ) h. % of medical patients required intubation, and the mortality rate was %. logistic regression was applied to all datasets. among medical and surgical patients there was no correlation between the type of respiratory failure, initial blood gas or ph and the need for subsequent intubation, or risk of death. hematology patients had a mortality rate of % and accounted for % of overall deaths. oncology patients also had a % mortality rate, and accounted for % of overall deaths. amongst the mp that presented with hypoxemia, the intubation rate was % and the mortality rate was % (although not all patients that died were intubated). amongst the mp that presented with hypercarbia, the intubation rate was % and the mortality rate %. summary. niv successfully prevented intubation in more than % of patients. patients presenting with hypoxic respiratory failure were no more likely to be intubated than those presenting with hypercarbia. two-thirds of hematology and oncology patients treated initially with niv subsequently died. a microdialysis system was composed and the time delay of the system, recovery time, was introduced and tested with a fluids switching method. twelve sd rats were divided into ir or control group. myocardial ir was induced by ligating ( min) or releasing ( min) the suture underlying lad. mycrodialyisis probe was implanted into the left ventricular myocardium perfusion area to be occluded. dialysate samples were collected every min. blood samples were drawn at the beginning and at the end of the procedures. dialysate calcium concentration ([ca++]i) was detected with an atomic absorption spectrophotometer. serum calcium and ctnt were detected. recovery time for the microdialysis system was min, recovery rate was %. [ca++]i showed no changes during ischemia and descended immediately after reperfusion,reached the lowest level at min after reperfusion, then escalated slowly while keeping lower than control with significant difference. there was no difference in serum calcium at the beginning ( objectives. to evaluate the causes, incidence and impact on outcome of admission hyperlactatemia in patients admitted to a general micu. methods. data were retrospectively collected from the patient records for all adult patients admitted in the micu during the -months period. data regarding patient demographics, probable cause of hyperlactatemia, presence of shock on admission, need for organ support and icu outcome were recorded. patients were divided into two groups based on admission lactate levels: high lactate, with levels of mmol/l or more and normal lactate, with levels less than mmol/l. patients in these two groups were compared in terms of need for organ support and icu mortality. the efficacy to discriminate between survivors and non-survivors was assessed by area under the receiver operating characteristic curve (auroc). introduction. during critical illness alterations in blood flow are thought to predispose to organ dysfunction and hemodynamic therapy is often targeted at maintaining organ perfusion. however, abnormal blood flow distribution during critical illness may cause regional blood flows to correlate poorly with systemic haemodynamics ( ) . currently, our understanding of blood flow distribution during critical illness in humans has been limited by the invasiveness of established techniques for its measurement. objectives. phase-contrast mri (pc mri) represents an entirely non-invasive, contrastfree, method of measuring blood flow in major blood vessels ( , ) . we sought to apply this technique to technique to the measurement of organ blood flow in the critically ill. in a pilot proof of concept study, we measured renal and portal blood flow by pc mri critically ill humans with sepsis, multi-organ dysfunction and acute kidney injury (aki). in individuals cardiac output was measured by thermo-dilution in the icu, in the remaining patients we measured cardiac output (ascending aortic flow) and also descending thoracic aortic blood flow using pc mri techniques. we studied critically ill individuals with severe sepsis and aki. when studied, were mechanically ventilated, were on continuous haemofiltration and required vasopressors. transport and mri examinations were carried out without complication. in these patients, median cardiac index was . l/min/m (range . - . ), median renal blood flow ml/min ( - , ) and median renal fraction of cardiac output . % ( . - . ). median portal blood flow was ml/min ( - , ). descending aortic blood flow (measured in patients) ranged between and % of cardiac output (median %). conclusions. phase-contrast mri can efficiently and safely assess organ perfusion during critical illness in man. near simultaneous measurement of cardiac output enables organ blood flow to be assessed in the context of the global circulation. preliminary observations suggest renal blood flow is consistently reduced as a fraction of cardiac output in established aki. pc mri may be valuable to future investigation of organ dysfunction and vasoactive therapies in sepsis and critical illness. objectives. we were interested in the effects of the higher pco -levels on the microcirculation of infants with birh weights \ , g. data were collected from infants, who were randomized either to treatment with permissive hypercapnia or normocapnia. inclusion criteria were a birth weight between and , g, a gestational age from rd to th+ weeks, intubation during the first h of life and no malformations. the pco target range was increased stepwise and was mmhg higher in the intervention group. skin microvascular parameters were assessed noninvasively with sdf on the right arm every h during the first week of life and on the th day. results. pco (auc: ± vs. ± ) differed significantly between the two groups (p = . ). functional vessel density (fvd) was significantly lower in the intervention group on the th day of life ( ± vs. ± cm/cm ; p = . ). the proportion of small vessels increased in the control group whereas they decreased slightly in the intervention group, but did not reach stat. sig. increasing target pco lead to a temporary hyperdynamic flow in both groups. conclusions. pco -levels influence significantly the microcirculation in preterm infants. elevation of pco -levels leads to a decrease in fvd, presumably due to shunting and vasoconstriction and might cause temporarily hyperdynamic flow. methods. blood from healthy volunteers were diluted with hes, albumin %, rl or autologous plasma to obtain a final hematocrit of %. in vitro wbv measurements were made by the rheolog tm device (rheologics, exton, pa), a new viscometer with a u-formed capillary. the flow rate (determined by the rate of change in height of the columns of blood) is directly related to the pressure drop across the capillary tube. the shear rate (from , to s - ) and viscosity of the sample can be mathematically derived. results were expressed as median values (with - % intervals) and compared by anova with bonferroni correction. a p value . was considered as statistically significant. hemodilution with rl and albumin decreased significantly the wbv for all shear rate compared with autologous plasma and hes ( fig. ). conclusions. in contrast to albumin and ringer's lactate, hes and autologous plasma increased the whole blood viscosity, suggesting that these solutions may be preferred in severe hemorrhagic shock to better preserve plasma viscosity and microcirculation. we divided into two groups the randomly selected sample from the scope of patients come through open-heart operation assisted with extracorporeal support at the university of pécs: therapeutic (continuous blood gas monitoring/cdi- ) and control (intermittent sampling) group. after the retrospective data collection we carry out the analysis with (prevalence) frequency and confidence interval calculation and khi square test. results. the following accompanying diseases occurred significantly higher rate in the therapeutic group: ami (p = . ), kidney disease (p = . ), chronic pulmonary disease (p = . ), and the aggregation of the accompanying diseases showed also significantly high degree (p = . ). the long interval operations occurred significantly higher rate (p = . ) in the therapeutic group, and the times of the aorta clinch (p = . ) and the perfusion (p = . ) was also significantly longer. despite of that during the perfusion in a significantly more cases remained the rates in the normal range concerning to the therapeutic group (ph: p \ . ; be: p \ . ; pco : p \ . ), and the prevalence of the restart of the heart showed also significantly higher rate (p = . ). the continuous blood gas analyses assure reliable and the postoperative recovery assisted ecc circulation support. this assists considerably for keeping the parameters in the physiological limits even in the higher rate of the incidences of complex operations and accompanying diseases. this could contribute to lower incidence of side effects, preventing the causeless elevation of the postoperative hospital charges. objectives. describe the changes in capillary perfusion after erythrocytapheresis during severe falciparum malaria. we report two cases of severe falciparum malaria and describe the evolution of the sublingual capillary perfusion after erytrocytapheresis. the sublingual microcirculation has been studied with sidestream dark-field imaging (microscan; microvisonmedical tm , amsterdam). the device was applied on the lateral side of the tongue and the video images ( - captures of - s.) of capillary perfusion were recorded. the microcirculatory scores were analysed offline: small vessels (\ lm) density (number of vessels/mm), percent of continuously perfused small vessels (ppv%) and mean flow index (mfi). mmol/l. the capillary perfusion has improved: capillary density increased ( . /mm), the proportion of perfused vessel increased ( %) and flow was continuous in most vessels (mfi: ). clinical evolution was rapidly favourable and the patient was discharged from the intensive care unit. case . severe falciparum malaria with high parasitemia ( %) and acute renal failure. before erythracytapheresis: macrohemodynamic parameters were normal but microcirculation was reduced: vessels density ( . /mm) with % of small vessels perfused and the flow was slow in most vessels (mfi: . ). after erythracytapheresis: parasitemia decreased ( . %). sublingual microcirculation has improved with an increase in small vessels density ( . /mm) among which . % were perfused with a continuous flow (mfi: ). the patient had a good outcome. conclusions. microcirculation monitoring should be assessed specifically in some critically ill patients, even if macrocirculatory parameters are in the normal range. during severe plasmodium falciparum malaria, this monitoring could be specifically important to assess the effect of erytrocytapheresis therapy on tissue perfusion. rd esicm annual congress -barcelona, spain - - october s objective. perioperative myocardial infarction (pomi) is associated with significant mortality and morbidity in cardiac surgery. the primary objective of this prospective multicenter study is to investigate whether monitoring of coronary sinus metabolic markers can reliably predict ischemia and pomi faster than conventional monitoring. method. patients undergoing cardiac surgery were monitored perioperatively using a transjugular implanted microdialysis catheter (cma microdialysis) to study the metabolic changes of the heart. coronary sinus (sc) samples of lactate, pyruvate and glycerol were obtained continuously through -h post-operatively. pomi was defined by ckmb c u/ l and troponin t c . lg/l. a total of patients met the criteria for pomi. patients showed at least one adverse event during the postoperative course. lactate, lactate-pyruvate-ratio and glycerol levels in the sc sharply increased up to h before rise of cardiac enzymes. analyses of regression and discriminate analyses showed statistically significant (p \ . ) relationships between elevated metabolite values and the occurence of pomi. roc analysis revealed that lactate, lp-ratio and glycerol from the sc are sensitive markers to predict pomi and postoperative clinical events. conclusions. coronary sinus metabolic markers are sensitive and early predictors for the detection of perioperative myocardial infarction and severe complications in patients undergoing cardiac surgery. beginning disorder can be detected far earlier than with any existing monitoring device. perioperative red blood cell transfusions (btx) are commonly used in patients undergoing cardiac surgery to correct for anemic conditions caused by blood loss and hemodilution associated with cardiopulmonary bypass circulation and anesthesiological procedures. however, several studies have shown btx might have adverse effects on patient outcome. the goal of btx is to correct anemia and to ensure an improvement in the oxygen delivery to the parenchymal cells by the increased presence of red blood cells in the microcirculation. the aim of this investigation was to test the hypothesis that btx during onpump cardiac surgery have a beneficial effect on sublingual microcirculatory perfused vessel density, and oxygenation. methods. adult patients undergoing on-pump cardiac surgery were selected for this study. sublingual microvascular flow index (mfi), detected vessel length (dvl), and functional capillary density (fcd) were assessed using sidestream dark-field (sdf) imaging in patients. sublingual reflectance spectrophotometry was applied in patients to monitor sublingual tissue oxygen saturation. in group a, btx resulted in increased fcd and dvl as depicted in fig. . mfi for small and medium microvessels was not affected by btx (fig. ). in group b, reflectance spectrophotometry demonstrated increases in microcirculatory hemoglobin and oxygen saturation ( fig. ). the main findings suggest that leukoreduced btx improves the systemic circulation and oxygen carrying capacity of the microcirculation by increasing fcd and thereby reducing diffusion distances without increasing significantly the convection of red blood cells. this reduction in diffusion distances causes an increase in microcirculatory oxygen saturation. d.m.j. milstein , k. yürük , r. bezemer , c. ince academic medical center at the university of amsterdam, translational physiology, amsterdam, netherlands aims. anemia is a common adverse effect of oncologic diseases as is the therapeutic options required for their treatment. however, as blood transfusions are directed at correcting for anemia and intrinsic hypoxic conditions, little evidence exists claiming that blood transfusions have successfully resolved anemic challenges as storage can significantly deteriorate rbc function. the aim of this study was to investigate the influence of rbc transfusions on sublingual microcirculatory perfusion and tissue oxygenation in anemic oncology patients. methods. eight consecutive ambulatory patients scheduled to receive packed rbc transfusion bags were selected for this study. baseline sublingual microcirculation functional capillary density (fcd) was measured using sidestream dark-field (sdf) imaging prior to and after min of the completion of the last infused blood bag. sublingual mucosal oxygen saturation (sto ) was measured at the same anatomical location and time points using near-infrared spectroscopy (nirs). results. figures and capillary refill time (crt) is a generally accepted method of assessing the circulatory status of a patient. we have previously showed that using . s as the upper limit of normality in critically ill patients could discriminate patients with a more unfavourable outcome . however, this upper limit of normality was defined based on variation of crt in an adult healthy population . the best crt in critically ill patients, therefore, should still be redefined. objectives. we aimed to define the best crt as predictor of organic and metabolic dysfunction in an intensive care unit (icu) population. methods. capillary refill time was measured by applying firm pressure to the distal phalanx of the index finger for s, and a chronometer recorded the time of returning to normal colour. we performed receiver operating characteristic curve (auc) to detect the best crt consistent with severe organ and metabolic dysfunction, as evaluated by sequential organ failure assessment (sofa) [ and acidosis (lactate [ mmol/l and be\ - meq/ l), respectively. in addition, we performed logistic regression analysis using the cutoff crt as binary to investigate its estimated odds ratio (exp(b)). of patients included in the study (age ± ; male), had circulatory shock, of whom had septic shock. mean crt in all patients was . ± . . figures and show the roc curve for sofa score[ and metabolic acidosis, respectively. using the best crt value, logistic analysis revelled the following estimated odds ratio: for sofa score[ : exp(b) = . ; p = . ); for metabolic acidosis (exp(b) = . ; p = . ). roc curve for crt relative to sofa score [ roc curve for crt relative to acidosis conclusions. we found that . s is the best time to define prolonged crt in critically ill patients, and that using this crt cutoff value could discriminate patients with a more severe organ and metabolic dysfunction. introduction. impairment of microcirculation in acute situations is associated with organ failure and depends on macrocirculation but also on specific factors ( ) . micro-perfusion, assessed by tissue hemoglobin saturation (sto measurement) or micro-blood flow (laser doppler, ld) are easy to use and non invasive methods. the obtained data could be an end point in critical care resuscitation or optimization. objectives. to assess the impact on microcirculation of cardiovascular (cv) support on the basis of mean arterial pressure (map) and cardiac output (co), to evaluate when microcirculatory parameters improved or not the modifications observed in map and co. methods. observational study: measure of co, map, svco , and lactate, thenar nirs (inspectra ; hutchinson technology) baseline sto , with performance of an arterial occlusion test ( mn, mmhg) so calculate occlusion-os and reperfusion slopes-rs ( ). similarly, forearm skin blood flow velocity (ld, blf d, transonic systems) basal ld, and post-ischemic peak velocity ldmax) ( ) were measured. data were collected before and after cv optimization (fluid loading, vasoactive or inotropic drugs). patients were defined: macrocirculatory responders (r) when co increased more than % versus nonresponders (nr); microcirculatory responders (rs+) when rs increased more than % versus nonresponders (rs-). statistical analysis: nonparametric tests (wilcoxon and mann-whitney test). results. patients ( % in shock) were studied. had sepsis ( %), hemorrhage ( %), pulmonary oedema ( %), or other ( %). therapeutic optimization challenges were performed: fluid challenges ( ml, . % nacl), dobutamine c/kg/min, nitrates, diuretic, electric shock and an increase in dosage of norepinephrine. in r group (n= , %), co was increased associated with map (p \ . ), svco (p = . ) and decreased lactate (p = . ). the micro-oxygenation improved with an increase of rs ( . [ . - . ] vs. . [ . - . ]%/s, p = . ) as microperfusion did: increase in ldmax ( . [ . - . ] vs. . [ . - . ] tpu, p = . ). in the nr group, both the macro or the microcirculation did not change. since no microcirculatory differences between r and nr were observed, patients with good or poor microcirculation could not be detected. the study based on microcirculatory responses showed % of responders (rs+). in this group, baseline sto (p = . ), basal ld (p = . ) and ldmax (p = . ) increased in a large amount in association with an improved co and map (p = . and p = . ). in the rs-group, co and map were also improved (p = . and p = . ). conclusions. improvement of macrocirculatory parameters can improve microcirculation but not in all patients. improvement in microcirculation may also be a target, regardless the effects on macrocirculatory parameters. this concept has to be tested prospectively. introduction. hypothermia is regularly used for brain protection after resuscitation from cardiac arrest but its impact on cardiovascular function, however, is not well defined. objectives. the aim of this study was to evaluate the cardiovascular response to mild therapeutic hypothermia and rewarming in a large animal model. seven anesthetized, mechanically ventilated and invasively monitored sheep were cooled with a cold intravenous saline infusion, ice packs and nasal cooling (rhinochill system, benechill, ca) to achieve a core temperature of - °c (the basal temperature in sheep is around °c). after maintenance of this temperature for h, sheep were progressively rewarmed to baseline temperature. a positive fluid balance was maintained during the entire study period to avoid any hypovolemia. the sublingual microcirculation was observed using sidestream dark-field (sdf) videomicroscopy and the proportion of perfused vessels (ppv) and perfused vessel density (pvd) evaluated using a semi-quantitative method. results. during cooling, systemic and pulmonary artery pressures did not change, but cardiac output decreased significantly along with the increase in vascular resistance. left and right ventricular stroke work index decreased reflecting altered ventricular function. nevertheless, there was an increase in mixed venous oxygen saturation (svo ), reflecting a decrease in oxygen extraction. sublingual microcirculation analysis showed a significant decrease in ppv and pvd. all the variables returned gradually to baseline during the rewarming phase. conclusions. in this intact healthy large animal model, the alteration in cardiac function during hypothermia was well tolerated because of the simultaneous decrease in oxygen requirements. arterial pressure was maintained by an increase in systemic vascular resistance associated with a reduction in peripheral microcirculatory density. grant acknowledgment. *rhinochill system was supplied by benechill, inc. objectives. to evaluate consequences of hypoxemia occurence on intestinal microcirculatory perfusion in mice submitted to controlled hemorrhage. tracheotomized and ventilated balb/c mice were submitted to systemic hypoxemia (pao = mmhg) during h. controlled hemorrhage to mean arterial pressure of mmhg was associated (from th to th min). groups were constituted: hh = hypoxia and hemorrhage, hr = hemorrhage, hx = hypoxia, cl = control (neither hypoxia nor hemorrhage). a segment of ileon was exteriorized through an abdominal midline incision. it was opened along the antimesenteric border and placed on a specially designed piedestal to facilitate observation of the villi with transilluminating and epifluorescent microscopy. the bowel segment was superfused with krebs solution maintained at °c. villous perfused density (dvp), red blood cell velocity in villous tip arteriole (vart) and villous capillaries (vcap) were observed after fitc-labeled erythrocytes were intravenously administered. mice were included in each group. leucocytes adhesion to intestinal wall venules ( - lm) was observed in a separated set of experiments including also mice per group. number of adherent leucocytes (l adh ) and leucocytes flux (l fl ) were observed in each group. measurements and arterial blood gases were collected at , , min (t ). data were expressed as mean ± sem and were compared by analysis of variance (anova). introduction. despite remarkable progress in hemodynamic monitoring, clinical examination, assessment of peripheral perfusion and comparison of surface and body core temperature still are diagnostic cornerstones of critical care. infrared non contact thermometers provide accurate measurement of body surface temperatures. the picco device using an arterial line with a thermistor tip in the distal aorta-in addition to transpulmonary thermodilution (tptd)-provides continuous body core temperature. objectives. therefore, it was the aim of our study to evaluate the predictive capabilities of surface temperatures and their differences to body core temperature regarding ci, svri and parameters of microcirculation. in icu-patients body core temperature was measured four times per day using a picco-catheter (tp), a thermistor-tipped urinary catheter (tu) and an ear thermometer (te) (thermoscan; braun). additionally, surface temperatures were determined on the great toe, finger pad, forearm and forehead using an infrared non contact thermometer (thermofocus; tecnimed). furthermore capillary refill time (crt), lactate and scvo were measured and peripheral perfusion was clinically assessed (normal, pale, mottled). immediately afterwards tptd was performed to obtain ci and svri. statistics: spss . . spearman correlation. compared to tp, t forehead (- . ± . °), t forearm (- . ± . °), t finger pad (- . ± . °) and t toe (- . ± . °) were significantly lower (p \ . for all comparisons). in multivariate analysis tptd-derived ci ( . ± . l/min sqm) was significantly correlated (r = . ) to the difference ''tp-t forearm '' (p \ . ), ''tp-t finger pad '' (p = . ), crt (p = . ), scvo (p = . ) and map (p = . ). tptd-derived svri was multivariately associated (r = . ) with ''tp-t forearm '' (p \ . ) and map (p \ . ). scvo was independently correlated to the difference ''tp-t finger pad '' (r = . ; p \ . ). lactate was independently correlated (r = . ) to crt (p \ . ). the roc areas were . and . for (tp-t forearm ) and (tp-t finger pad ) to predict ''ci \ . '' and ''scvo \ '', respectively. the sensitivity, specificity and negative predictive value of ''tp-t forearm [ . °'' were , and % regarding a ci \ . l/min/sqm. .) measurement of surface temperatures using non contact infrared thermometers and comparison to body core temperature provides useful data on macro-and microcirculation. .) the differences (tp-t forearm ) and (tp-t finger pad ) were independently associated to tptd-derived ci and svri, and ci and scvo , respectively. .) crt was independently associated to lactate level. v. shilov , a. astakhov ural state postgraduate medical academy, chelyabinsk, russian federation introduction. actuality of this problem consists of different disturbances of heart rhythm and heart conductivity (from sinual bradycardia and ventricular extrasystolia till sinuatrial arrest and fibrillation of ventricles) provoked by traction of oculomotorial muscles and pressure on eyeball. this reaction is called oculocardial reflex (ocr). it is necessary to note there is no definite strategy of ocr prevention. objectives. this study was conducted to estimate the possibility of the control of haemodynamic effects of ocr. the haemodynamics and hydrobalance were investigated with electric current probe ( and khz) using monitoring complex of cardiorespiratory system and hydratation of tissues -km-ar- «diamant». data documentation was carried out at stages of evisceroenucleation: . before anesthesia and surgery; . at induction; . during the intubation; . at eyeball mobilization and oculomotorial muscles traction; . while deepening of endotracheal anesthesia by inhalative anesthetics during - min after preceding stage; . at the end of surgery, after the extubation. results. the study confirmed ocr reflex, to appear at eyeball extraction and to manifest as bradycardia, cardiac output decreasing heart productivity, but peripheric vessel resistansce does not change. monitoring-controlled gradual deepening of inhalative anesthesia during - min has restored the haemodynamic data to normal eliminated ocr vessel reactions. hydrostatic changes took place only at the end of the operation, after the extubation. it manifested ad increasing of extracellular liquid confirmed by decreasing of low-frequent impedance. intracellular liquid remained intact. it seems the most possible, hydrostatic changes of extracellular liquid to depend on crystalloid infusion in blood vessels up to , ml during anesthesia and they eliminate with hypovolemia. conclusions. thus we can conclude that vascular manifestations of hemodynamics in ocr at eyeball extraction or active oculomotorial tractions may be eliminated with gradual deepening of inhalative anesthesia and monitoring of registed date of haemodynamic and hydrobalance. probably it's necessary to optimige the anesthesia using of pterygopalatal and pterygoorbital blockade to prevent ocr before the induction as retrobulbal anesthesia may be an ocr trigger. f. corradi , c. brusasco , a. vezzani , f. altomonte , p. moscatelli university of genoa, anesthesia and intensive care, genoa, italy, ospedale maggiore di parma, anesthesia and intensive care, parma, italy, azienda ospedaliera universitaria san martino, emergency medicine, genoa, italy introduction. despite improvements in trauma care, uncontrolled bleeding is the leading cause of potentially preventable early in-hospital deaths contributing to to % of trauma-related deaths ( ) ( ) . about % more deaths occur within the second/third hour after injury due to occult major internal haemorrhage. failure to recognize this situation may in part be due to lack of sensitivity of hb/hct levels, arterial blood pressure, heart rate, respiratory rate, injury severity score and markers of hypoperfusion (lactate and base excess) in initial assessment of blood loss. to study if early changes in spleno-vascular resistance index predict the development of hypovolemic shock after trauma. a prospective observational study conducted in adult haemodinamically stable patients admitted to the emergency department because of suspected or definite severe trauma and retrospectively divided into groups depending on whether or not they developed haemorragic shock requiring blood transfusion. doppler ultrasound measurements of splenic arterial branches at ilum were obtained and splenic doppler resistance index (sdri) was recorded at admittance (within h from trauma) and related to arterial blood gas analysis (haemoglobin, base deficit, lactate, co , ph), heart rate, and outcome in the first h (intensive care unit admittance, blood transfusion, sepsis, mortality). results. statistically significant differences between patients who developed shock within h and those who did not were the following: higher sdri ( . ± . vs. . ± . , p \ . ), lower base deficit (- . ± vs. . ± meq/l, p = . ) and higher lactate ( . ± . mmol/l vs. ± mmol/l p = . ). auc's of roc analysis were significant for sdri (auc = . , ci . - . , p \ . ) and lactate (auc = . , ci = . - . , p = . ), and borderline for bd, hr, hb, and ph. by multivariate analysis, sdri at admittance resulted to be the only good independent predictor of hypovolemic shock and bleeding (p \ . ), whereas haemoglobin, base deficit, heart rate, lactate and ph were not significant. in trauma patients with stable haemodynamic conditions at admittance spleen constriction occurs very early under heavy adrenergic stimulation in response to occult bleeding and can be non-invasively detected by sdri. the present study proposes sdri as a non-invasive measurement of changes in splanchnic circulation to detect blood loss and occult hypovolemia, which may help activate early surgical or radiological intervention for patients with major trauma and guide therapy to optimize splanchnic perfusion. introduction. approximately % of patients require temporary circulatory support due to cardiogenic shock following cardiac surgery. these patients are at risk of a mismatch between oxygen delivery and demand and carry a substantial mortality and morbidity risk. mixed venous oxygen saturation (svo ) is the still the ''gold standard'' for the determination of the ratio between systemic oxygen delivery and consumption (do /vo ratio) in cardiac surgery patients. a nonivasive technique is thought to be cerebral near-infrared spectroscopy determining cerebral oxygen saturation (rso ). purpose. the present analysis aims to compare rso and svo levels in adult patients undergoing ecmo therapy for postoperative cardiogenic shock. methods. data were collected hourly for the first h post operatively. each patient was equipped with a pulmonary artery catheter (pac) for continuous determination of svo connected to a vigilance ii-monitor (edwards lifesciences, irvine, usa) and an invos monitoring system (somanetics, troy, usa) to determine rso . data were analyzed by parametric testing and bland-altman analysis. a total of patients were enclosed. all svo values were in a range between and %. in this range, the linear correlation coefficient between svo and rso was r = . (p \ . ). the correlation coefficient for svo values below % was r = . (p \ . ) and r = . (p \ . ) for svo levels equal or higher than %. bland-altmann analyses of all collected oxygenation data (n = ) revealed a bias of . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ) for the raw data of the whole group ( figure ). bland-altmann analyses of svo values below % (n = ) showed a bias of . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ). bland-altmann analyses of svo values equal or higher than % (n = ) revealed a bias of - . % (mean % ci: . to . ) and limits of agreement ( . standard derivation) of . to - . % (upper % ci: . to . ; lower % ci - . to - . ). interestingly, despite svo values [ %, we noticed events in patients with rso values less than % for more than min. all events had been associated with arterial co levels below mmhg, whereas no other changes in hemodynamic or oxygenation parameters could be determined. conclusions. this pilot study suggest for the first time that rso highly correlates with svo in patients undergoing ecmo therapy due to refractory cardiac and/or pulmonary dysfunction. therefore determining rso may be a noninvasive alternative to monitor global tissue oxygenation under this condition. additionally, it was noted that cerebral hypoxia may be present despite a svo c mmhg. rd esicm annual congress -barcelona, spain - - october results : during severe hypothermia ( °c) cardiac index (ci), stroke index, mean arterial pressure and indexes of lv contractility (prsw and dp/dtmax) were reduced. after rewarming all variables remained reduced, except for ci that returned to prehypothermic values due to increased heart rate. systemic vascular resistance (svr), lv isovolumetric relaxation time (tau) and oxygen content in arterial and mixed venous blood increased during °c, while lv end diastolic pressure (lvedp) was constant. after rewarming svr and lvedp were reduced, while tau and the blood oxygen contents normalized. troponin-t and tnf-a were constant during °c but increased after rewarming. albumine plasma concentration was reduced during °c and remained so after rewarming. conclusions. surface cooling to °c followed by rewarming caused reduction of systolic, but not diastolic lv function. there were no signs of inadequate global oxygenation throughout experiments. the posthypothermic increase in troponin-t may reflect degradation of myocyte troponins secondary to a hypothermia-induced calcium overload. the increase in tumour necrosis factor alpha together with a posthypothermic reduction of plasma albumin concentration may indicate that the cooling and rewarming initiated an inflammatory response. we studied patients, mean age . ± . years, % male. the etiology of cardiogenic shock was: % (n = ) dilated cardiomyopathy, % (n = ) acute myocardial infarction, % (n = ) acute cardiac allograft rejection and % (n = ) acute myocarditis. the duration of ecmo support was . ± . h. weaning was possible in % (n = ) and the ecmo was used as a bridge to transplantation in % (n = ). -day survival was and . % of our serie were discharged from the hospital. in cases the ecmo was withdrown as a result of a limiting treatment decision. objectives. to describe the characteristics of patients with ca and its management with moderate hypothermia using arctic sun Ò device with hydrogel patches. descriptive, observational and retrospective study of patients who suffered ca and received moderate therapeutic hypothermia ( °c) according to the protocol implemented in a coronary intensive care unit of a tertiary hospital. we collected patients from june to april , first months of this therapy in our hospital. moderate therapeutic hypothermia is applied using the arctic sun Ò device consisting of hydrogel patches applied to the skin covering % of the body surface. the device is connected to a temperature control console, measuring core temperature with an urinary catheter. we analyzed demographic characteristics, cardiovascular risk factors and other relevant comorbidities. we collected data about the ca, its initial treatment and its icu management with moderate hypothermia, analyzing length of events and systemic and neurological outcome at discharge from icu. we also collected data about the infectious complications during the icu stay. results. during this period, moderate therapeutic hypothermia was applied to patients with a mean age of ± years. . % were male. the most frequent cardiovascular risk factor was cigarette smoking, present in % of individuals. the ca cause was an ami by % of cases; however, myocardial infarction or angina was documented before the event only in . % of patients. the ca event was outside the hospital in . % of cases and the initial heart rate recorded was ventricular fibrillation in . % of cases. the average ca length was . ± min. obtaining a temperature of °c took between and h from the ca in most cases; and this temperature was maintained for an average of ± h. the average time of induction of hypothermia was . h. the re-heating was performed between . to . °c per hour, averaging h to reach temperatures of . °c. midazolam sedation was performed in all patients and severe chills required muscle relaxation with cisatracurium in . % of patients. infectious complications occurred in . % of patients, the most common site of infection was respiratory. the average stay was days. at the time of icu discharge, average gcs was and the average gos was . mortality was . % ( patients). -implementation of a therapeutic hypothermia protocol is feasible. -infectious complications are common, being respiratory ones the most observed. -the arctic sun Ò device is quick and safe for induction of moderate therapeutic hypothermia. rd esicm annual congress -barcelona, spain - - october s objectives. up to now, it is not clear, however, whether mild hypothermia influences also markers of oxidative stress and nitric oxide production. methods. eleven patients after out-of-hospital cardiac arrest were included into this study, all were treated with mild hypothermia using endovascular system thermodard xp. target core temperature °c was maintained for h, re-warming rate was set at . °c per hour, followed by normothermia of . °c. blood samples for measurement of nitrotyrosine and nitrates/nitrites were taken at admission and then every h for days. during hypothermia the levels of nitrotyrosine and nitrates/nitrites were comparable with baseline values. in re-warming period serum levels of both parameters gradually increased and in normothermia the levels were significantly higher as compared with hypothermia: nitrotyrosine . ± . vs. . ± . lm/l, p = . ; nitrates/nitrites . ± . vs. . ± . lm/l, p = . . our results revealed that during mild hypothermia in cardiac arrest survivors the levels of nitrotyrosine and nitrates/nitrites are significantly lower. these data indicate that the reduction of oxidative stress and suppressed nitric oxide production may be involved in the protective effect of hypothermia. grant acknowledgment. this study was supported by the grant of the czech ministry of health, nr. . new volumetric variables of preload, such as total end-diastolic volume index (tedvi) and active circulation volume index (acvi) and central blood volume index (cbvi), have been shown to be good predictors of fluid responsiveness. during acute changes of intravascular volume, such as hemorrhagic shock, these variables allow a more accurate intervention. objectives. the aim of our study was to investigate the changes in tedvi, acvi, cbvi in a juvenile model of hemorrhagic shock. seven anesthetized ponies ( - months of age) were studied at normovolemia (base), after blood withdrawal to mean arterial pressure (map) of mmhg (hemo), after infusion of norepinephrine to a map of mmhg (ne), and after retransfusion (resu). tedvi, acvi, cbvi were measured by ultrasound dilution (ud) technology with costatus device. data were analyzed using kruskal-wallis analysis and dunn's t test. comparison of fluid load agreement by blant altman. results. tedvi and acvi had significant change during hemo and resu status. percentage of tedvi and acvi changes agreed with percentage of blood volume removed/ infused with bias and limits of agreement (loa) % (- . , . ) and - . (- . . %) respectively. ne administration induced map and cvp significant changes, whereas tedvi and acvi remained unchanged. cbvi showed high variability and seemed to be inconsistent on the identification of the volume status. conclusions. in this animal model, tedvi and acvi were superior to cbvi in accurately reflecting hemorrhage and were also suitable to predict fluid responsiveness. ne administration did not affect the volumetric variables tedvi and acvi. ( ). objectives. we sought to identify independent predictors of post-arrest neurological recovery, and of survival to hospital discharge with neurological recovery. in the course of a pre-planned interim analysis, we analyzed the data from participants of nct . this three-center, double blind, placebo-controlled, clinical trial is ongoing (estimated enrollment = patients) and aims to asses the efficacy of combined vasopressin and epinephrine during cardiopulmonary resuscitation (cpr) and of steroid administration during and after cpr. post-arrest neurological recovery was defined as glasgow coma scale score[ documented at least once by study-independent physicians in patients not receiving sedation for at least h. we identified a total of patients who were subjected to at least one post-arrest assessment of their neurological status. subsequently, we used backward stepwise logistic regression, and assessed the following potential predictors: cause of cardiac arrest (cardiac vs. non-cardiac); area of cardiac arrest occurrence (monitored vs. non-monitored); use of therapeutic hypothermia; number of cpr cycles; mean arterial pressure and serum lactate at min following resuscitation; and patient group allocation. results. the sole independent predictor of post-arrest neurological recovery was the occurrence of the cardiac arrest in an area of monitored patient care (i.e., intensive or coronary care unit, and operating or emergency room): odds ratio: . , % confidence interval = . - . ; p = . . the sole independent predictor of survival to hospital discharge with neurological recovery was the serum lactate concentration at min after resuscitation: odds ratio: . ; % confidence interval = . - . . conclusions. the results of this preliminary analysis suggest that post-arrest neurological recovery seems to depend more on the use of pre-arrest patient monitoring rather than the employed cpr protocol. also, patients with lower, early post-arrest serum lactate concentration seem to have a better chance of surviving to hospital discharge without concurrent, severe neurological deficits. reference(s). to quantify the attribution of intra-operative defibrillation on markers of myocardial injury (ck, ck-mb, tnt and hfabp). methods. single centre prospective study in which elective cabg patients were included in a month period in . patients with valve, emergency, off-pump surgery or rethoracotomies were excluded. patients were grouped as having had defibrillation or no defibrillation during surgery. serum levels of ck, ck-mb, tnt and hfabp were analyzed in blood samples taken at arrival on the icu and at , and h after admission to the icu. levels of these biochemical markers were compared using a paired t test. results. all data presented as mean ± standrad deviation conclusions. atrial fibrillation is a common problem associated with morbidity and mortality in critically ill patients; however, evidence-based recommendations are lacking leading to variability in treatment. our audit confirmed variability and low compliance to nice in treating new af. inconsistency in using appropriate first line drugs for rate control and inadequate thromboprophylaxis reflects lack of familiarity with nice guidelines. educating itu medical staff and promoting the use of well validated, easy to remember chads scoring system might improve compliance with nice guidance. also,promoting hemorr hages scoring system for assessing risk of bleeding and carat tool to guide prescribing antithrombotics may allow itu physicians to anticoagulate more patients with af with less fear of bleeding complications. in patients with acute coronary syndromes (acs) combined antiplatelet and anticoagulant therapy is recommended in addition to percutaneous coronary revascularization. heparins and glycoprotein iib/iiia receptor inhibition can be associated with immune-mediated thrombocytopenia of clinical significance in less than %, resulting in major bleedings and increased mortality rate. to evaluate the incidence of thrombocytopenia and its impact on in-hospital complications-bleedings, reinfarctions, in-hospital heart failure and mortality in patients with acs. retrospective evaluation of patients admitted during months, fulfilling the criteria for acs: rest chest pain up to h, changes in standard ecg with or without st-elevation with or without elevated serum troponin i. serum troponin i was estimated by immunochemical method (boehringer, mannheim, germany, normal levels . lg/l). patients were treated by combined antiplatelet therapy, heparins and percutaneous coronary revascularization. platelets were estimated by automatic analyzer sysmex xe , kobe, japan (normal levels - /l). thrombocytopenia was defined as platelet count less than /l or a drop in platelet count of more than % during inhospital stay. we registered demographic, laboratory, clinical data and in-hospital mortality. we included acs patients, . % ( / ) with and . ( / ) without stelevation ( . % men, mean age . ± . years). mean admission troponin i was . ± . lg/l, platelet count . ± . /l. in-hospital thrombocytopenia was observed in . % of patients. in thrombocytopenic patients in comparison to non-thrombocytopenic ones we observed significantly increased mean age ( . ± . vs. . ± . years, p = . ) and admission serum creatinine ( . ± . vs. . ± . lmol/l, p = . ), significantly decreased admission systolic blood pressure ( . ± . vs. . ± . mmhg, p = . ) and hdl-cholesterol ( . ± . mmol/l vs. . ± . mmol/l, p = . ), significantly increased bleedings ( . vs. . %, p = . ), in-hospital heart failure ( . vs. %, p = . ), but nonsignificantly increased reinfarctions ( . vs. . %), arrhythmias ( . vs. . %) and in in-hospital mortality ( vs. . %). thrombocytopenic patients were less likely treated by percutaneous coronary revascularization ( . vs. . %, p = . ). admission thrombocytopenia in comparison to normal admission platelet count was associated with significant increase in inhospital mortality ( vs. %, p = . ) and icu-mortality ( . vs. . %, p = . ). conclusions. thrombocytopenia, observed in more than % of acs patients, was associated with in-hospital complications and mortality, especially thrombocytopenia on admission. introduction. stress cardiomyopathy, also known apical ballooning or takotsubo cardiomyopathy (tts), has been recognized for several years. this syndrome is characterized by transient systolic dysfunction of the apex or mid segments of the left ventricle (lv) in the absence of coronary artery disease. several forms of mostly physical stress may evoke this syndrome. in this case we describe a very uncommon cause for tts in an unusual situation. a -year-old woman without cardiovascular history found her husband non-responsive in bed. after resuscitation he was admitted to icu. visiting her husband, she complained of chest pains, shortness of breath and hyperventilation. physical examination revealed no abnormalities but her ecg showed deep negative t-waves in leads i, ii, iii, avf, v -v . her troponin t level was . lg/l (ref \ . ), nt-pro-bnp was , ng/l (ref \ ). ck was ng/l with ckmb of ng/l. echocardiography showed very poor lv function with the typical apical ballooning of the lv along with hyperkinesis of the basal ring ( fig. ). there was no coronary artery disease. she was admitted and treated with beta-blockers. within days, the enzymatic changes normalized and echocardiography showed improved lv function with and normalization of the apical segments. she made full recovery within weeks. discussion. icu admittance has significant impact on family members. in the acute phase of the illness, most medical attention goes to the admitted patient. especially when prognosis is poor, stress to the family may be considerable. mostly spouses and relatives with female gender are at the highest risk for depression and anxiety disorders . in contrast, little is known about the occurrence in relatives of broader physical symptoms like pain and nausea or even acute onset severe medical conditions requiring treatment. in our case the wife experienced pain, anxiety and nausea along with hyperventilation. however, the underlying disease was a severe cardiomyopathy requiring admittance and treatment. the tts cardiomyopathy is known to icu physicians in relation to subarachnoid hemorrhage, but most likely not in the context of severe emotional stress. in summary, we stress the importance for intensive care physicians to be alert to the fact that despite many diverse symptoms related to stress and anxiety, relatives can develop acute medical conditions as well. a retrospective observation study. demographic profiles, operative data and short term outcomes in the icu were reviewed in the patients who underwent beating-heart (b-h) operation. we also compared b-h operation group ( - ) and conventional cardiac arrest (c-a) operation group (before ). both groups of patients were similar with respect to preoperative demographics (age, co-morbidities, lv function). in the b-h operation group, mean age was years ( - ). preoperative mean nyha functional class was . . and the mean lvef was . %. patients underwent single valve operation, and the rests needed combined valve operation or cabg. patients were included in the c-a operation group, with mean age of years ( - ), nyha functional class of . and mean lvef of . %. in the b-h operation group, no dc shock was needed, whereas % of the patient with c-a operation needed dc shock after aortic unclamp. in the single aortic valve replacement, b-h operation group had a tendency of shorter assist perfusion time after intracardiac procedure ( . vs. . min). in the icu, inotropic support (maximum dose of dopamine) was much less ( . vs. . r) than conventional c-a operation (p = . ) and additional iabp support was not required ( vs. % in c-a operation). low cardiac output syndrome was not encountered in the b-h operation group ( vs. % in c-a operation). no major postoperative complication was encountered except ventricular tachycardia in one patient. there was no day mortality ( vs. % in c-a operation). conclusions. in our series, valve surgery on the beating-heart had a superior postoperative hemodynamics and lower associated morbidity compared to conventional cardiac-arrest operation. this procedure is recommended especially in the patients with impaired lv function. ( ) objectives. does hrt measured during daytime or nighttime predict: one-year all-cause mortality in acs?; hospital readmission within one-year? methods. secondary analysis of the immediate aim study, prospective clinical trial of patients presenting to the emergency department (ed) with symptoms of acs (n = , ): holter recordings of patients, positive for acs and admitted to the hospital, started min (median time) after arrival in the ed; -year follow up after hospital discharge in % of the sample; recordings scanned to exclude artifact and non-sinus rhythm. hrt analysis performed using research software at the washington university heart rate variability lab; hrt parameters measured: ) turbulence onset (to), which characterizes the initial rate acceleration after a ventricular premature contraction (vpcs); and ) turbulence slope (ts), which characterizes the subsequent oscillation in heart rate. results. holter recordings eligible for hrt analysis; eliminated due to unanalyzable rhythm, \ vpcs needed to calculate hrt, or recording time \ -h. patients were diagnosed with ua, with nstemi, and with stemi. patients died and were re-hospitalized during follow up. hrt measures were dichotomized into low and high-risk groups based on previously reported cutpoints: to \ % normal, to c % abnormal; ts [ . ms/beat = normal, ts b . abnormal. chi square statistics calculated. findings include: abnormal -h ts significantly associated with -year mortality [odds ratio (or) . (p = . )]; re-hospitalization significantly associated with both abnormal -h to (or . , p = . ), and -h ts (or . , p = . ); abnormal night ( - ) to and day ( - ) ts also significantly associated with -year mortality (or . , p \ . for both); abnormal daytime to (or . , p = . ) and ts (or . , p = . ) each significantly associated with re-hospitalization. conclusions. patients with acs who have a ts \ . measured over h or during the daytime are at higher risk of dying within year after hospitalization. those who either have to c % or ts b . have a greater risk of re-hospitalization. assessment during the daytime only might provide sufficient information for risk stratification. hrt measured close to acs symptom onset may aid in risk stratification. objectives. we tried to find a correlation between trs and the severity of coronary artery disease (cad) found in coronary angiography. we analyzed all consecutive patients with nsteacs admitted to intensive care unit from june to december . all patients were stratified at admission with trs. pci were performed when it were indicated. for the study we grouped patients according to trs and the severity and extend of cad. considering the trs the patients were classified into three categories: trs - , trs - and trs - and considering the results of the coronary angiography were grouped into three categories: normal angiogram, one or two vessel disease and three vessel or left main disease. we excluded patients without pci. qualitative variables are expressed as absolute value and percentage and quantitative variables are expressed as means ± standard deviation or median ± interquartile range when correspond. comparisons between groups were made with the v or fisher's exact test for categorical variables and mann-whitney test for quantitative variables. a total of patients were admitted with nsteacs during the period of the study and underwent to pci. age median were higher in patients with trs - than other groups ( . years ± . p \ . ). men percentage and in-hospital mortality were similar in all groups (pns). between groups there weren't significant differences in prevalence of diabetes, hypertension, dyslipidemia, smoking, mean first troponin i and mean highest troponin i (pns). the v for all comparisons were . (p \ . ). normal angiogram were most likely found in patients with trs - than in those with trs [ (p \ . or , % ci . - ). one or two vessel disease were found more often in those with trs - than in those with trs\ o [ (p \ . or . , . three vessel or left main disease were found more often in those with trs - (p \ . or . , % ci . - . ). conclusions. the relationship between trs and clinical outcomes (recurrent angina, acute myocardial infarction and death) is well known but its relation with the extent and the severity of cad is not well determined. in our study we found a correlation of trs with the number of vessels affected in coronary angiography, making the trs as a good predictor of the extent and the severity of cad. a.b. ratnaparkhi , j. walton freeman hospital, anaesthetics, newcastle upon tyne, uk introduction. acute onset atrial fibrillation (af) is common phenomenon in the intensive care unit. atrial fibrillation poses risk for thromboembolism. practice of commencing anticoagulation after acute onset af varies in different intensive care units. anticoagulation comes with its own side effects in the already compromised patients in the intensive care unit. this regional audit was carried out in intensive care units of the north east region of the uk. to assess the practice of use of anticoagulation after acute onset of atrial fibrillation in the intensive care units. postal questionnaire were sent to the intensive care units of the north east region of the uk including two cardiac surgical intensive care units. the questions asked were; is there a protocol in your unit? are you aware of any guidelines? if yes, which guidelines? do you commence anticoagulation for acute onset af? what do you use for anticoagulation and in what dose? after what duration of onset of af you consider starting anticoagulation? how long do you continue anticoagulation? do you commence anti platelet therapy? we also put six clinical scenarios with acute onset atrial fibrillation. the aim was to assess if the units consider stroke risk stratification for commencing the anticoagulation. one example is; how would you manage anticoagulation for a year old patient with hypertension and diabetes, presented with sepsis following pneumonia. results. we received responses from out of intensive care units. the management of anticoagulation strategy was different in different unit. two units were aware of the nice guidelines, one unit was aware of the accp guidelines and two units were aware of the other guidelines. ten units responded that they commence anticoagulation for acute onset af. commonly used anticoagulation was low molecular weight heparin. four units use anticoagulation within less than h of the onset of af. there was no fixed duration for the continuation of the anticoagulation. different units consider various factors before commencing anticoagulation. conclusions. use of anticoagulation in acute onset af varies in the different units. each unit takes into account different factors for the commencement of anticoagulation. this audit highlights the possible need for the evidence based protocol for the use of anticoagulation in acute onset af in intensive care units. objectives. to study of the clinical features and analytical features of those patients with dilated cardiomyopathy treated with ecmo as a bridge to cardiac transplantation in order to determine which parameters are useful to predict the outcome methods. a retrospective study from december to december . all patients were divided into two groups: the a group: patients who died before transplantation; the b group patients who got transplantation. several clinical and analytical characteristics are compared before starting ecmo, at and h after the onset and immediately before withdrawing (''end time'') ecmo treatment (either for transplantation or for death). qualitative variables are expressed as % and quantitative ones a mean and standard deviation (sd). chi square and t student test are used as appropriated. a p \ . denotes statics significance. there are statistically significant differences between patients who died and patients who survived to be transplantated. the presence of multiorgan failure and severe tissue oxygen hypoperfusion, and its persistence after initiated treatment, denotes a worse prognose. the study of this differences could be useful to decide which patients benefit of ecmo treatment. objectives. to measure the diagnostic contributions of routinely used (nt b type natriuretic peptide (nt probnp), cardiac troponin i (t), ddimeres (dd), c-reactive protein (crp) and procalcitonin (pct)) and new biomarkers(mid-regional pro-atrial natriuretic peptide-(mr-proanp), pro adrenomedullin (pro adm), pro endothelin (pro et) and copeptin [pro vasopressin (cp)] for diagnosing infection in patients with severe acute dyspnea. we designed a prospective study of patients admitted in the emergency department and in medical intensive care unit in a university hospital. inclusion criteria were acute dyspnea with spo b % and/or respiratory rate (rr) c b/min. patients with obvious myocardial infarction or pneumothorax were excluded. clinical-biological data were recorded and biomarkers sampled. an independent blinded expert panel classified the patients according to all the data including response to treatment and outcomes blindly to biomarkers' results. the roles of biomarkers were assessed quantitatively and then using terciles of the distribution. the contribution of the biomarkers in the diagnosis was assessed using auc-roc curves and by multiple logistic regression taking into account other clinical and biological explanatory variables. objectives. to compare differences between a group of patients with lmca treated with percutaneous coronary intervention (pci) and others with cabg. to evaluate direct results and make a long term prognosis analyzing mayor cardiovascular complications (mcc) rate. observational retrospective study that includes a total of patients with lmca submitted to ca between january and december : patients ( %) were treated with pci and compared to patients ( %) treated with cabg. in the total of the pci cases drug-eluting stents were used. we exclude patients in cardiogenic shock and those with protected left main coronary artery. results. average age of the patients was . ± . . in the pci group most of the patients were older than years. in the cabg group there was a majority of male patients ( . vs. . %, p = . ) without significant differences in the rest of demographic information. in the pci group (p = . ) there were more previous record of acute myocardial infarction (ami) and pci found, and also a greater percentage of patients with lvef\ % (p = . ). average euroscore of patients from the pci group were greater than those from the cabg group. complete revascularization was obtained more frequently in the cabg group. in the cabg group (p = . ) the number of days between diagnosis and therapeutic strategy as well as the days hospitalized were greater. in the multivariate analysis, the type of therapeutic strategy wasn t associated to mortality when hospitalize. the median follow-up period was months. according to the classification ccs (p = . ), there was no significant difference in the grade of angina. tendency to a greater restenosis of stent, greater mortality during follow-up and greater mcc without statistically significant. in the multivariate analysis surgical strategy was associated to a lower mortality during follow-up (or . objectives. our objectives were to analyze the characteristics of the patients who were done a cardiac catheterization, the differences of the procedure and the incidence of complications. methods. we randomized consecutive patients referred to the hospital for cardiac catheterization since august until october . results. among patients, the age (mean ± sd) was ± . years and more frequently male ( . %). . % were angioplasty. the radial approach was used in patients ( . %; . % with f arterial sheaths and . % with f), and the femoral approach in patients ( . %). there was no difference in the baseline characteristics of the patients. the time required for the procedure and the fluoroscopy time were longer in the radial group (p = . ). a cross over was more often necessary in the radial group ( patients, . %) due to radial artery spasm, deviousness, loop, unstable catheter or artery dissection. only one patient required cross over from femoral to radial approach ( . %) due to serious deviousness in iliac artery. the intravascular ultrasound (ivus) and rotablator always were done by femoral approach. the incidence of complications was higher in the femoral approach group ( . vs. . %, p = . ). in the radial approach group, the most important complication was wrist haematoma ( % radial artery occlusion checked with allen test), however the femoral approach complications were: inguinal haematomas ( . %), big haematomas required blood transfusions ( . %), femoral artery pseudoaneurysms ( . %), arteriovenous fistulas ( . %), retroperitoneal haemorrhages ( . %), strokes ( . %). these complications increased the hospital stay ( . ± vs. . ± . days, p = . ). conclusions. the radial approach reduces peripheral arterial complication rates and allowed earlier ambulation, so also reduces the hospital stay. however, needs higher learned time, and the size of the artery can limit several procedures (ivus/rotablator on the other hand, the development of bundle branch block after that procedure has been associated with higher rates of complete av block, syncope, and sudden cardiac arrest at long term. objectives: our aim is to describe the incidence of cardiac conduction problems after pavi and to identify possible risk factors associated with these conduction problems. patients and methods. a total of consecutive patients who underwent a pavi were included in our analysis. the indication for pavi was a severe symptomatic aortic valve stenosis in patients who were rejected or had a high risk for conventional savr. permanent pacemaker implantation was performed in case of the presence of complete heart block or symptomatic bradycardia, persisting after at least the second postprocedural day. data are expressed as mean value ± sd for continuous variables and as numbers with percentage for categorical variables. between the variables selected for predicting av block after pavi (basal valvular area, annulus diameter, valsalva sinus diameter, left and right bundle branch block), the only independent predictor was the last one (or . , % ci . ( ). implementation of care bundles have been advocated to reduce the infection rate ( ). objectives. the aim of the study was to identify the effect of the introduction of the central venous catheter (cvc) bundle on crbsi rate on our critical care unit over a threeyear period. retrospective audit on the rate of crbsi for a months period before the implementation of the cvc bundle provided baseline data. prospective audits for the corresponding months were carried out after the cvc bundle was firmly embedded in clinical practice. the data was collected based on the information recorded in our clinical information system (cis). the cvc bundle consisted hand hygiene, barrier precautions on insertion, % chlorhexidine skin preparation, using femoral site as last resort, daily review of necessity of central access, daily inspection of insertion site, use of tpn on a dedicated port and maintaining asepsis when accessing the line. robust educational program was rolled out during the implementation phase for medical and nursing staff. compulsory elements of the care bundle were recorded in our cis. we collected data on overall compliance with the bundle, mean dwell time, number of crbsis, site of infection and whether the patient left the unit with a cvc line in situ. for statistical analysis chi-square test and wilcoxon test were used. our main results are summarised in table . lines removed prior to transfer (n) we have seen a significant increase in the compliance with the bundle and it resulted a significant and sustained reduction in mean dwell time, cvc related infection rate and number of patients transferred to the ward with cvc lines (all p \ . ). the bundle resulted in bigger scrutiny for cvcs, hence the reduction in the number of lines inserted. conclusions. our data shows that implementation of care bundles can significantly and sustainably reduce the rate of crbsi on the icu in a real life setting. our previously unacceptable infection rates were reduced and now are comparable with the recently published data ( ) . evidence-based catheter-care procedures, guided by healthcare workers perceptions and including bedside teaching, reduce significantly the crbsi rate and demonstrate that improving catheter care has a major impact on its prevention. to evaluate the incidence of catheter-related bloodstream infection (cr-bsi) and of the use of central venous catheters (cvc) after an intensive improvement program aimed at reducing cr-bsi. before-and-after study in patients admitted to a -bed medical-surgical icu from january through december . in we implemented an improvement program (analysis of barriers, creation of a working group, review of protocols, and implementation of an educational program and checklist) and a set of measures to reduce cr-bsi during cvc insertion and maintenance based on provonost et al.'s model ( ) . in the postintervention period, we suspended the use of the checklist and evaluated the degree of completion of the online training module ''bacteremia zero program'' and analyzed the staff turnover rate. we have monitored cr-bsi using the ''estudio nacional de vigilancia de infección nosocomial en uci'' (envin-uci) criteria since . we calculated the incidence rate ratio of cr-bsi and cvc utilization ratio for , , and . we compared the incidence rate ratios using the epitab module from the stata program and utilization ratios using chi-square tests. results. nine cr-bsi were diagnosed in , one in , and five in . the incidence rate ratio of cr-bsi in these periods was . , . , and . %, respectively. the incidence rate ratio in the postintervention period ( . %) was significantly lower than in the preintervention period ( . %) ( . : % ci . - . , p = . .) the increase in incidence rate ratio between and was not statistically significant ( . vs. . %, p = . ). the pre-and post-intervention cvc utilization ratios were . and . , respectively (no significant differences). during the year , and for existing staff in , rotating residents, nurses (turnover rate %), and nurse's aides (turnover rate %) joined the icu. the training module was completed by % of the new nurses and none of the physicians or nurse's aides. conclusions. the program was effective; its effectiveness may be related to the intensity of the measures. a low preintervention incidence rate ratio does not preclude the usefulness of an improvement program. introduction. in the intensive care unit (icu) the bloodstream infections (bsi) related to the central venous catheters (cvcs) represent a serious clinical complication and are a substantial economic burden. although the data are still somewhat controversial, the use of antibiotic impregnated cvcs is one of the generally accepted approaches in reducing the risk of bsi [ , ] . objectives. in order to determine the efficacy of antibiotic impregnated cvcs in our clinic we evaluated retrospectively the data of the cultures of cvcs and blood obtained from patients during their stay at icu within the last years (january till august ). conclusions. surprisingly, there was no difference in the incidence of the cvc and bloodstream infections in both groups. we can conclude that the strategy of using mrimpregnated cvcs did not reduce the incidence of catheter related bsi. although earlier studies have indicated that mr-impregnated cvcs are cost saving [ ] , our data add further proof to the suggestion that the cost effectiveness of these catheters is at least uncertain. results. from all patients, ( . %) developed infection from any reason during the icu stay. patients developed crbsi, . % of the total patient number and . % of the patients who developed any infection. we recorded episodes of bacteremia due to cvc during days of cvc placement stay, . % while the standard limit is four episodes of crbsi per , days cvc placement. during the year , we chanced our practice in order to avoid as risk factors as we can, using only antimicrobial/antiseptic impregnated catheters, improving our hand hygiene and aseptic technique, using only chlorhexidine and semipermeable polyurethane dressings and making catheter replacement at scheduled time intervals as a method to reduce crbsi. the previous year the recorded crbsi incidence was . % respectively. conclusions. the incidence of intravascular catheter related infection is recorded above the standard limits for second consecutive year assuming that we have to improve further our surveillance policy. on the other hand, the incidence is recorded smaller than the incidence of the previous year according to the change to our practice, assuming that our reforming policy, although not fully effective, still is better for the prevention of intravascular catheter related infections. introduction. intravenous catheter related blood stream infection is a major factor contributing to in hospital morbidity and mortality and extending hospital stay by days and expenditure by , to , lb . the incidence of central line associated blood stream infections (cr-bsi) in our unit was audited in and a comprehensive infection prevention program that included staff education, hand hygiene, maximal sterile barrier precautions and daily assessment of the need for a central line was introduced. we are also taking part in the national audit project matching michigan. objectives. assess the effectiveness of the infection prevention programme and re-audit the incidence of cr-bsi methods. data was collected daily for a period of months. this included the number of patients with central venous catheters in the unit, the number of lines removed or re-sited, the indications for line change, the site of line insertion and incidence of line infection. the lines were reviewed daily and removed if indicated clinically (pyrexia or raised white cell count) or if not required. results. over a period of months central lines were used amounting to line days. the lines inserted were subclavian (sc)- ( . %), femoral (f)- ( . %) and internal jugular (ij)- ( . %). the percentage of lines removed for clinically suspected cr-bsi reduced in this period from to . %. the average duration of stay for the lines were sc . days, ij . days and f days which was shorter than our previous audit showed. the percentage of microbiologically proven cr-bsi also dropped from . to . % ( from internal jugular lines and one from a femoral line). conclusions. introduction of simple and cost effective practices decreased the prevalence of cr-bsi in our unit by a factor of five. daily review of lines led to earlier removal of central lines once they were no longer required. the unit being a neurointensive care unit has a greater proportion of patients in whom femoral lines are often the only option. our survey proves that with strict adherence to guidelines and following infection control protocols diligently the risk of cr-bsi from all line types can be reduced. conclusion. this study implies that the scale of crbsi may be higher than is currently recognised and that the blood culture positivity rate for crbsi is %( / ). as concurrent antibiotic therapy may reduce blood culture and cvc tip positivity, the blood culture rate of % suggests that crbsi has an inherently high blood culture positivity rate despite concurrent antimicrobial therapy. ( ). in this context, we tested the introduction of chlorhexidine(chx)-impregnated sponges ( ) ( ), acinetobacter baumannii . % ( ), serratia marcescens . % ( ), stenotrophomonas maltophilia . % ( ), escherichia coli . % ( ) jai salmonella enteritidis . % ( ) . production of extended-spectrum beta-lactamases (esbls) was detected in % of klebsiella spp. and e. coli strains, overproduction of ampc beta-lactamases was recognized in . % of enterobacter spp., while only one k. pneumoniae strain was found to produce metalloenzyme. all eight strains of p. aeruginosa were susceptible to aminoglycosides, ciprofloxacin and carbapenemaces, both strains of s. maltophilia were susceptible to ticarcillin/clavulanate and trimethoprim/sulfamethoxazole. among a. baumannii isolates, . % were susceptible only to colistin. in total, . % of isolates were susceptible to imipenem and ciprofloxacin. conclusions. gram-negative bacteremia, in particular in the critically ill, is associated with significant morbidity and mortality. significant susceptibility to ciprofloxacin and imipenem was demonstrated. empiric treatment regimens should be based on unit-specific data. ben objective. to assess whether implementation of a national safety program to prevent cvc-related bacteremia had an impact on rates of devices-associated infections acquired in icu. methods. prospective, multicenter, incidence, surveillance study of vap, crb and uti carried out from - - to - - . simultaneously, a bundle for prevention of cvcrelated bacteremia and a comprehensive safety program were introduced at the national level. infections were diagnosed according helics definitions. the follow-up was carried out until discharge from the icu or to a maximum of days. the severity was assessed by the apache ii score. the rates are expressed as incidence density (id) per , days of risk factor. rates are compared with those of previous years ( ) ( ) . introduction. acute kidney injury (aki) is one of the most dreaded complications of severe malaria. occurs as a complication of plasmodium falciparum malaria in less than % of cases, but the mortality rate in these cases may be up to % [ ] . to evaluate the incidence of aki and compare akin and rifle classification systems with regard to hospital mortality. a retrospective analysis based on medical records of adult patients with severe plasmodium falciparum malaria admitted in the general icu of clínica sagrada esperança, in luanda, angola, from january to december . criteria for diagnosis included the standard who definition for severe malaria. only changes in serum creatinine were used to define the presence of aki by both criteria. logistic regression was used to access the association of each rifle and akin with hospital mortality. data are presented as odds ratios with % confidence intervals (ci). we enrolled patients. thirty-nine ( . %) were males. the mean age recorded was . ± . . the mean apache ii score was . ± . , with a mean predicted dead rate of . %. the mean sofa score on admission was . ± . . the mean length of stay in the icu was . ± . days. rifle allowed the identification of more patents than akin as having aki ( . vs. . % there was no statistic association between corticosteroids therapy and length of icu stay less than days (p = . ), duration of mechanical ventilation less than days (p = . ), severe infection (p = . ), re-intubation (p = . ), tracheotomy (p = . ), nosocomial infections (p = . ), myopathy (p = . ) or mortality (p = . ). although there is a tendency for a higher prescription of corticosteroids in dni patients with severe infection, the difference did not reach statistical significance. the use of steroids is neither associated with a better outcome nor with a higher frequency of adverse events or side effects, namely critically illness myopathy or nosocomial infections. ozbek introduction. q fever, a zoonosis due to coxiella burnetii, is more frequent and severe in men than women, despite a similar exposure. here we explore whether the severity of c. burnetii infection in mice is related to sex differences in gene expression profiles. methods. experimental study analyzing the transcriptome of c bl/ j mice. ten females and males were sterilized at weeks of age. after weeks, males and females ( intact and castrated animals of each gender) were killed. the other series of mice were injected intraperitoneally with c. burnetii organisms and sacrificed at day one after infection. organs were aseptically excised and stabilized in rnalater. total liver rna was retrotranscribed and labelled with cy . labelled cdna were hybridized onto whole mouse genome oligo microarray k (agilent). raw signal data were normalized with the quantile method. the significance analysis of microarrays test was used to study the gene expression in uninfected and infected mice. supervised analyses were carried out with r with the library bioconductor. pca was used to visually explore global effects for genome wide trends, unexpected effects and outliers in the expression data (library made ). in another set of experiments, mice ( intact males, castrated males, intact females and castrated females) were killed at , , and days after c. burnetii infection (same protocol). liver rna was analyzed by rt-pcr to confirm microarray results. results. multiclass analysis (sex and infection) identified , modulated genes (fdr = %, |fold change| [ . ) . we found that % of the genes are specifically modulated in males or females. only % of the genes are sexindependent. castration showed that sexual hormones are responsible for more than % of this sex-specific differential expression. the reduction of gene expression modulation upon castration is seen almost exclusively in males. functional annotation of male specific signature identified groups of keywords linked to cellular adhesion, signal transduction, defensins and cytokines and jak/stat pathway. functional annotation of female specific signature identified two group of keywords linked to intracellular metabolism and circadian rhythm. these results were confirmed by rt-pcr. the increased susceptibility to infection in males may be related to the overexpression of il and stat . the modulation of the circadian rhythm in female is linked to a more efficient bacterial clearance. conclusions. this study showed for the first time that the sexual dimorphism observed in q fever is reflected by sex related gene modulation, and is under the control of sexual hormones. this study also showed that the circadian rhythm seems to play an important role in infection in mice. this work open the way for deciphering the role of sex and circadian rhythm in human infections. the author's report a p.aeruginosa sepsis with skin and heart involvement in a previous healthy woman. a years old woman without a pertinent medical history came to the hospital after days with high fever ([ . °c), vomiting and diarrhea. at admission she was in septic shock with multiple organ disfunction (hemodynamic, cardio respiratory and renal) and presented genital skin lesions (round, ulcerated, painless lesions with necrotic black eschar and erythematous margin-ecthyma gangrenosum). the laboratory tests showed bicytopenia (leucocytes and platelets), hepatic necrolysis and elevated troponin t, associated with t wave inversion in anterior leads in the ecg. the ecocardiogram showed apical dyskinesis with normal systolic function suggesting tako-tsubo cardiomyopathy. hemocultures ( ) were positive to pseudomonas aeruginosa and skin lesions biopsy showed vascular ulcers with local p. aeruginosa inflamation. results. besides the fluid challenge and supportive therapy she began empirically piperaciline-tazobactam with rapid improvement of the clinical picture. she needed vasopressors (norephynefrine and dopamine) for h. the skin lesions have resolved in days and cardiac treatment was conservative and symptomatic. the patient was discharged from the intensive care after days. conclusions. ecthyma gangrenosum although relatively uncommon, was first considered a pathognomonic sign of p. aeruginosa sepsis, but now we known that other bacterias can have the same presentation. tako-tsubo cardiomiopathy or broken heart syndrome is a stress-induced cardiomiopathy characterized by transient systolic dysfunction that mimics myocardial infarction but without coronary disease. although the unusual p. aeruginosa clinical presentation sepsis should be treated with prompt supportive measures and the most adequate antibiotic. objective. we undertook this study to determine the relative frequency of meningitis and sepsis in a paediatric intensive care and to define the clinical and laboratory features at the time of admission and the outcome of these children. we reviewed the medical records of patients with sepsis and meningitis, in our paediatric intensive care, from to . results. among these patients % had meningitis, % had sepsis, % patients had bacteraemia, and % had meningitis and sepsisage ranged from month to years old ( % were - years old. boys %, girls %. temperature at the moment of admission was in % patients greater than °c. leucocytosis was noted in % (from , to , / mm ) and leucopenia % ( , - , /mm ) % of the patients had petechiaes, % had a positive lumbar puncture and % who did not have lumbar punctures had diffuse intravascular coagulationthe species of microorganism were in % meningococcus group b, in % no organism was found, in % were pneumococcus, and meninococcus group d in %. on admission, % of our patients had seizures. the duration of hospitalization in our picu was % (average length of stay from to days) % had hemodynamic instability, and % had a normal arterial pressure. from the patients who had hemodynamic instability, needed only fluids %, and % needed fluids and inotropes % of the patients received intravenous ceftriaxonewe had no mortality. conclusion. meningitis and sepsis remain a serious problem in picu. with the existing guidelines of therapy and prognostic signs at the moment of admission in picu we have a better outcome. howitz introduction. community acute bacterial meningitis is a relatively common disease. three bacteria are responsible in most cases: streptococcus pneumoniae (adults), neisseria meningitidis (older children and young adults) and listeria monocytogenes (in the elderly, alcoholics and immunosuppressed). the mortality rate ranges between and % and is higher in case of pneumococcal meningitis ( %) due mainly to increased intracranial pressure and the intense inflammatory reaction that produces pneumococcus in the cerebrospinal fluid. objectives. to study epidemiology, aetiology, clinical and evolution in acute meningitis in the adult community in our icu. methods. retrospective and descriptive study of patients admitted to a tertiary icu with beds from january to december . a total of patients of whom were males ( . %) and women ( . %). the mean age was . years (range: - ). the apache ii at admission was determined in of the patients with an average of points, which is associated initially with a good prognosis. the glasgow coma scale was found in % of the cases the majority ranging between and with a range: - . the average stay in icu was . days. patients died ( . %). risk factors include: infections in otolaryngology: cases ( . %) alcohol: case ( . %) and states of immunosuppression: ( . %) of which: there were two diabetic patients ( . %); hiv: ( . %) were chronic treatment with corticosteroids in one case ( . %); advp: case ( . %) liver transplantation: one case ( . %) and other case cerebrospinal fluid leak ( . %). in patients (% . ) found no risk factor. the most common complication was the need for endotracheal intubation and mechanical ventilation in a . % of patients, hydrocephalus followed by . %. hearing sequelae were found in patients ( . %) and persistent vegetative state in case ( . %). the outcome was favorable and without sequelae in cases ( . %). the etiology was bacterial germs and virus in cases in . bacteria, not unknown in cases ( %). filiated of the causative agent in the majority ( . %) were streptococcus pneumoniae, followed by neisseria meningitidis in cases ( . %), listeria, staphylococcus aureus, e. coli and mycobacterium tuberculosis were isolated in one case each ( . %) . in relation to the vhs virus was found in one case ( . %) and unable to filial the rest. conclusions. community acute meningitis is a disease with low prevalence and mortality in our environment. the agent most commonly streptococcus pneumoniae, clearly associated with increased morbidity. the most frequent complication was the need for endotracheal intubation and secondly hydrocephalus. mortality was associated with longer hospital stays and lower glasgow at the beginning, but not with age. rd esicm annual congress -barcelona, spain - - october s evaluated factors: patient characteristics, signs, symptoms, abscess location, time between symptoms and hospital admission and surgery, lab results, microbiology, antibiotic therapy, apache , saps , sofa, length of icu stay, surgical re-intervention, duration of mechanical ventilation, infectious complications, critical illness myopathy (cim), renal replacement therapy (rrt), re-intubation, tracheotomy, mortality. descriptive statistics were used to analyze data. objectives. to assess ventriculitis (vg) and to study outcome and disability indices in patients admitted in icu due to cerebral hemorrhage (spontaneous or traumatic). we prospectively studied patients hospitalized due to cerebral hemorrhage in the icu of university hospital of thessaly, between and . patients were followed for median follow up of ( - ) days. on admission, the neurological status of patients was described by the glasgow coma scale; disability was evaluated at months by the rapid disability rating scale (rdrs). results. one hundred twenty-one patients ( male) were studied; median (iqr) age was ( - ) years, gcs before intubation ( ) ( ) ( ) ( ) ( ) ( ) objectives. to analyze characteristics of patients diagnosed with infective endocarditis in a third-level hospital from january until december , evaluating the echocardiography findings, the therapeutic strategy used, and both morbidity and mortality rates in hospital and during long term follow-up. observational retrospective study of consecutive patients with following duke criteria with a mean follow-up of ± months. conclusions. this study showed a low mortality of sepsis and its sequential stages in children with meningococcal disease admitted to the picu, which was probably associated with the early use of antibiotics (up to the sixth hour) and aggressive fluid esuscitation. diagnosis and treatment of infections in critically ill patients: - background. about one-third of hospital mortality in critically ill patients occurs after intensive care unit (icu) discharge. post icu deaths may arise from incomplete resolution of the primary condition or from the development of new complications. some authors have recently hypothesized that unresolved or latent inflammation and sepsis may be an important factor that contributes to death following successful discharge from the icu. aim. the aim of our study was to determine the ability of the clinical and inflammatory markers at icu discharge to predict post-icu mortality. a prospective observational cohort study was conducted during a -month period in an bed polyvalent icu. acute physiology and chronic health evaluation (apache) ii score, simplified acute physiology score (saps) ii, sequential organ failure assessment (sofa) score, c-reactive protein (crp), body temperature and white cell count (wcc) of the day of icu discharge were collected from patients who survived their first icu admission. results. during this period patients were discharged alive from the icu. a total of patients ( . %) died in hospital after icu discharge. there were no differences in clinical and demographic characteristics between survivors and nonsurvivors. c-reactive protein levels at icu discharge were not associated with hospital mortality (mean crp concentration of survivors = . introduction. early diagnosis of bacterial infection can be challenging in critically ill patients, however prompt recognition and initiation of antibiotics improves outcome. serum procalcitonin (pct) has been proposed as a more reliable marker of bacterial sepsis than white cell count (wcc) or c-reactive protein (crp), however there is no consensus in how it should be used and pct measurement has not disseminated widely into critical care practice in the uk. to identify if clinical recommendations based on procalcitonin levels are being followed. we retrospectively studied pct use between october and december . assay results were interpreted as: . ng/ml, possible local bacterial infection . - . ng/ml, possible bacterial systemic infection, moderate risk of severe sepsis . - ng/ml, likely systemic bacterial infection, high risk of severe sepsis \ ng/ml, almost exclusively severe bacterial sepsis or septic shock. , this was compared to changes in antibiotic prescribing which were identified from our local audit database and used as a surrogate marker for clinical suspicion of sepsis. to provide context we also compared this to crp and wcc trends in a larger sample from june to december . results. forty-four episodes had matched antibiotic prescribing data and pct results. a further episodes provided synchronous wcc and crp data. pct assays were typically requested on day (median, interquartile range - ). distribution of pct results pct value (ng/ml) . . - . - [ number (%) ( ) ( ) ( ) ( ) there was poor concordance between pct and both wcc and crp trends and also when wcc and crp trends were compared. pct assays did not have significant correlation with antibiotic prescribing. pct conclusions. our study suggests pct results did not influence clinical practice. pct testing may be of greater benefit if used with a protocol with guidance for clinicians based on assay levels. routine and serial quantitative pct testing protocols may also be useful to guide antibiotic initiation and duration, particularly in cases of greater diagnostic uncertainty, for example traumatic brain injury. , references. introduction. procalcitonin (pct) is a reliable marker for diagnosis of infection after cardiac surgery, except in patients who previously received antibiotics, but its diagnostic role in patients with post-sternotomy pre-sternal wound infection and mediastinitis has not been studied in detail. ( ) . objectives. this retrospective study focused on the role of pct in the differentiation between poststernotomy pre-sternal wound infection and mediastinitis. methods. all patients (n = ; age: median , - years) who underwent surgical treatment due to poststernotomy superficial pre-sternal wound infection and mediastinitis between january and september were included in the study. procalcitonin (pct), c-reactive protein (crp) and leukocyte counts were routinely measured within the last h before surgical wound revision. body temperature and hemodynamic parameters were evaluated immediately before operation. bacteriologic samples were also routinely taken intraoperatively. results. the primary cardiac operation was cabg (n = ), cabg and valve procedure (n = ) and others (n = ). time between primary operation and wound revision was in median days (range sensitivity, specificity, positive and negative predictive value for diagnosing sepsis are presented in table . roc curves and auc are presented in figure . roc curves and auc conclusions. patients with sepsis have significantly higher levels of crp, pct, il- and lbp on admission to the icu as compared to patients with sirs. pct is more usefull in differentiating between sepsis and sirs than crp, il- and lbp. b. ergan arsava , s. bilekli , n. alayvaz aslan , e. er , a. topeli hacettepe university, ankara, turkey introduction and objective. the incidence and mortality of bacterial infections significantly increase with age. aging is associated with an impaired immune response, which causes not only an increased susceptibility for infections, but also a poor inflammatory response against them. procalcitonin (pct) is an inflammatory biomarker used as a diagnostic and prognostic tool in bacterial infections. there is no data regarding the diagnostic yield of pct in elderly patient populations. in this study we sought to identify the relationship between age and the magnitude of pct response in patients admitted to the intensive care unit (icu). methods. patients, who were admitted to icu between january and december , with the diagnoses of severe sepsis, pneumonia and chronic obstructive pulmonary disease exacerbation (copde) were included into the study. patients' demographics, apache- scores, admission pct values, intensive care and hospital outcomes were extracted from a database of prospectively collected clinical data. results. we studied a total of admissions ( female/ male, mean age ± standart deviation . ± . years). median (interquartile range-iqr) apache score was ( - ); the icu and hospital mortalities were . and . %, respectively. median (iqr) admission pct levels were . ( . - . ) ng/ml in patients with severe sepsis (n = ), . ( . - . ) ng/ml in patients with pneumonia (n = ) and . ( . - . ) ng/ml in patients with copde (n = ). there was a negative correlation between age and pct levels (spearman correlation coefficient: r = - . , p = . ); the median (iqr) pct levels were . ( . - . ) ng/ml in patients\ years-old and . ( . - . ) ng/ ml in patients c years-old (p = . ). in subgroup analyses it was found that the inverse correlation between age and pct levels mainly arised from patients with severe sepsis (r = - . , objectives. we intend to define the role of pct in the initial evaluation of the patient with a suspected sepsis admitted to the icu. preliminary data from a prospective observational single centre study (polyvalent icu in a third level university hospital). the ethics committee of the centre has approved this study. we included all patients admitted to our unit with diagnosis of sepsis since june- . we measured pct (lgr/ml) at admission and at the second and third day of stay beside the routine screening for the source of infection. then we analyzed the relation of pct with culture results. chi-square and anova have been used for the analysis. (fig. ). pct at admission showed an auc of . ( . - . ) for discriminating bacterial infection. we detected higher mortality in those patients with bacterial infections and sustained high levels of pct the third day ( fig. ) (p \ . ). figure , conclusions. in the initial approach to the septic patient, pct does not seem in our experience useful as an aid in decision-making but an early decrement of serum levels can be a marker for response and for a better outcome of patients with bacterial infections. ( - ) b-d-glucan (bg) assay in early detecting ici in critically ill pts and assess its reliability on arterial blood specimens compared to venous blood specimens. methods. all pts admitted to the -bed icu of our university hospital, between th of february and th of march , harboring an arterial line for more than days and suspected to have an ici, were prospectively enrolled. from all the pts, two blood samples drawn from the arterial line and direct femoral site were simultaneously obtained and subjected to both conventional cultures and bg assay determinations. candida colonization index (cci) and candida score (cs) were also calculated. results. during the study period, from admissions, pts were enrolled. bg assays, cutaneous and mucosal swabs and urine cultures were collected. in pts bg assays resulted negative from either arterial line and femoral site. all but one did not develop ici. in pts bg assays resulted positive. four of these pts did not develop ici, whereas the other six developed ici ( fungemias and mediastinitis). the positive and negative predictive values (ppv, npv), sensitivity (se) and specificity (sp) of bg assay, cci, and cs are shown in table . among pts with ici, (median sofa score value ± . ; median saps ii value . ± . ) had at the diagnosis bg levels c pg/ml and developed septic shock; two of them died within few days. in contrast, the clinical course of pts with bg assay below pg/ml was not complicated by septic shock (median sofa score . ± ; median saps ii value ± . ) and a rapid clearance of bg levels was observed. in addition, we observed a % agreement between arterial line and femoral site bg assays (positive and negative). in particular, we detected bg levels from arterial site specimens that did not significantly differ by those obtained from femoral site specimens (p = . ). conclusions. although conventional mycological culture remains the gold standard for ici diagnosis, we showed that bg assay seems to be a diagnostic tool that may help physicians in early detecting ici. sampling blood from the arterial line was shown to give a simple and adequate specimen to be used for bg assay. further studies are in progress in order to define the role of bg as a surrogate marker for an early diagnosis of ici. objectives. to assess which marker, if any, and at which cut-off value could add diagnostic information to enhance clinical assessment in the difficult context of long-term icu-patients. methods. long-term ([ days) critically ill patients prospectively enrolled in the general icu of a university-hospital. all patients were daily assessed by the attending physician for the accp-sccm classification. c-reactive protein (crp, mg/dl), procalcitonin (pct, ng/ ml), and interleukin- (il- , pg/ml) were measured after patient's discharge on daily stored sera. an independent overall clinical evaluation after patient's discharge, aware of the clinical course but blinded against biomarker's measurement, an ''a posteriori'' accp-sccm classification, was chosen as reference standard for all comparisons. results. we studied clinical variables and biomarkers in patient-days ( patients). the day by day accp-sccm classification of the attending physician overestimated the severity of the inflammatory response to infection. discriminative ability of each biomarker for diagnosis of sepsis is shown in table . methods. icu patients ( males and females) with new onset of fever and leukocytosis within the first days of icu admission were prospectively included in the study. exclusion criteria: age \ or [ years old, heart or renal failure, hypertension, copd, pregnancy and head trauma. serial plasma samples were taken on days , and after the onset of fever for procalcitonin and bnp levels measurement. procalcitonin and bnp values were correlated with severity scores (apache ii and sofa), progression to septic shock and final outcome. statistical analysis was performed. results. patients included in the study were divided in three groups according to clinical and laboratory findings: sirs, sepsis and septic shock. procalcitonin value on days and and bnp value on days , and was significantly associated with sofa max value and with sofa value at the first day of fever, but not with apache ii. there was found no correlation between procalcitonin value on days , and and final outcome. bnp value on days and was significantly associated with final outcome (p = . and . respectively). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). procalcitonin value on days , and was not able to differentiate between patients with sirs and those with sepsis. also procalcitonin value on days , and was not significantly associated with progression to septic shock. bnp value on day was useful in differentiating between patients with sirs and those with sepsis (p = . ). the optimal cut-off bnp value was estimated to be pg/ml (sensitivity = %, specificity = %). bnp value on days and was significantly associated with progression to septic shock (p = . ). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). the optimal cut-off bnp value on day was estimated to be pg/ml (sensitivity = %, specificity = %). conclusions. in icu patients with new onset of fever during the first days of icu hospitalization, bnp value on days and seems to be a good predictor of icu mortality and progression to septic shock. also bnp value on day may be useful in differentiating between patients with sirs and those with sepsis. in our study procalcitonin value on days , and was not found useful in predicting progression to septic shock nor the final outcome. due to the small number of patients included in our research, further studies are needed to confirm these findings. objectives. as c-reactive protein (crp) is regarded a marker for both inflammation and infection we decided to analyse the pct and eo status next to every crp request of critically ill patients, during month. a two-side immunoassay (sandwich principle) for procalcitonin, using both anti-katacalcin and anti-calcitonin (see fig. a ) was used for quantitative analysis of procalcitonin with the roche modular e . pct concentrations [ . lg/l were regarded as positive. crp was measured by immunoturbidimetric analysis using the roche modular p. a positive blood culture was regarded as infection, with exclusion of the coagulase negative staphylococcus aureus since this organism doesn't induce pct expression. every crp request of the icu during month was accompanied by a pct, wbc, and eosinophil count. conclusions. pct at randomly measured at the icu doesn't seem to contribute to an earlier diagnosis of sepsis. pct measurement seems to be useful only when sepsis is suspected and a blood culture request has been summoned. however, its non-specificity for infection, as demonstrated by the high number of pct-positive, no blood-culture requested patients (concerning mostly post-cardiac arrest and post-heart surgery patients), makes it difficult to apply routinely. the recently displayed effort of various companies to market pct in combination with cd and neopterin (other potential markers of infection) supports the conclusion that not one marker by itself can substitute the golden standard of blood culture today. objectives. in this prospective observational study we sought to investigate the role of serum c-reactive protein (crp) and procalcitonin (pct) in the diagnosis and prognosis of patients admitted to the icu with suspected h n infection. all patients older than year-old, presenting with severe acute respiratory disease (cough, fever and respiratory distress) admitted to the icus of an university hospital in southeast brazil were included in this study. serum levels of crp and pct were measured at inclusion and at day , and . were also were also significantly higher (p \ . and p = . , respectively) independently from the presence or not of a co-infection. conclusions. as a conclusion, in our experience, some severe forms of influenza a/ h n with respiratory failure had elevated levels of pct and/or crp in the absence of proven bacterial co-infection. low values were unusual in the presence of co-infection but high values are not synonymous of co-infection and may be related to the severity of the disease. a large prospective randomized study is needed to assess the clinical interest of these biomarkers during the next pandemic of influenza. methods. descriptive study of pregnant with influenza a admitted in the obstetric section icu. the study period runs from september to january . during this period patients were admitted. entry criteria (%): gestosis %, complicated postoperative gynecology and obstetrics , postpartum hemorrhage , acute respiratory failure in influenza pneumonia: . , sepsis and others respiratory failure respectively, others (pregnant myocardial infarction, trauma, renal failure, arrhythmias and heart failure) . acute respiratory failure due to influenza pneumonia was assessed using severity criteria the ats/idsa (major criteria ( ) were admitted in icu cases of severe influenza pneumonia, nasopharyngeal specimens confirmed with rt-pcr positive for influenza a (h n ): pregnant in icu og, and women and men general icu. the average age of pregnant was ± years, average stay days. % were in the rd trimester and one in the nd trimester (week ). two-third pregnancy and two primiparous. the apache ii on admission ranged between and . only one patient with pre-existing disease (diabetes type ). admission due: acute respiratory failure complicating pneumonia multilobar in %, with more than days of typical symptoms (fever [ °c, malaise, myalgia, headache and respiratory symptoms), no starting oseltamivir within h symptoms. caesarean was performed at %; % in the first h of admission and one after days (week ) intrauci, posterior cerebral hemorrhage fetal death. all newborns free of viral disease. invasive mechanical ventilation (mv) in the first h in patients and did not require. required aggressive parameters %: bipap, alveolar recruitment and prone. a percutaneous tracheostomy for weaning. the average duration of mechanical ventilation: ± days complications: barotrauma (pneumothorax and a pneumomediastinum ). % required vasoactive drugs. one patient with acute renal failure that required extracorporeal clearance techniques (hdfvvc), recovering renal function, deep vein thrombosis complicated with shaldon catheter. one brain death by massive subarachnoid hemorrhage. nosocomial infections in patients, most common germ staphylococcus epidermidis catheter and candida sp in urine. initial empiric coverage with ceftriaxone and clarithromycin, as well as oseltamivir. conclusions. during pregnancy, especially in the second and third quarters, there is an increased risk of complications associated with infection by influenza a virus h n , highlighting pneumonia, with more rapid progression to severe respiratory complications. objectives. the aim of this study was to describe baseline characteristics, management and outcomes of critically ill patients with influenza a (h n ) infection who were treated at icu. we performed a retrospective observational study which included critically ill patients with influenza a (h n ) infection admitted to icu between rd november and th march . the primary outcome measure was mortality. secondary outcomes included the rate of influenza a (h n )-related critical illness and introduction of mechanical ventilation as well as intensive care unit (icu) length of stay and hospital length of stay. in the early th century, burns patients were dying of multi-organ failure due to dehydration and hypovolaemia [ , ] . the parklands formula was devised to guide fluid resuscitation and prevent multi-organ failure from occurring. however, over enthusiastic fluid resuscitation will lead to other complications [ ] . objectives. we aimed to assess the adequacy and complications of fluid resuscitation in the st h of a burns patient admitted to our icu, a tertiary centre for burns intensive care. • a retrospective medical case notes audit on all patients admitted to our icu in with [ % tbsa (total burns surface area). • st h of burns resuscitation initiated by the referring hospital and our icu compared to the parkland's formula. • statistical analysis by spss . results. patients audited. • mean duration of transfer from burn injury to our unit = . h • mean age = years, burn area %, length of stay . days • day mortality = % • % had an inhalational injury • no statistical difference between the emergency department (ed) estimation of tbsa and whiston icu. • mean iv fluids given . l but the actual predicted requirement is . l, therefore an excess of . l (p \ . ) • average urine output during this period was . ml/kg/h suggesting that this amount was adequate. iv fluids in the st h conclusions. excessive amount of iv fluids in the st h is associated with prolonged ventilation and length of stay but is not associated with increased day mortality. the mean amount of fluid required in the st h is approximately ml/kg/h which is consistent with other studies [ ] . urine output is still an accurate marker of resuscitation. there was no statistical difference between the determination of tbsa by the ed and burns surgeons, contrary to other studies [ ] . introduction. icu-acquired hypernatremia appears to be associated with mortality in the icu . to reduce iatrogenic rise of serum sodium the use of balanced colloids has been advocated. objectives. aim of this study was to establish the incidence of clinically relevant hypernatremia on our icu and to evaluate the change in incidence of hypernatremia due to the introduction of a natriumacetate based colloid solution. we performed a single centre retrospective study in a -bed mixed icu with all available medical specialities except neurosurgery. sodium measurements of all patients were analyzed during a -month period prior to and after a switch from sodium-based (s) to natriumacetate -based (na) colloids. s contains a % kda polystarch with a mmol/l na and mmol/l cl concentrations (voluven Ò ). na contains a % kda hydroxyeethylstarch with a mmol/l na and mmol/l cl concentrations (volulyt Ò ). serum sodium measurements were routinely performed -hourly. by protocol colloids were provided to a maximum of l/day, independent of bodyweight. patients with hypernatremia at icu admission were excluded. data are expressed as mean ± sd. comparison of na concentrations between groups was performed with a t test for independent samples and comparison of incidence of hypernatremia with a pearson chi-square test. results. patient characteristics and number of samples are summarized in table . after the introduction of na mean serum sodium concentration in the total icu population decreased significantly from . ± . to . ± . , p = . . the incidence of serum na[ mmol/ l decreased from . to . %, p = . . the percentage of patients with at least one na measurement[ mmol/l did not change significantly: . % (s) versus . % (na), p = . . introduction of a natriumacetate based colloid solution in stead of a sodium-based colloid solution reduces the overall incidence of clinically relevant hypernatremia; however, the number of patients with such hypernatremia did not change significantly. patients admitted to intensive care frequently have a metabolic acidosis with previous studies demonstrating an association between the degree of acidosis and outcome. hyperchloraemia is a significant cause of metabolic acidosis and there is increasing interest in the adverse consequences associated with it, which include hypotension, renal dysfunction, impaired gut perfusion and increases in inflammatory cytokines. previous studies, however, have failed to show that hyperchloraemic metabolic acidosis (hcla) has a significant effect on survival. to assess whether patients with hcla had a worse prognosis than our general intensive care unit (icu) population, and the factors associated with the development of hcla. consecutive admissions to the intensive care unit over a month period were studied. patients with a base deficit[ mmol/l and a serum chloride[ mmol/l on the same arterial blood sample during their icu admission were classified as having an episode of hcla. apache ii scores on admission, length of stay on the unit, mortality rates and reason for admission were collected. hospital survival was investigated by logistic regression analysis, controlling for illness severity (apache ii) and admission category, and displayed as a kaplan-meier curve. of patients entering the unit during the retrospective study period, had an episode of hcla, with an odds ratio of death of . ( % ci . , . ) compared with those without hcla. after controlling for apache ii score on admission, and admission category the odds ratio reduced to . but was still statistically significant (p = . , % ci . , . ). the development of hcla was significantly more associated with medical than surgical admissions with an odds ratio of . ( % ci . , . ). within the surgical admissions, the occurrence of hcla differed significantly with the urgency of surgery, with an odds ratio of . ( % ci . , . ) for emergency surgery versus elective surgery. those with hcla had a longer median duration of stay and were overrepresented in the group of patients whose length of stay was c days. kaplan-meier graph showing survival to days conclusions. the results demonstrate that hcla occurs frequently in a general icu population and is associated with a significantly worse outcome. this is in contrast to previous studies which have demonstrated acidosis secondary to lactate and an elevated strong ion gap are associated with poorer outcomes, but not hyperchloraemia. a. dumoulin , a. janssen , j.j. de waele , j. decruyenaere , e.a. hoste universitair ziekenhuis gent, gent, belgium increased creatinine clearance or hyperfiltration has been reported in icu patients. enhanced renal clearance of antibiotics in patients with hyperfiltration may result in suboptimal antibiotic serum concentrations, and so affect patient outcomes. there are only limited data on the incidence of hyperfiltration in icu patients. objectives. assess the epidemiology of hyperfiltration in a cohort of icu patients. single center retrospective cohort study, including adult patients hospitalized during the period / - / in the bed icu of the ghent university hospital, a tertiary care center. data were retrieved by a specially designed electronic alert from the electronic icu database. urinary creatinine clearance (ccr) was calculated as ( h urine volume) (urinary creatinine)/([creatinine day - + day ]/ )/time. we retrieved the initial ccr, and the minimum and the maximum ccr. hyperfiltration was defined as a ccr c ml/min. patient days with anuria were excluded from the analysis. data are reported as median (interquatile range). patients with neurological disease. several factors may interfere with water and sodium homeostasis in these patients, including factors that are also present in other icu patients. in addition, these patients may develop a syndrome of antidiuresis (siad), or salt wasting syndrome (sw). the latter by secretion of brain natriuretic peptide (cerebral salt wasting syndrome (csw)), release of atrial natriuretic peptide in volume overload, or renal salt wasting. objectives. assess the epidemiology of hypona in icu patients with neurological disease. methods. retrospective single center study. data were retrieved from electronic icu databases. inclusion criteria were age c years, hypona (\ mmol/l), and neurological disease. only the first episode of hypona was considered. siad and sw was assessed with tonicity balance on data of the preceding h in patients with urinary sodium[ mmol/l, in whom other etiologies were excluded. sw was defined as negative salt balance and negative fluid balance, and siad as positive fluid balance. to evaluate the prevalence of anaemia among patients attended at the emergency room (er) and to estimate the need of an early diagnose and efficient treatment. observational transversal trial in which days in june were randomly chosen. all patient attending to the er is included. paediatric, gynaecologic and traumatic cases fall out of this research. anaemia was diagnosed according to who criteria. comparison means statistics methods for quantitative variables and chi square for categorical variables were used. prevalence data for the entire cohort, for men and women separately and for different age bands, medical history, anaemia related medication and red blood cells data were extracted. results. patients were interned through the er channel. % men, mean age . ± . years old (median ), and , % were subject of blood analysis using classification proceedings. from the analysed . % were anaemic. . % of them were under years old, % aged from to and . % elderly patients (over years old). most frequent co-morbidity was chronic obstructive pulmonary disease (copd) (n = , . %) and most related drug aspirin (n = , . %). % of the sample had a bleed but only . % needed red blood cell transfusion. we found statistic difference in mean age, antiplatelets therapy use, bleeding episode, need for transfusion, creatinin value and hospitalisation. anaemia classification according to vcm: microcytic . %, normocytic %, macrocytic . %. conclusion. unknown anaemia detection in the er and its following treatment could be a strategy to further reduce allogeneic blood transfusion. the presence of disorders of sodium balance on icu admission could be independently associated with mortality. we decided to study if the existence of dysnatremias at the time of icu admission could be related to mortality in critically ill patients. we conducted a retrospective study in a mixed icu with a database of , adults admitted consecutively over a period of years ( - ) . most patients ( . %) had normal sodium levels ( b na b mmol/l) on icu admission. the frequencies of borderline ( b na b mmol/l), mild ( b na \ mmol/l), and severe hyponatremia (na \ mmol/l) were . , . %, and . %, respectively. the frequencies of borderline ( \ na b mmol/l), mild ( \ na b mmol/l), and severe hypernatremia (na [ mmol/l) were . , . , and . %, respectively. all types and grades of dysnatremia were associated with increased raw and risk-adjusted hospital mortality ratios. multiple logistic regression analysis showed an independent mortality risk rising with increasing severity of both hyponatremia and hypernatremia. odds ratios and % confidence interval (ci) for borderline, mild, and severe hyponatremia were . , . and . , respectively. odds ratios and % ci for borderline, mild, and severe hypernatremia were . , . , and . respectively. conclusions. this observation suggests the possible correlation of natremia on icu admission with hospital mortality and confirms that both hypo-and hypernatremia present on admission to the icu could be independent risk factors for poor prognosis in icu populations. ( ) . a relationship between mortality and delay from time of pars trigger to critical care admission for patients not requiring surgery has recently been described ( ) . objectives. this study was to test the hypothesis that in cases of emergency laparotomy, prolonged physiological deterioration pre-operatively is associated with higher hospital mortality. we reviewed notes of patients that underwent emergency laparotomy between july and february at the northern general hospital, sheffield, uk. time at which patients triggered (pars c ), time of arrival in theatre and hospital mortality were recorded. two-tailed fisher's exact test was used to test null hypotheses that a delay of more than h after pars trigger does not affect hospital mortality. . patients had an emergency laparotomy during this period. of notes retrieved by our patient record service, were incomplete. of remaining patients patients did not trigger, of whom died ( . % mortality). patients triggered, died ( . %). amongst patients that triggered, arrived in theatre within h, of whom died ( . % mortality); of the patients that arrived in theatre after h died ( . % mortality). the odds ratio of death for those with a prolonged pre-operative deterioration (n = ) compared to those without (n = ) was . ( % ci . - . , p = . ). the number needed to treat early to save one life was . conclusions. our data suggest that in cases of emergency laparotomy, those who trigger pars pre-operatively have higher hospital mortality than those who do not. specifically, our data indicate that patients triggering pars c should arrive in theatre within h of first triggering. nothing is known about the effect of the duration of icu-related therapies on acute outcome. to identify the importance of the duration of invasive ventilation and of renal replacement therapy for acute prognosis of surgical patients treated in an intensive care unit (icu). we performed a retrospective analysis of prospectively collected data of an icu patient cohort linked to a local database. adult patients (n = , ) admitted to a -bed icu at a university hospital in munich, germany, between and who had an icu length of stay of more than days and who were followed-up until the end of the acute phase after icu admission. cox-type additive hazard regression models were used to analyse linear, nonlinear or time-varying associations of therapeutic variables with survival time. duration of different invasive therapies was evaluated by constructing specific vectors, which tested potential effects of time-dependant variables on outcome after a lag time of days. . patients ( . %) were still alive at the end of the acute phase after icu admission. during the acute phase, . % of the patients required invasive ventilation, and . % a continuous renal replacement therapy. besides the underlying disease and disease severity at icu admission, the need for invasive ventilation or renal replacement therapy was associated with poorer outcome. duration of invasive ventilation shortened survival (with a lag of week), if treatment lasted for more than days (non-linear association). in contrast, duration of renal replacement therapy was unimportant for acute prognosis. conclusion. prolonged duration of invasive ventilation, but not of renal replacement therapy is inversely related to acute survival. objectives. to identify the prognostic importance of preceding invasive ventilation, renal replacement therapy and catecholamine therapy for long-term survivors after surgical critical illness. we performed a retrospective analysis of prospectively collected data of an icu patient cohort linked to a local database. adult patients (n = , ) admitted to a -bed icu between and , who had an icu length of stay of more than days, were followedup until the end of the second year after icu admission. hazard function was explored by weibull modelling and likelihood ratio tests. cox-type structured hazard regression models were used to analyse linear, non-linear or time-varying associations of therapeutic variables with -year survival time of a patient subgroup, which had survived the period of high hazard. hazard rate declined exponentially up to day after icu admission, and became constant thereafter. patients reached this stable stage of their disease forming the study population. of these patients ( . %) were still alive at the end of the second year after icu admission. underlying diseases were major determinants for long-term outcome. long-term mortality was significantly associated with the acute extent of physiological derangement during icu stay (maximum apache ii score), but was independent from the duration of preceding invasive organ support. in surgical patients with a prolonged icu length of stay, an exorbitant mortality exists for about half a year after icu admission. later on, life expectancy of surviving patients is largely determined by the underlying disease and, to a minor degree, by the acute extent of homeostatic disturbance during icu stay. the duration of preceding invasive therapies does not limit long-term survival. b. rozec , a. desdoits , k. asehnoune , c. lejus , y. blanloeil chu nantes, hôpital laënnec, anesthesia and intensive care, nantes, france, chu nantes, hotel-dieu, anesthesia and intensive care, nantes, france postoperative stroke could be an endpoint in non-cardiac surgery morbidity studies [ ] . therefore, its frequency established in old studies and considered higher than in the non surgical population remains to be estimated more precisely. objectives. the aim of this evaluation was to calculate the frequency of stroke, firstly in a prospective study, and secondly in a review of the literature. strokes diagnosed in the prospective follow-up ( days) of surgery for hip fracture was confirmed by a neurologist and a ct-scan. retro and prospective studies (except abstract) published in journals (pubmed, ovid) from to were included in the analysis. statistics:% ic , multivariate analysis (effects of population size, date of publication, type of surgery, patient age, prospective vs. retrospective studies were evaluated). results. mean pre-operative possum scores between the two groups showed no significant differences. continuous measurements taken by the odm showed a mean stroke volume increase of mls at the end of surgery (paired t test, p-value = . ). ( . %) patients following implementation compared to ( . %) prior to implementation required post-operative critical care admission. following odm implementation, critical care los was reduced from . to . days and post-operative length of stay within hospital was also significantly reduced by . days. introduction. local (skeletal muscle necrosis) and remote (lung neutrophil infiltration) ischemia-reperfusion injury (ir) have been described in animals [ ] and humans after aortic surgery. postconditioning with cyclosporina (csa) was recently shown to prevent skeletal muscle infarction in pig latissimus dorsi muscle flaps [ ] . objectives. the aim of this study was to investigate local (gastrocnemius muscle, gc) and remote (lung and liver) ir in rats exposed to aortic cross-clamping with special focus on mitochondrial respiratory chain complexes activities and reactive oxygen species (ros) production. we also investigated whether pharmacological post-conditioning with csa would be protective in this setting. methods. anaesthetized (isoflurane) and mechanically ventilated wistar rats underwent laparotomy and were randomly assigned to one of the following groups: sham (n = ), ir (n = , clamping of the infrarenal aorta for h followed by h of reperfusion), ir+csa (n = , mg/kg csa administered intraperitoneally and min prior to reperfusion). maximal oxidative capacities (vmax) and complexes i, ii and iv of the mitochondrial respiratory chain were determined using glutamate-malate (vmax) and succinate (vsucc) as substrates in the gc permeabilized fibers and freshly harvested liver and lungs isolated mitochondria. tissue superoxide anion production was assessed with dihydroethidium (dhe) in thin sections of frozen gc. data are expressed as mean±sem and analyzed with anova followed by newman-keuls post-hoc test; a p value. was considered significant. esophagectomy with gastric tube reconstruction is associated with frequent postoperative complications due to a (surgery induced) systemic stress response, provoked by the overproduction of proinflammatory cytokines. in elective postoperative esophagectomy patients, we previously showed that levels of serum crp are associated with the occurrence of postoperative complications and reduced survival. plasma ngal (pngal) and urine ngal (ungal) are early predictors of acute kidney injury, however sepsis/sirs seems to accelerate their production even in the absence of aki. objectives. we examined the role of pngal and ungal as early indicators of postoperative complications at the icu in patients undergoing elective esophagectomy surgery methods. in a prospective follow-up cohort study, data of a total of patients admitted to the icu following elective esophagectomy with gastric tube reconstruction were collected in the period from september to april . patients who developed aki at the icu were not included in this study. postoperative pngal and ungal levels were determined at consecutive time points and the relation between the course of postoperative serum pngal and ungal, development of complications and outcome of the patients was investigated. in our experience, assisted by dv robot radical prostatectomy, despite requiring longer surgery time, was shown to be safer than conventional radical prostatectomy, with a significant less blood loss during surgery, less need for blood transfusion, fewer postoperative complications, included need to reoperate, and also a shorter length of hospital stay than conventional radical prostatectomy. objectives. the aim of the study was to evaluate safety and effectiveness of m infusion, impact on fluid balance and urine output (uo) and also whether we can avoid cvc line insertion. we conducted a prospective analysis of patients (pts) treated with m who were admitted to the shdu between oct and aug . demographic data and vital parameters were collected through the individual questionnaires before ( ) introduction. an ever increasing number of patients over the age of year are being admitted to critical care units [ ] . with no marked expansion in the number of critical care beds in our hospital and in the health region as a whole, this may lead to a huge strain on the service provision, with less availability of beds to treat elective and other emergency admissions. to determine the factors that affect outcome following admission to critical care of patients aged years and above(medical and surgical). methods. ethical approval was sought but deemed unnecessary as our study was observational (non-interventional). we prospectively looked at the number of patients (age year and above) who were admitted to icu/warrington general hospital over the period of year. our unit is a modern, -bedded general icu with an annual admission rate of approximately ( level and level care). we examined data that was related to the source of admission, gender, apache scores, the use of vasopressors (including inotropes) and the need for ippv in the first h of admission. we analysed the effect that each factor had on patient mortality (applying chi-square and z tests). we followed the patients up for months post-discharge from icu. the final report produced results that showed icu, hospital and -month mortality. results. there were admissions during the period st may - th april . last set of mortality data was obtained in september . female: male ratio was : . the overall -month mortality was %. in our study, patients admitted through a&e, theatre and ward had mortality rates of , and % respectively. patients who received vasopressors (including inotropes) in the first h had a significantly lower mortality than patients who did not receive any vasopressor support ( vs. %). invasive ventilation in the first h of admission was associated with significantly higher mortality rates ( vs. %). in this patient cohort, the overall -month mortality is higher than the general icu population. factors that determine mortality include the source of admission to icu, the need for vasopressor support and invasive ventilation in the first h of admission. introduction. the optimization of oxygen delivery (do ) is an intervention with fluids and inotropics to achieve supranormal goals of do during surgery, before disturbances of perfusion occur and oxygen debt accumulates. oxygen debt is directly linked to multiple organ failure and death. we aimed to evaluate the temporal pattern of oxygen debt in the intraoperative period in patients included in two studies of goal directed therapy to supranormal values of do . oxygen debt was calculated from data obtained from high risk surgical patients included in two randomized controlled trials were analysed. , the oxygen deficit was calculated by subtraction of the basal vo value from subsequential values of vo obtained during surgery and after the icu admission. the oxygen debt was calculated by the product of oxygen deficit and time (minutes) between measurements. patients treated with supranormal goals of do ([ ml/min/m ) using fluids and dobutamine showed lower levels of oxygen debt during icu stay. the peak of oxygen debt was , ml/m at min of surgery in the control group in comparison to , ml/ m in the protocol group. in the second study, the peak of oxygen debt occurred at min in the volume group ( , ml/m ) which was significantly higher than in the dobutamine group ( , ml/m ). higher oxygen debt during peroperative period correlated with poor outcome as shown on the original studies. conclusion. the use of supranormal goals of do with dobutamine and fluids in the peroperative period results in lower oxygen debt. post-operative nausea and vomiting (ponv) is a common problem in the patients undergoing laparoscopic surgery. the release of serotonin during surgical procedure may induce ponv. we investigated if postoperative increase in plasma serotonin metabolite was associated with ponv after gynecologic laparoscopic surgery. objectives. the patients who experienced nausea after gynecologic laparoscopic surgery (ponv group, n = ) and patients who had no or mild nausea (control group, n = ) were enrolled into this study. postoperative nausea was assessed during h in post-anesthetic care unit and ondansetron was administered if needed. blood samples were obtained before anesthesia and h after surgery. plasma serotonin metabolite ( -hydroxy indole acetic acid, -hiaa) was analyzed using high performance liquid chromatography (hplc) assay. perioperative change of plasma -hiaa and the degree of nausea were compared between groups. results. the degree of post-operative nausea varied from to ( mm visual analogue scale, vas) and median value was ( - ) in control group and ( - ) in ponv group (p \ . ). average -hiaa concentration of all patients increased after surgery ( . ± . to . ± . ng/ml, p \ . ). baseline plasma -hiaa concentrations were similar between groups, however, -hiaa of ponv group increased higher after laparoscopic surgery compared with control group ( . ± . to . ± . ng/ml vs. . ± . to . ± . ng/ml, p = . ). conclusions. the patients who experienced post-operative nausea showed more increase in -hiaa concentration. ponv after gynecologic laparoscopic surgery may be associated with a peripheral release of serotonin. introduction. the intracavitary ecg method is an easy, accurate and inexpensive methodology for real time positioning of the tip of central venous catheters. in particular, when the ecg method is performed using not the guidewire but the saline-filled catheter as electrode, the methodology is completely safe and can be applied to any central venous access device (vad). we have tested a new specific device (sapiens tls, romedex) which simplifies and standardizes the ecg method; it consists of a hardware (a small box with cables connecting it to a pc and to ecg electrodes) plus a software (which can be used on any pc). we tested the sapiens tls in patients who underwent positioning of central vads ( totally implantable ports, piccs and tunnelled catheters, all inserted by ultrasound guided venipuncture). our goal was to position the tip of the catheter at the cavoatrial junction: the length of the catheter was estimated by anthropometric measurements and the correct positioning was achieved by the intracavitary ecg method during the procedure. the final position was checked by a post-procedural chest x-ray. there was no insertion-related complication. the intracavitary ecg method was easily performed in all cases. at the final x-ray control, % of all tips were correctly positioned at the cavo-atrial junction (± cm), confirming the accuracy of the intracavitary ecg method. the anthropometric measurement tended to overestimate the length of the catheter both in port insertions ([ cm in % of cases) and in picc insertions ([ cm in % and [ cm in % of cases). conclusions. the intracavitary ecg method as performed with the sapiens tls was more accurate than the anthropometric measurement in terms of correct positioning the tip of the catheter during the procedure. the sapiens tls simplified the method, by standardizing the ecg tracking, and making it easy (no need of ecg monitor, no need of ecg commuter since the sapiens tls displays simultaneously the surface ecg and the intracavitary ecg). also, the sapiens tls allows the print-out of the intracavitary ecg reading for documentation, as well as the storing of the ecg reading in a computer-based database. previous studies have shown that hypernatremia impact graft function after orthotopic liver transplant (olt). the purpose of this retrospective investigation was to determine whether differences in serum sodium values after olt influenced postoperative short-term patient outcomes. objectives. the study was aimed at exploring the incidence of hypernatremia after orthotopic liver transplantation (olt) in order to provide critical monitoring and intensive care services. clinical and sicu laboratory data were collected; serum sodium was assessed an average of three times per day. hypernatremia was defined as two daily values of serum sodium above mmol/l. from to , we analyzed patients with hypernatremia after olt. the major outcome was death in the icu after days. conclusions. in sicu, olt patients are easy to suffer from hypernatremia ( . %) and have high mortality ( . %). hypernatremia is associated with an increased risk of death in patients with olt. early active fluid infusion is crucial, besides optional continue venovenous hemofiltration (cvvh). cywinski objectives. the aim of this study was to determine the value of blood lactate sequential dosages during the first postoperative hours for the diagnosis of gd. we conducted a retrospective study on consecutive patients admitted in icu after lt, between july and june . lt with auxiliary or splited grafts were excluded so were patients with septic or cardiogenic shock occurring during the first h after lt. criteria for gd diagnosis were: sgot [ , u/l with pt \ % between d and d , or re transplantation or death between d and d . demographics and biological data (transaminases, pt, serum bilirubin) were recorded between d and d . hopital bicêtre, kremlin-bicêtre, france, hôpital saint-louis, paris diderot university, biostatistics, paris, france, hôpital hôtel-dieu, medical intensive care unit, nantes, france, hôpital gabriel montpied, nephrology and transplantation, clermont-ferrand, france, hôpital edouard herriot, medical intensive care unit, lyon, france, conclusions. in kidney transplant recipients, arf is associated with high mortality and graft loss rates. increased pneumocystis and bacterial prophylaxis might improve these outcomes. early icu admission might prevent graft loss. a. umgelter , k. lange , p. büchler , h. friess , r.m. schmid technical university of munich, transplantationszentrum münchen rechts der isar, ii. medizinische klinik, münchen, germany, technical university of munich, transplantationszentrum münchen rechts der isar, chirurgische klinik, münchen, germany introduction. the shortage of donor organs in the eurotransplant region results in late allocation at a time when liver disease is already very advanced. the severe condition of patients at that stage negatively affects outcomes of orthotopic liver transplantation (olt). to support decision-making in these situations, clinical data are urgently needed. objectives. to evaluate outcomes of liver transplantation (olt) in icu-patients with multi-organ failure due to advanced acute on chronic liver failure (aclf). methods. in our centre, patients on the waiting list for olt are not automatically excluded from the procedure, if their condition deteriorates to multi-organ failure. a consensus of the team in each individual case is based on criteria such as the previously manifested will of the patient, exclusion of current infection, absence of neurologic damage or other organ damage expected to impair the possibility of rehabilitation. we retrospectively analyzed a database comprising data from evaluation for the waiting list of all patients transplanted in our center since implementation of the meld-score for allocation. only cirrhotic patients treated on our intensive care unit before transplantation were included. patients treated on the icu before retransplant for primary graft failure were excluded from analysis. data are presented as median ( th - th percentile). wilcoxon or mann-whitney u tests were used for comparisons of paired and unpaired data, respectively. results. from january until september patients ( m, f; age ( - ) years) fulfilled inclusion criteria. cirrhosis was due to alcohol (n = ), hcv (n = ), alcohol+hcv (n = ), alpha- -antitrypsin deficiency (n = ), budd-chiari-syndrome (n = ) or cryptogenic (n = ). upon icu admission icu, apache ii scores were ( - ), sofa scores ( - ); meld ( - ). after ( - ) days on the icu, directly before transplantation, sofa scores had deteriorated in all patients to ( - ) and meld scores to ( - ). patients had renal replacement therapy and patients were on single-pass albumin dialysis. the -day-mortality was %, hospital mortality % and -year mortality %. in hospital survivors, surprisingly, sofa scores ( ( - ) vs. ( - ); p = . ) and inr ( . ( . - . ) vs. . ( . - . ); p = . ) upon admission to the icu were significantly higher than in non-survivors. there were no significant differences in age, gender, meld scores or use of extracorporeal treatment in survivors vs. non-survivors. conclusions. liver transplantation in selected cirrhotic icu-patients with multi-organ failure is not medically futile. outcome, however, is much worse than usually considered acceptable. objectives. this work tries to study the clinical profile and the results with the immediate postoperative outcome of patients suffered from pancreas-kidney transplantation (pkt) and only pancreas transplantation (pt) admitted in our intensive care unit (icu) setting. methods. prospective study during years (from to ). we recorded epidemiological, demographical and clinical data, surgical and postsurgical complications, therapy, morbidity and mortality rate, length of stay in icu, organs survival, etc. the data were expressed in mean±typical deviation, median and percentages. results. we recorded patients. table expresses some of the data. the mean age was . ± . years old male . %. pkt from unic deceased donor: %. pt: %. the mean ischemia time was . ± . h for the kidney and . ± . for the pancreas. the most frequent surgical complications were bleeding ( . %), technical difficulties ( . %) and anesthetic complications ( . %). postoperative immunosuppression consists in methyl-prednisolone, tacrolimus, mycophenolate mofetil and thymoglobulin (as our protocol recommends) and was administered to the % of the patients. prophylactic antibiotic and antiviral therapy (ampicillin, ceftriaxone, fluconazole and gancyclovir) was given to almost the % of the patients. table expresses the blood test results. the mean insulin requirements per day during the stay in icu was ( - . ) iu. table represents the complications in the icu. the first leading cause of reoperation was vascular thrombosis ( %) followed by intraabdominal bleeding ( %). conclusion. the clinical profile of this patient in our setting is a years old man, with high blood pressure, retinopathy, dialysis, pancreas-kidney transplant recipient, with unic decesed-donor. he needs no insulin or minimal requirements. the principal complication is pancreatic vascular thrombosis that frecuently leads to removal of the graft. ( ) . in a clinical practice, a specific marker to evaluate and predict ischemic-reperfusion injury in liver transplantation (olt) is not available. poor organ perfusion and high pct levels appeared to predict early graft failure only in the cardiac donor ( ) . objectives. we evaluated pct as a predictor of ischemic-reperfusion injury in liver transplantation and pdr, as a predictor of complication and graft outcome. methods. prospective study. patients (age, child-pugh score, aetiology of liver cirrhosis) undergo liver transplant. bilirubin levels and pdr ( . mg/kg of ig in a central catheter with limon system Ò , pulsion medical system, munchen, germany) was measured once a day for postoperative days (pod). on the same day, aspartate aminotransferase (ast/gpt) and alanine aminotransferase (alt/got) were measured. sofa score was as a patient severity score. serum level of pct, c-reactive protein (crp) was collected at the liver reperfusion time and from the st to the rd pod. warm and cold ischemia time was collected. statistical analysis was performed with wilcoxon, spearman tests (p \ . ). linear correlation was performed too. a small rise on pct levels were observed early after olt, with a peak in the st day after olt. it was associated neither with hepatic post-olt dysfunction nor with other non infective complications. pct increased significantly after liver reperfusion (p \ . ) and correlate with pdr on the nd pod, but not correlation were found with crp, white blood cells, or liver enzymes after olt. crp levels increased rapidly after olt. pct increasing after liver reperfusion correlated with child-pugh olt (r = . at nd pod) in the recipients. the cold ischemia time did not correlate with pct serum levels after liver reperfusion as well as the warm ischemia time. a negative correlation was found between pdr and liver function in the recipient. pdr did not correlate with child-pugh score. the cold ischemia time well correlated with ast and alt on the first day after transplant (r = . ). it negatively correlate with pdr (r = - . ) at the same time. the warm ischemia time did not correlate with pdr, ast and alt. the same results were found between pdr and liver enzymes and lactates. no correlation was found between pdr and sofa score. conclusions. pct peak in the recipient at reperfusion and early post operative was not predictive of graft dysfunction or other non infective complication. it may represent a marker of ischemia-reperfusion injury. crp levels increased rapidly after olt and it could be an expression of surgical procedure, and it doesn't correlate with pct. objectives. the aim of this prospective observational study was to describe the kinetics of ngal following renal transplantation and to assess its ability to predict delayed graft function. introduction. lung transplantation is the recognized therapy for end-stage respiratory failure. many serious medical complications have been described occurring from months to years after lung transplantation, often necessitating admission to an intensive care unit (icu), which has been associated with a high mortality. we examined the factors associated with mortality. methods. all patients admitted to the general intensive care unit between and following lung transplantation were included in this retrospective study. data was collected regarding demographic parameters, intensive care unit stay and outcome. over the study period, forty patients were admitted to the icu. the main pretransplant diagnosis was idiopathic pulmonary fibrosis followed by chronic obstructive pulmonary disease. the majority ( %) of patients required mechanical ventilation during their icu stay. the main reason for icu admission was septic shock in patients ( %) of cases. an organism was isolated from of these patients; in cases, the organism was shown to be multi-drug resistant. the icu mortality was . %. non-survivors were characterized by a higher admission sofa score (p = . ), an admission diagnosis of sepsis ( . vs. . % for all other diagnoses, p \ . ), and a requirement for mechanical ventilation (p = . ). in addition, the incidence of chronic rejection was significantly higher in the non-survivors (p = . ). conclusions. severe sepsis remains the most important factor associated with a poor outcome. new strategies are required to alter the course of this common complication of lung transplantation. (the % of the infections were respiratory) and ( %) patients presented pulmonary allograft rejection. according to our immunosuppressive protocol, we started with methylprednisolone and tacrolimus and we added mycophenolate later. the ccd length of stay was ( - ) days and the median days of mechanical ventilation were ( - ). thirteen ( %) patients died, basically due to refractory respiratory failure, multiple organ dysfunction syndrome and haemorragic shock. conclusions. in our large series of lung transplantation a remarkable incidence of complications has been observed. despite this complications, lung transplanted patients presented an excellent short term outcomes. introduction. acute kidney injury (aki) poses a massive challenge after kidney transplantation, especially when kidneys from brain dead adult donors are transplanted into small paediatric recipients. inflammation mediated by cytokines is a key event in experimental models of ischaemic aki. objectives. the aim of this study was to investigate whether remote ischaemic preconditioning (ripc) reduced the inflammatory cytokine load and apoptosis in the kidney after transplantation. methods. kidneys were harvested from eight -kg brain dead donor pigs and transplanted into two groups of -kg recipient pigs after h of cold ischaemia. in one group (+ripc, n = ) ripc was performed before the -h reperfusion period, while no ripc was performed in the other group (-ripc, n = ). non transplanted kidneys from brain dead pigs served as controls. concentrations of tnf-a, il- , il- , and il- in renal tissue were determined by an immuofluorometric assay. renal apoptosis was quantified by immunohistochemistry for activated caspase- . high concentrations of tnf-a, il- , il- , and il- were detected in renal cortex in all three groups. no statistical differences between the two transplanted groups were found for any of the cytokines. compared to controls higher cortical levels of il- (control vs. -ripc, p = . , control vs. +ripc, p = . ) and lower levels of il- (control vs. -ripc, p = . , control vs. +ripc, p = . ) were found in transplanted kidneys. no differences were detected for tnf-a or il- . transplantation significantly increased the number of apoptotic cells in both glomeruli and tubuli (control vs. -ripc, p = . , control vs. +ripc, p = . ). no difference was found between recipients, (p = . ). conclusions. in transplanted kidneys from brain dead donors exposed to h of cold ischemia and ±ripc, we found increased tubular and glomerular apoptosis, but no increase in pro-inflammatory cytokines. the levels of il- were higher in transplanted kidneys compared to controls. remote ischaemic preconditioning did not modify cytokine load or apoptosis in the kidney graft. objectives. we present the case of a patient with confirmed hit and the management of its status during the perioperative period of the cardiac transplantation. a years old patient with a cardiac myxoma was operated under heparin anticoagulation. thrombocytopenia is noted at day after surgery. an enzymelinked immunosorbent assay (elisa) was performed and since the result was positive, the treatment was changed to lepirudin. the hit was confirmed by a heparin-induced platelet activation (hipa) test. the internal jugular vein thrombosis was observed. the post operative evolution was marked by the necessity of the implantation of a ventricular assisted device. the patient was submitted to two sessions of plasmapheresis which turned the antibodies negative. the patient underwent heparin anticoagulation during the surgery time and bivalirudin as the post operative treatment. the antibodies remained negative. two months later, the cardiac transplantation was performed; heparin was used for anticoagulation during surgery. due to a restored renal function, danaparoid was used postoperatively. conclusions. hit is a serious complication of heparin therapy. the diagnosis is difficult. when hit is strongly suspected, a non-heparin anticoagulant is recommended. the choice of the anticoagulant depends on the hepatic and renal function. plasmapheresis is a solution for the antibody purging prior to cardiac surgery. objectives and methods. a nationwide qualitative study investigating their perception of the meaning of professionalism, and how they learn to behave professionally was performed. all eight dutch icm training centres participated. the moderator asked participants to clarify the terms professionalism and professional behaviour. next, participants were asked to explore the questions 'how do you learn the mentioned items?' and 'what ways of learning do you find useful or superfluous?' qualitative data analysis software (maxqda ) facilitated analysis: an inductive approach applying open, axial and selective coding principles was used. results. fellows across eight groups participated. results relating to the subtopics 'elements of professionalism' and 'teaching and learning of professionalism' are described consecutively. elements of professionalism relevant to intensivists: the elements most frequently addressed were communication, keeping distance and boundaries, medical knowledge and expertise, respect, teamwork, leadership and organization and management. medical knowledge, expertise and technical skills seem to become more tacit when training progresses, and relate to ethical, cultural and legal dilemmas originating in the specific icu context, and working as a multidisciplinary icu team member. teaching and learning professionalism: topics can be categorised into the themes workplacebased learning, by gathering practical experience, by following examples and receiving feedback on their actions, including learning from own and others' mistakes. formal teaching courses (e.g. communication) and scheduled sessions addressing professionalism aspects were also valued. conclusions. the emerging elements considered most relevant for intensivists were adequate communication skills, and keeping boundaries with patients and relatives. the specific icm context, and working as multidisciplinary icu team member substantially influenced the icm fellows' perception of professionalism. whereas medical knowledge, expertise and technical skills seem to become more tacit when training progresses, professionalism issues continue to be learned during icm training. professionalism is herein mainly learned 'on the job' from role models. formal teaching courses and sessions addressing professionalism aspects were nevertheless valued, and learning from own and others' mistakes was considered especially useful. selfreflection as a starting point for learning professionalism was stressed. the latter can e.g. be stimulated by means of assessment, structured feedback and use of portfolios, for which guidelines are now being developed within the cobatrice project. introduction: during the past decades there has been an increase in mass casualty events with changing geopolitical and climate situations. in a mass casualty event comprehensive care for the individual is expected [ ] . to meet these obligations further education in disaster medicine seems obligate [ ] . therefore the german home department responsible for mass casualties passed a concept for student education in disaster medicine [ ] . objectives. the introduction of a summer academy ''disaster medicine'' (sadm) is a first approach at charité university of berlin to establish a curriculum for disaster medicine. the sadm is sponsored by the german academic exchange service (daad) for years. the enhancement of student education in disaster medicine is supposed to raise the level of skills and knowledge of future physicians in the face of mass casualties [ ] . international participants and an interdisciplinary approach are keystones of the sadm concepts. in a globalized world international networking should enable students to exchange knowledge about the handling of mass casualties in different parts of the world. disaster medicine needs an interdisciplinary approach [ , ] . psychological aspects are always a key factor in the successful handling of mass casualties. the teaching concept of sadm consists of four parts: e-learning ahead of a week training session, emergency medicine training, disaster medicine training and excursions to evaluate already existing disaster concepts. the concept will be evaluated [ ] using a knowledge test, a skills test and a structured written interview concerning motivation and satisfaction of the students. conclusion. the support of the daad for three consecutive years allows a further evolution of this concept by integrating the evaluation results. the sadm should enable future physicians to meet the challenges of mass casualties with greater confidence and skills. educational programs are being set up to provide training and skills in these core subjects for dental care professionals. objectives. to evaluate dental practitioner (dp) skills and knowledge prior to a day continuous medical education (cme) training session, and assess training efficacy at the end of the session. methods. nine ( ) multiple choice questions concerning medical emergencies and pain treatment were handed out to dps at the beginning of cme training sessions over a year period in metropolitan france. after the day training session, the same multiple choice was taken again and collected for statistical analysis (kruskall-wallis test). examination before and after cme, p \ . we evaluated dps and obtained a % answering rate. before the cme session, the correct answer rate was below % for several items, like the european emergency telephone number or performing back blows before the heimlich manoeuver for severe choking, and below % for identifying vasovagal malaise by bradycardia, giving insulin for diabetic malaise or treating anaphylactic shock by epinephrine. more worrisome still is the fact that nearly out of dps would prescribe non steroidal anti inflammatory drugs (nsaids) during late pregnancy. the overall impact of cme was highly significant (p \ . ), showing real efficacy but correct answering rates after cme still remained between and %, which leaves room for improvement. further studies are under way to evaluate long term memorization of cme sessions in order to determine their optimal frequency. conclusions. medical skill and proficiency evaluation before cme training sessions for dps allows to target the training sessions and to evaluate their efficacy in the short run. introduction. the positive impact of immediate bedside echocardiography for rapid diagnosis and management of acute hemodynamic disturbances in the critically ill patient is well established. it is advocated that peri-resuscitation echocardiography should be an integral part of training for all intensivists. however, a major challenge for the intensive care clinician is access to appropriate echocardiography training outside of specific fellowship programmes. objectives. one suggestion to meet this training need is to combine supervised practical instruction with self-learning through the use of on-line educational tools. the internet is ideally suited to studying echocardiography as e-tutorials serve to convey theoretical principles whilst stills/video clips aid image recognition and interpretation. here we review currently available web based learning resources. methods. an online search was performed using google Ò and yahoo Ò search engines with the following key words: echocardiography, tte, toe, education, training, programme, courses, on-line, web-based, critical care. the resulting hits were screened to identify relevant sites and these were then evaluated independently by each author before an overall consensus was reached. one author had no previous echocardiography training whilst the other had passed the american national board of echocardiography perioperative transesophageal echocardiography examination. a total of sites were identified for evaluation (see table ); these are listed below with a brief description. conclusions. our search demonstrated a number of sites dedicated to facilitating echocardiography training. these varied from those which were essentially atlases, to those with a modular learning programme supported by interactive discussions and self assessment. some were targeted at the beginner seeking a basic understanding of echo whilst others were aimed at the enthusiast preparing for examinations. with growing interest in critical care ultrasound it is likely that we will see the use of such resources increasing. however echocardiography is a practical skill and it is essential that on-line learning is conducted in parallel with supervised bedside training in a process of 'blended learning'. . to determine level of supervision for trainees in the elective mri setting as compared with critical care transfers to mri. . to gain insight into the learning resources used by medical staff on mri to allow existing training to be improved. methods. two online surveys were conducted in february , with invitations to participate via e-mail. the survey population included all anaesthesia and intensive care medicine consultants in the local tertiary neurosciences centre and all trainees for these specialties in the northern ireland deanery. first year trainees were excluded. results. the response rate was % for consultants and % for trainees. in total, consultants responded with over % having no experience of mri at consultant level, even though % worked in areas where mri skills could be required. trainees completed the survey, with % having experience of mri in the elective setting, all of whom had been directly supervised by a consultant. % of trainees had experience of critical care transfers for mri, but this was in an unsupervised capacity more than % of the time. despite this, % of trainees did not feel competent to work in mri unsupervised. web based learning was found to be a poorly utilised mri training tool, particularly among consultants. conclusion. we have demonstrated a need to formalize training for mri in our institution and for trainees in the local deanery. we propose to meet this need by a combination of e-learning and experiential sessions with defined competencies. this should increase the cohort of physicians who can provide optimal care , in this unique environment and subsequently improve both service delivery and patient safety. was not a priority in health systems. following the report: ''to err is human. building a safer health system'', by the institute of medicine, which had a great impact on the media, ''patient safety'' is included as an strategic line in most health systems. training in patient safety is essential to implement safety culture and as a result improve it. for that reason we developed a training program ( courses) in for physicians and nurses from our icu. objetive. patient safety training program assessment. methods. we designed a h course ( % practical), using simulated scenarios common in icu clinical practice. we pointed out the relevance of human factors such as teamwork and communication, and its leading role in the genesis of error. we discussed a ''sentinel case'', using the root-cause analysis method, and analysed an icu process through failure mode and effects technique. adverse events reported to the department website were reviewed. participants and instructors discussed specific aspects about insertion of central venous catheter, prevention of nosocomial infection and improvement of security in the different groups of icu patients, highlighting the need for fidelity to the established protocols for this purpose. finally, participants completed a survey that assessed various aspects in a score from to . results indicated the most and least interesting aspects and suggestions for improvement were included. results. assessment surveys were analysed. participation rate was %. overall results: appropriate and clear targets, accomplished goals and utility ( . ) , appropriate content objectives and organization ( . ) , time invested in development activity and oral presentations ( . ), faculty competence ( . ) , interest and faculty adaptability to the group needs ( . ), degree of satisfaction and practices ( . ) . most interesting comments: practice of root-cause analysis ( . %), continued participation and motivation ( . %), practices with hps and group discussions ( . %), importance of human factors ( %), theory and practice good balance ( . %). least interesting comments: too condensed contents ( . %), few scenarios ( . %)suggestions: do it again( . %), enhance preventive medicine sessions ( . %), increase course duration ( . %). conclusions. overall assessment was positive. adaptability and competence of teaching staff have been the most valued aspects; too condensed contents and oral presentations were the least valued. practice of root-cause analysis ease of participation, ongoing motivation, hps scenarios and group discussions are the most appreciated activities. final comment: good acceptance has encouraged us to continue in to complete participation of all interested professionals. introduction. our intensive care unit (icu) was one of the first to initiate a humanization program in daily routine in . since then, the program suffered changes, the icu grew up in number of beds and complexity and had great renewal of the members of our interdisciplinary group. objectives. to improve our knowledge we continually re-evaluated the stress factors for the patients from our staff members' perspective, putting them in the patients place. methods. between january and march of , a research form was used with the interdisciplinary icu team. the following items were analyzed: profile of the interviewed, evaluation of the environment of the icu and the stress factors for the patients. the results were compared with the questionnaire form filled by the patients after icu discharge, as a part of our quality improvement program. results. about . % of our icu team answered the research (n = ). the mean age is . years (sd . ), . % of female, . % married, . % protestants and . % catholics and icu professional experience of . years (sd . ). our icu is noisy for . %, very illuminated for . %, easy-going for . %, organized for . %. in a preview research we found closed results. according to the team, factors that bother the patients are: noise ( . %), bed bath ( . %), loneliness ( . %), lack of privacy ( . %), anxiety ( . %), distortion of time perceptions ( . %) and fear ( . %). the patients (n = ) described as main complaints after icu discharged: distortion of perceptions of time ( . %), anxiety ( . %), sleeplessness ( . %), noise ( . %), loneliness ( . %), fear ( . %), pain ( . %)bed bath ( . %) and lack of privacy ( . %). the study showed differences of icu team opinions and the patients' complaints. when the team is placed in the patient's perspective they may experience a better view of how harmful is an icu and how much we can do to improve it. this is our daily challenge: take care with quality, respect, affection and always search for improvement. introduction. endotracheal intubation is a routine procedure to protect the airway in critical care, that is performed by a wide variety of clinicians from different specialities with different levels of experience in airway management. serious complications can result from misplacement of an endotracheal tube (ett) in a main stem bronchus. a widely recommended method for the prevention of this complication is bilateral auscultation of the lungs; but this method frequently provides only inconclusive results ( ) . other routinely used tests to verify correct endotracheal tube placement include observation of symmetric chest movements, and inserting the ett to a specific depth, but it remains unclear which of these tests detects endobronchial intubation best. objectives. we therefore designed this study to determine which bedside method has the highest sensitivity and specificity for detecting endobronchial intubation in adults and whether sensitivity and specificity increases as a function of the anesthesiologist's experience. methods. surgical patients were randomized to two study groups. in the first, the ett was fiberoptically positioned . - -cm above the carina, whereas in the second group the tube was positioned in the right main stem bronchus. first year residents and experienced anesthesiologists randomly performed only one of the following tests to verify the position of the tube: ) bilateral auscultation of the chest (auscultation); ) observation and palpation of symmetric chest movements (observation); ) estimating the position of the ett by the insertion depth (tube depth); and, ) a combination of all three mentioned tests (all three). results. patients ( female/ male) with observations by experienced and inexperienced anesthesiologists were included in the study. tube depth and all three had a higher sensitivity ( . and ) in detecting endobronchial intubation than auscultation ( . ) and observation ( . ) (p \ . ). experience increased the sensitivity only for auscultation, with % of first year residents versus % of experienced anesthesiologists detecting endobronchial intubation by auscultation correctly. the optimal ett insertion depth was found to be cm in women and cm in men. we conclude that auscultation alone is inadequate for assessment of correct ett insertion depth, and that checking for symmetric chest movements is of little use. our results suggest that the hierarchy of the methods used to assess the correct ett insertion depth should be changed and that clinicians should rely more on depth of ett insertion than on auscultation. this is especially true for physicians with less experience in airway management and in situations where auscultation is difficult or impossible. min usa) , uses a new probe measuring hemoglobin saturation at a lesser depth ( vs. mm before), with more data output ( value/ s vs. value/ . s). the new device contains automated software to compute parameters such as occlusion and reperfusion slopes of sto obtained during and after a vascular occlusion test (vot). objectives. to compare nirs parameters obtained with the devices used simultaneously in healthy volunteers and critical care patients to test if the new device gave similar results than the older one. methods. micro-oxygenation parameters were collected simultaneously with the different nirs models, one on each thenar eminence, before (baseline) and during a min upper arm (brachial artery) vot in patients ( septic shock (g ), trauma (g )), compared to healthy volunteers (hv)(g ). nirs probes were then shifted to the contra lateral thenar eminence and a second vot was performed. sto occlusion and reperfusion slopes from both devices were calculated in all groups by the same software, using linear adjustment (r c . to be valid); p \ . was considered significant. following parameters were collected in patients: saps ii and sofa scores, macrohemodynamic (heart rate (hr), mean arterial pressure (map), central venous pressure (cvp), cardiac output (co) and svo (mixed venous o saturation) or scvo ), and metabolic parameters (ph, base excess, and lactate). results. median ± iqr. patients (g and g ) did not differ for macrohemodynamic or metabolic data, except map ( ( - )mmhg vs. ( - )mmhg; p = . ). baseline nirs sto values were similar for both groups and for both devices, but were lower than in hv. during vot, reperfusion slopes were also lower in patients than in hv regardless the device used. the minimum sto during vot, occlusion and reperfusion slopes were significantly different between the devices: intraclass correlation coefficient (icc) . , . and . , respectively, and bland and altman poor agreement and large bias. conclusions. data obtained with model largely differ from those obtained with model , regardless of the studied population for both sto baseline and slopes. these differences appeared more pronounced in hv than in patients. such differences may result from muscle depth, number of data output allowing to more precise linear adjustment, or the minimum value reached during occlusion. it becomes hazardous to compare data obtained with these devices either in hv or in critically ill patients. crrt is used increasingly for the management of acute renal failure in critically ill patients. one major problem with crrt is coagulation of the filters, leading to decreased efficacy and increased costs. regional anticoagulation with citrate is an effective and established form of anticoagulation during crrt in critically ill patients ( , ) . objectives. the aim of this study was to investigate the filter life span during regional anticoagulation with citrate and regarding cost effectiveness. methods. this observational, retrospective study was performed in a mixed surgical and trauma icu in a university hospital. clinical characteristics are shown in table . citrate crrt was performed using commercially available equipment and fluid solutions (multifiltrate Ò with integrated cica Ò -system; fresenius medical care; germany). to maintain stable metabolic and hemodynamic conditions we used an internal standard protocol for citrate crrt. reimbursement for crrt is calculated on procedure related rates (according to german drg). data are shown as mean or median and standard deviation. results. f patients treated with citrate crrt from april through december were evaluated ( table ). the mean circuit lifetime of crrt for all patients was ± h (fig. ) . mean daily costs per patient were calculated as eur and mean benefit for crrt as eur (table ) . commercially available interstitial glucose sensors have already been evaluated for this purpose with promising results. however, because of the range of medications administered in the icu, potential interference with sensor performance must be characterized. to minimize the undesired offset caused by these medications, an interference rejection membrane (irm) was uniquely developed for a new subcutaneous glucose sensor for in-hospital monitoring. the novel irm was studied within the icu setting to gain a realistic picture of its performance in clinical use. objectives. acetaminophen is known to be an interfering agent for electrochemical sensors. to study the functionality of the new irm, the effect of acetaminophen on sensors worn by critically ill patients was assessed. sensor signals were characterized to identify any undesired response from the medication. methods. icu patients simultaneously wore - -day sensors that were connected to ipro tm (medtronic diabetes, northridge, ca) recorders to gather blinded sensor glucose values. patients were given acetaminophen or a mix of hydrocodone and acetaminophen during their icu stays; staff charted the exact time of each medication administration. to assess whether a signal offset would be introduced by the acetaminophen, min of sensor signals before and after medication administration were compared. the period of min was chosen based on acetaminophen's pharmacokinetic profile and the time to reach maximal plasma concentration. the normalized medians for the signal segments before and after each acetaminophen delivery were calculated. the medians formed vectors, each with elements representing signal characteristics before and after the medication deliveries. a paired t test was used to compare the vectors and assess for any effect (p \ . ) on sensor performance. across the patients evaluated for this study, acetaminophen and a mix of hydrocodone and acetaminophen were administered a total of times. one sensor was not available during a medication delivery; thus, occurrences of acetaminophen administration were analyzed. no effect on sensor signals could be identified in the instances of acetaminophen delivery. no statistically significant difference was observed between the signal segments before and after administration (p [ . ). conclusions. this study demonstrates that a novel irm effectively reduces the undesired interference of acetaminophen on a continuous glucose sensor signal during clinical use. although this analysis was focused on acetaminophen, the outcome suggests that the irm may also effectively suppress interferences from other medications administered in the icu. [ ] . however, assessing elastance requires a highly invasive vena-cava occlusion maneuver and left and right ventricle pressure/volume waveforms, which are not typically available in an intensive care unit (icu) and may raise ethical issues in regular use. a validated, lumped-parameter chamber cardiovascular system (cvs) model is used to evaluate a time-varying elastance estimate at the bedside using standard clinical measurements. objectives. to assess time-varying elastance at the bedside for the left and right ventricles using available icu data, and prove the concept on a porcine model of pulmonary embolism. five pigs had pulmonary embolism (pe) induced via injection of blood clots over h, developing full pe in stages from a healthy state. at each state several data sets were taken ( in total over pigs), measuring aortic and pulmonary artery pressure waveforms (p ao (t), p pa (t)), left and right ventricular volume and pressure waveforms (vlv(t), vrv(t), plv(t), prv(t)). at each cardiac state in inducing pe, the time-varying elastances are estimated as elv = plv/ vlv and erv = prv/vrv. these values are correlated to readily measured quantities (pao and gedv). these correlations are used to approximate time-varying elastances erv* and elv* for use in a clinically validated -chamber cvs model. note these approximations are load dependent and thus change with cardiac state. a fivefold cross validation was used to validate the model. a time-varying elastance is generated from data from pigs and used to simulate the fifth pig. simulated pv loops are compared to the originally measured pv loops to validate the approach. results. p ao (t) and elv were highly correlated over the data sets (r = . to r = . ). p ao (t) and elv, gedv and erv are also well correlated (r = . to r = . in this case we report the worldwide first use of the novel deltastream-dp -system (medos corp.) in a patient suffering from acute right heart failure due to pulmonary embolism following cardiac surgery. in a year-old male patient days after mitral valve reconstruction cardiac arrest occurred during physiotherapy treatment. after failure of restoring circulation, a short-term ecls system (lifebridge Ò ) was implanted under cardiopulmonary resuscitation by inserting cannulas in venous and arterial femoral vessels and then switched immediately to the dp -deltastream system. ct-scan revealed the diagnosis of a massive central pulmonary embolism. transesophageal echocardiography showed a dilated failing right ventricle. a thrombolytic therapy was carried out by administering mg alteplase. following ct-scan showed reduced thrombus burden. the deltastream system was carried out for h. ptt was maintained to . -fold under i.v. heparine therapy. pump blood flow was held at a maximum of . l/min ( , - , r/min) for days. despite transesophageal echocardiography showing improved left ventricular function the ecls flow was maintained for further days focussed on the improvement of right heart. further on the pump flow was reduced every h and the system could be explanted after days in now stable cardiolpulmonary situation. the patient was discharged on day at home in good state without any neurological dysfunction. overall duration of the ecls deltastream therapy was h. no system related major complication occurred during the time. even in maximum blood flow of . l/min no relevant hemolysis was measured. ldh level was only slightly elevated to - u/l. introduction. airway management has progressed dramatically in the last years but the most significant advance has been video laryngoscopy. several devices have been introduced since, the most important currently available are the glidescope Ò , c-mac Ò , mcgrath Ò , pentax airway scope Ò , airtraq Ò , among others. a common practice has been to abandon direct laryngoscope intubation (dli) after attempts and move onto advance airway devices such as video laryngoscopy which is becoming the first choice when available. although dli is successful in the majority of patients, poor glottic exposure is more likely to require prolonged or multiple intubations attempts and therefore be associated with complications such as oxygen desaturation or airway and dental injuries. in the intensive care environment an airway should always be considered a difficult airway due to scarce time to perform assessment, to make decisions and to act. should the use of video laryngoscopy be implemented as a routine for airway management in a critical care setting ? objectives. the purpose in this study was to describe for the first time the use of video laryngoscopy, specifically the vel , as a routine choice for airway management in the intensive care environment. single center, prospective observational study, from november to february , was conducted in our intensive care facility, which involved utilization of the vel for all tracheal intubations, no exclusion criteria, rapid sequence intubation (rsi) was the standard procedure. information was recorded by the operator assistant on the same day identifying timings of intubation, number of attempts, success or failure and the difficulties encountered. vel was developed in our institution in and later adopted as a standard airway management by the department of anesthesia. the device has an original mccoy blade with an attached port that holds a channel for the displacement of an optical shaft mm long, . mm in diameter with a °angle view (tekno-medical Ò germany) which is assemble to a video camera (telecandx ii, karl storz, germany), an external light source and to a -in monitor. results. there were tracheal intubations performed by operators, crash intubations and rapid sequence intubations. all intubation attempts were successful, mean number of attempts . the median time to successful intubation was s with no complications. subjective assessment post intubation showed that in all cases vocal cords were view in full, all operators manifested to feel comfortable with the handling of the apparatus but felt dependent on a assistant specially to maintain view while maneuvering the endotracheal tube. conclusions. routine airway management with vel in critical care setting is effective with a high rate of success and most important, with a positive impact for patient safety. introduction. hypovolemia is a common complication in many clinical scenarios and its detection is considered of prime importance. in previous clinical studies, tissue oxygen saturation (sto ) measured by near-infrared spectroscopy (nirs) has been explored for this purpose; however, results are disappointing. it has been suggested that the sensitivity of nirs for detection of hypovolemia might be improved when nirs is applied in combination with a vascular occlusion test (vot). nirs in combination with a vot, consisting of a -min period of arterial occlusion followed by reperfusion, allows quantification of muscle deoxygenation during ischemia (sto downslope; a measure of muscle oxygen consumption rate) and muscle reoxygenation after ischemia (sto upslope; a measure of microvascular reperfusion rate). objectives. in the present study we applied multi-site and multi-depth nirs in combination with a vot in a model of simulated central hypovolemia; lower body negative pressure (lbnp). eight healthy male subjects, with a mean ± sd age of ± years, participated in this study. the lbnp protocol consisted of a stepwise increase of lbnp from to - mmhg. stroke volume (sv), heart rate (hr), cardiac output (co), and mean arterial pressure (map) were continuously measured using near-infrared finger plethysmography (nexfin). multi-depth nirs, with probing depths * and * mm, was performed on forearm and thenar for the measurement of sto . three-min vots were performed by rapidly inflating a pneumatic cuff around the left upper arm before application of lbnp and at lbnp = - mmhg. vot-derived sto traces were analyzed for baseline, downslope, and upslope. . from baseline to lbnp = - mmhg, sv decreased from ± to ± ml (p \ . ), hr increased from ± to ± bpm (p \ . ) and co and map were maintained around baseline level. forearm sto baseline decreased significantly from ± to ± (p \ . ) and ± to ± % (p \ . ) for the and mm probing depth, respectively. forearms sto downslope, measured with the and mm probe, decreased from - . ± . to - . ± . %/min (p \ . ) and - . ± . to - . ± . (p \ . ), respectively. forearm sto upslopes remained unchanged during lbnp. vot-derived sto parameters measured on the thenar did not shown any changes as a result of lbnp. conclusions. vot-derived sto parameters measured on the forearm seem to be more sensitive to the hemodynamic changes associated with lbnp compared to sto parameters measured at the thenar. grant acknowledgment. this project was supported in part by hutchinson technologies inc. introduction. hypovolemia is a common complication in many clinical scenarios and its detection is considered of prime importance. in previous clinical studies, near-infrared spectroscopy (nirs) has been explored for this purpose; however results are conflicting due to inconsistencies in methodology with respect to nirs probing depth and site. objectives. in the present study we applied multi-site and multi-depth nirs in a model of simulated central hypovolemia; lower body negative pressure (lbnp). fifteen healthy male subjects, with a mean ± sd age of ± years, participated in this study. the lbnp protocol consisted of a stepwise increase of lbnp from to - mmhg. stroke volume (sv), heart rate (hr), cardiac output (co), and mean arterial pressure (map) were continuously measured using near-infrared finger plethysmography (nexfin). multi-depth nirs, with probing depths * and * mm, was performed on forearm and thenar for the measurement of tissue oxygen saturation (sto ). . from baseline to lbnp = - mmhg, sv decreased from ± to ± ml (p\ . ), hr increased from ± to ± bpm (p \ . ), and co and map were maintained around baseline level. forearm sto decreased significantly from ± . to ± . % (p \ . ) and ± . to ± . % (p \ . ) for the and mm probing depth, respectively. thenar sto measured with the mm probe remained unchanged, but measured with the mm probe, a decrease from ± . to ± . % (p \ . ) could be observed. conclusions. forearm sto seems to be more sensitive to (simulated) hypovolemia compared to thenar sto and the sensitivity of nirs seems to increase for increasing probing depth. grant acknowledgment. this project was supported in part by hutchinson technologies inc. introduction. sidestream dark field (sdf) is a microcirculatory imaging modality implemented in a hand-held microscope for the non-invasive bed-side visualization of the human microcirculation. despite the many studies showing the importance of microcirculatory imaging in intensive care patients the introduction of sdf imaging into routine clinical practice remains cumbersome. one of the challenges is the need for automatic analysis of the images which currently is subjective and time consuming. objectives. in the present study, we introduce a rapid automated software method for automatic quantification of microvascular density, a key microcirculatory parameter, based on sdf image contrast analysis. methods. twenty-five sequential sdf images (duration = s, resolution = pixels) were isolated from an sdf movie clip, stabilized, and averaged. subsequently, the mean ± sd gray scale intensity in a sliding pixel window was calculated and the sdvalue was assigned to the window center pixel, creating an sdf contrast image. this is a simple and rapid algorithm for vessel wall detection as a pixel window at a tissue-vessel junction will have a high sd-value due to the presence of both light tissue cells and dark red blood cells. conclusions. here, we introduce and validate a rapid automated method for quantification of microvascular density in sdf images. as this algorithm detects vessel walls rather than vessel lumen, smaller and larger vessels have similar contribution to the microvascular density assessment. a limitation, however, is that vessel diameters cannot be detected with this algorithm. the preliminary results confirm the proof of concept of the sdf image contrast analysis software, however, further research is required for its optimization. the criteria believed to be necessary for the implementation of hcs in practice were that his name would be written{ ( )}, the document dated{ ( )} and signed{ ( )}. physicians in private practice wanted date(p = . ) and signature(p = . ) more often than in institution. ( ) physicians thought that the patient must be competent at the designation' time of hcs, especially those who possess advances directives(p = . ) and a hcs(p = . ) themselves. ( ) thought the hcs should know about the patient's wishes regarding treatment and care objectives. conclusions: more than / of physicians did not know who the hcs is. more than / thought hcs useful and at least / would encourage a patient to designate one before heart surgery. about % thought that being a hcs is a too high responsibility and that the hcs could not be the best representative when needed. the potential fear this topic might induce is a barrier for this minority. introduction. the use of a daily goals chart has been shown to improve communication between the multi-disciplinary team leading to an increase in understanding of daily patient goals and a decrease in length of patient stay on the intensive care unit (icu) [ ] . we have used a daily goals chart on our icu since . we wanted to assess the value of this initiative in a general adult icu. methods. the royal cornwall hospital is a large uk district general hospital. we conducted the survey over a week period in the icu. each day, after the morning multidisciplinary ward round, the consultant in charge was asked to give the main goals for each patient. these were compared with those written on the daily goal chart, or stated by the house medical and nursing staff. they were graded as complete match ( % of consultant goals matched), partial match ( - % matched) or non match (\ % matched). results. surveys were conducted. the daily goals sheet matched the consultant completely on ( %) occasions and partially on ( %) occasions. in comparison, the combination of house medical and nursing staff had complete match on ( %) occasions and partial match on ( %) occasions. house medical staff had a % complete or partial match, house nursing staff had a % complete or partial match. overall house staff understanding of the goals set on the ward round is far better than that recorded on the goals chart. the goals related by medical and nursing staff showed differences that reflected their differing clinical priorities. combining results of all staff led to higher levels of complete match than either group independently. low levels of non-matches indicate that there is good overall understanding and communication within the team. use of daily goals charts is an effective aid to augment communication on the icu multidisciplinary ward round. objectives. to assess the effectiveness of an icu diary on post-icu psychological symptoms of patients (pts) and their families. single centre prospective study. three periods: = control ( to / ), = diary ( / to / ), = control ( / to / ). all the pts admitted c days for the first time to our medical-surgical icu were included. during the intervention period, the diary was filled both by the caregivers and the pts' relatives, without directives except for the first (medical summary) and the last (recovery wishes) ones. at icu discharge, their families were asked to fill a satisfaction questionnaire (ccfni) and the hospital anxiety and depression scale (hads), and to be contacted by phone to assess peri traumatic stress disorders [dissociation and impact of event scale-revised (ies-r)], hads at months and year after icu discharge. we excluded pts if they or their family refused to participate, were not fluent in french, or if their family was not present around the day of icu discharge. the optimal theoretical content of the diary was determined by a delphi technique involving a panel of icu and non-icu caregivers and a voluntary visitor. the content of the diaries was analysed and linked to the outcome measurements. of the admitted patients, were included. after exclusion of pts, formed the basis of the study. the content of diaries and the results of ies-r are under analysis. the year data is not yet available the saps ii at admission, icu and months post icu mortality were not significantly different between the three periods. the family satisfaction score was high and was not significantly different between the three periods. included: patients with failure of two or more organs in the first h, admitted to icu during . excluded: neurocritical and politrauma patients. contact year following discharge from; questions were asked about the patients' different perceptions during their stay in icu. if it was not possible to contact the patient, the next of kin was asked. results. patients included. general characteristics during admittance to icu: % male; age . ± . ; sofa * ± . ; apache ** ii . ± . ; apache ** iv ± . ; length of stay in icu: . ± . days; . % on invasive mechanical ventilation and . % on non-invasive mechanical ventilation. data collection was carried out over a period of ± . months, on average months (range: - months). . % ( patients) had died at the time of contact. the person interviewed was the patient in . % of the cases, the spouse in . % and immediate family (patient s parent/child/sibling) in . % of the cases. overall, . % do not have any memory of their stay in icu. for . %, the experience was unpleasant and for . % of patients the memory is very unpleasant. . % experienced fear, . % disorientation, . % a feeling of lack of hygiene, . % a feeling of suffocation/drowning (with the endotraqueal tubes, etc.), . % a lack of privacy (nudity, etc.) and . % pain during procedures. . % were very grateful for our phone interview. . % were satisfied with the staff. conclusions. in patients with high severity scores during their time in icu, less than half have memory of their stay after year. in those who do, the feeling of fear and disorientation predominates. to determine the occurrence of communication failures in clinical icus, identifying their main detection tools and disclosing their effects on patient condition. a prospective cohort was conducted in four icus of a -bed academic, tertiary-care urban hospital in sao paulo, brazil, enrolling critical ill patients older than years from july to august . communication failures were identified by daily direct observation of medical and nursing rounds and also by chart reviews. the association between communication failures and adverse event occurence was determined using multivariate logistic regression. results. among the enrolled admissions, as much as admissions ( %) were affected by communication failures, with occurrences. the vast majority of the communication problems was not registered in patient charts, and could only be identified during the medical and nursing direct monitoring. none of the identified communication failures caused patient harm. nine out of ten communication issues involved exclusively members of the multidisciplinary icu health team, patients and their relatives being seldom included in this scenario. despite communication failures are considered important adverse event risk factors, no association was identified between these two variables. conclusions. the incorporation of direct observation as a research tool for identifying untoward events was essential to the detection of communication failures in our study. almost half of the studied admissions was affected by communication flaws, most of them involving exclusively the healthcare team. nevertheless, these figures are underestimated, since the research team remained in the studied icus for no more than h a day. although patients were not harmed fortunately, the presence of these communication issues suggests the existence of important gaps in the provision of critical care. the issue regarding communication deficiencies in icus setting affecting patient safety deserves attention. relatives of patients in the intensive care unit (icu) are exposed to considerable stress . effective communication with relatives has been shown to provide support and minimise stress whilst improving their wellbeing and decision making for critically ill patients . furthermore, satisfaction is dependent on communication by a senior caregiver . no published guideline or recommendation exists for when relatives should be first spoken to, how often they should be updated, or how these conversations should be documented. to determine how well relatives of patients in the icu are kept informed and to assess the quality of documentation. we retrospectively analysed data from the metavision Ò clinical information system of patients staying over days during / / - / / on the -bed icu at the nnuh. data obtained from the 'relatives communication' page included: when relatives were first spoken to, how often they were spoken to (according to the number of entries made) and the members of staff involved in the conversations. these variables were analysed in relation to patient outcome and length of stay on the icu. . patients were analysed. communication with relatives was not documented in % of patients. % of communication was carried out by a consultant. discussions were more likely to occur with relatives of patients who died; % compared to % of patients discharged to the ward. similarly, relatives of patients who died were spoken to more frequently; % were talked to on more than one occasion compared to % of patients surviving to discharge. relatives were more likely to be spoken to with an increased duration of admission on the icu; communication occurred with only half the relatives of patients staying - days, compared to % of those staying more than days. two-thirds of relatives of patients staying more than days were not communicated with until after the fourth day of admission, although the majority of these were spoken to on numerous occasions and all were seen by a consultant. relatives of patients dying on the icu are more likely to be communicated with, and are updated more often than those of patients surviving to discharge. a delay in communication with relatives of patients staying more than days on the icu was noted, but conversations occurred more regularly and involved a consultant. we suspect that our results demonstrate a lack of documentation rather than actual communication; auditing relatives' satisfaction with communication on the icu may help clarify areas for improvement. assessment of satisfaction with the quality of care provided to patients hospitalized in intensive care units, in most cases, is transferred to the relatives of the same, given the context of the patient himself unable to speak. the diagnosis of the needs of families of critically ill patients has been the subject of several studies. aiming to assess the needs of relatives of patients admitted to the picu (polivalent intensive care unit), we conducted studies in particular through an adapted version of the questionnaire ccfni (critical care family needs inventory) developed from the adaptation made by johnson and col. ( ) and focus group. one of the needs identified in these studies was to improve information about what happens in the picu. with this in mind we designed a manual to support relatives in order to improve communication and understanding in the context of the intensive care unit. objectives. this study aims to assess the impact on the level of family satisfaction of a manual we've created. the manual is available from january to all visitors at the entrance of that unit. the questionnaire was mailed to all families who had a family member hospitalized in the picu during the year following the introduction of the manual. together followed a letter to present the study and a stamped and addressed envelope for their return. beyond the satisfaction and access to the manual or not, were collected socio-demographic data from relatives and socio-demographic and clinical data of patients. we obtained responses, representing % of all potential families. questionnaires were returned because of address failure ( . %). statistical analysis was performed using spss Ò v. . results. the satisfaction of family members who had access to the manual was better in all dimensions tested (support, comfort, information, access, trust), and with a statistically significant difference (p \ . ). this difference was clearer in the fields support (med , / . ) and information ( . / . ). conclusions. the impact of the manual on the improvement of family satisfaction was positive in the various dimensions assessed. the questionnaire of family satisfaction monitoring and understanding of information given through a manual created by us can contribute to a better understanding of the needs of families and hence for the continued improvement of service quality. johnson introduction. the burnout can be defined in its multidimensionality: emotional exhaustion, understood as a feeling of exhaustion and failure of the person to give more of herself; depersonalization, in which the person's relationship with patients and with colleagues becomes cold, distant and guided by some cynicism, lack of personal and professional completion, which may manifest itself, on one hand, by the sense of incompetence and inability to respond to requests or, on the other hand, by the sense of omnipotence. the provision of intensive care can lead to health care provider's physical, psychological and emotional exhaustion, which may develop to burnout. we notice the absence of specific studies on this syndrome, in portuguese intensive care units. objectives. the study here presented intend to identify the levels of burnout of physicians and nurses working in portuguese intensive care (adult polyvalent units in the north of the country), and to identify factors that can lead to the development of burnout in the portuguese physicians and nurses working in that setting. the methodology presented consist of application of a questionnaire for self fulfilment with items: , socio-demographic data of the study population; , experiences in the workplace; , maslach burnout inventory-general survey. for the application of methodological tools, we requested the authorization by the competent institutional bodies: the board, ethics committee and directors of services. the professionals who participated in the study were asked informed consent, whether in formal or informal. in addition, each instrument was accompanied by a cover sheet of the same. we have also done observation of the work contexts, and interviews. in this study we will focus on the results of the questionnaire. . sample: hospitals with a total of intensive care units. professionals participants in the study , physicians nurses. the mean ages of respondents , of professional experience years and of experience in intensive care were years. mbi preliminary results:distribution of levels of burnout by occupational category: at the moment, portuguese physicians and nurses who work in intensive care units seam to have medium levels of burnout, obtained through the mbi. results show higher levels at emotional exhaustion in nurses never less in general they showed higher personal and professional completion than physicians. depersonalization were higher in physicians. the results presented here underline the importance of promoting the prevention of burnout at intensive care. the development of the burnout syndrome in physicians and nurses in intensive care has serious consequences, both for themselves, or the consequences that entails for patients and their families. introduction. the hospitalization of a member of the family in the intensive care unit (icu) usually occurs in an acutely and inadvertent way, leaving little time for a family adjustment. facing the stressful situation, the family may feel disorganized, helpless and with difficulties to mobilize themselves, enabling the rise of different types of needs. the scope of those needs leads to the alleviation of tension and uncertainties that could provide to the family the stability needed to cope with the situation disease . to identify the needs of care of family members with persons admitted to the icu. methods. this is a transversal study, held in two icus (a public one and a private one) in the city of feira de santana, bahia, brazil, after approval by ethics and research committees. the relative person is understood by the person who had consanguinity ties or who was closest to the patient, who lived with him and had close relationships. relatives were interviewed when his relative was over h of hospitalization. the the brazilian adaptation of the critical care family need inventory (inefti) was used for measuring the degree of importance, once it has items distributed in five dimensions. descriptive statistics were used for analysis. the inefti reliability was satisfactory (cronbach a = . ). results. the needs of care considered most important by family members were those related to the security dimension, expressed by the items ''to know what are the chances of improvement of the patient'' ( . ± . ), ''to be informed about everything that relates to the evolution of the patient'' ( . ± . ) and ''to feel that hospital people care about the patient'' ( . ± . ). in the category information, the item ''be able to talk to the doctor everyday'' ( . ± . ) obtained more average. in the category proximity was consider more important to ''see the patient frequently'' ( . ± . ). the needs of the categories support and comfort categories showed lower scores. these results are similar to those presented by literature , , what confirms the appreciation of the family to the aspects related to the recovery of the hospitalized relative, in detriment of their own needs. conclusions. having security, information and being around its ill relative is what the families need. the security is provided by the conviction that the person receives the best care in the pharmacological, technological and human aspects, and can be perceived by the information transmitted by the team and by the proximity established in the interaction with the sick relative. a collaborative project was developed between the itu clinical staff of a large, inner city teaching hospital, palliative care clinicians and an academic department of palliative care. qualitative data collection included: (i) semi-structured interviews with staff and relatives of patients thought to be at the end of life; (ii) focus groups with staff (iii) observation of care and (iv) clinical note review. data was analysed using the framework approach to identify key themes. results. semi-structured interviews were carried out with staff and focus groups took place. a total of relatives, representing patients thought to be at the end of life, were interviewed. half the patients represented were female, with diagnoses including infection, hypoxic brain injury, malignancy and liver failure. the participants were aged - and included a range of ethnic groups and religious affiliations. non-participant observations of care took place for and clinical note review for of these patients. data from the interviews with staff describe that an existing withdrawal of treatment document was working well but could be developed further along with suggestions for amendments. the interviews with relatives, observations and review of clinical notes show key themes: communication, decision-making, patient and family needs, and symptoms and their management. through discussion at itu end of life group meetings, a consensus was reached to pilot a complex intervention comprising an amended withdrawal document; a psychosocial assessment; education and awareness-raising; palliative care team input and increased psychosocial support. the psychosocial assessment document was deemed valuable to all patients and was rolled out for all patients admitted to itu. initial evaluation shows greater staff awareness. documentation of end of life issues and the collaborative research process has improved communication between itu and palliative care staff. introduction. consumer-centric healthcare is a key component of nhs policy. when patients are critically ill, family members act as surrogates. family members alone may inform patients of events that occurred, and provide physical, emotional and socioeconomic support during rehabilitation. thus, high family satisfaction (fs) is important. the fs-icu instrument was developed in canada to quantify family satisfaction and benchmark intensive care units (icus). we have piloted and validated previously an adaptation of the fs-icu such that its language was appropriate for the uk . to date, no intervention has demonstrated improvement in the fs-icu for a critical care unit. we hypothesise that provider-driven interventions fail to recognise central issues. co-production is a framework that enables creation of parity between providers and consumers by validating both individual worth and specialised knowledge . there are no published data on the use of co-production in intensive care. we undertook to co-produce interventions targeted to improve family satisfaction. the fs-icu instrument will be used as an objective measure of their efficacy. objectives. to co-produce some interventions targeted to improve family satisfaction and to use the fs-icu instrument as an objective measure of their efficacy. methods. fs-icu questionnaire responses were used to highlight potential areas for service development. focused interviews with families provided detailed descriptions of the ''the way the icu works''. these data were used to build exercises for a workshop of service users and providers which aimed to co-produce service developments. results. fs-icu questionnaires were received over the months to april ( % response). quality and consistency of communication between icu doctors and relatives; the level of relatives' inclusion in decision-making processes; and the icu waiting room atmosphere were identified as needing improvement. four families were interviewed in detail. workshop participants included trust directors, managers, clinicians, nurses, patients and their families. proposed interventions from the workshop included: development of a non-clinical family liaison officer role with a dedicated contact number; increasing focus on managing patients' and relatives' expectations of care delivery; specific improvements to the waiting room area. intensive care patients' relatives provided a unique insight into the icu functioning that should be utilised as a resource. co-production was used to design service improvements that may not have been obvious from a provider perspective. workshop transactions were empowering for both staff members and patients' families, generating social capital that creates and improves social provider-consumer networks, now and in the future. to evaluate the degree of satisfaction of icu patients regarding their icu stay. as the result of a fund sponsored by former patients and their relatives, our dept of intensive care is able to provide a small team of assistants to welcome and accompany the relatives of icu patients. one role of this team is to collect and evaluate impressions and criticisms from patients and relatives shortly after the icu stay. we studied a convenience sample of icu patients who stayed in our multidisciplinary dept of intensive care between september and april . the evaluation included simple questions about the welcome (friendliness of the personnel, explanations), quality of care (including pain control, attention to patient needs, availability of nurses and speed of response) and comfort (temperature, light, noise). data were analyzed using non-parametric (mann-whitney) and chi tests. we collected answers from of patients ( were incapacitated, had died and declined), including unplanned admissions and patients after major surgery. more than % of the patients were very satisfied with all items, except for information provided by the attending physician ( % of patients) and the room temperature ( % of patients) (figure ). post-icu enquiries can provide valuable feed-back information that could improve the quality of care in the icu. introduction. previous research suggests that family members of critically ill patients hospitalized in the icu frequently suffer from severe anxiety. a survey conducted in our unit-a -bed, university-affiliated tertiary-care, closed, general icu with restricted visiting hours-revealed a willingness of family members to participate in a support group. such a group was recently introduced and we report on our initial experience over the last year. methods. the purpose of the support group was to provide a forum where family members could freely raise any topic related to the care of their loved one as well as to family-related issues. the meetings were held weekly in the icu and chaired by a senior nurse and the unit social worker. family members were informed of the meetings when the patient was admitted to the icu and notifications were placed in the family waiting room. all family members were encouraged to take part and to raise any topic they felt was relevant. results. since its introduction in , there has been an increase in the percentage of a family representative attending the meetings from to %. the most frequently raised issues included staff-family interaction (especially lack of empathy), lack of information regarding the patient's status and prognosis, and the lack of adequate visiting hours. in addition, other issues included technical aspect related directly to the family, in particular, overcrowding and lack of privacy in the waiting room. finally, participants wanted to learn skills in order to cope with their new and uncertain circumstance. we have noted an ongoing readiness of family members to take part in the support group. the issues raised have and will allow us to make appropriate changes and to improve the current situation. in particular, the meetings help us to identify family members at risk who require more immediate and personal attention. introduction. the soap study suggested outcomes of cancer patients admitted to icu are similar to those without cancer in contrast to other reports . we wanted to compare this with our own experience. ( ) to determine critical care and hospital outcome of patients with malignancy referred to critical care in the previous years. ( ) to identify any factors influencing treatment decisions and survival after admission. retrospective chart review of patients undergoing treatment for malignancy admitted to icu for medical or surgical reasons from may to feb . leukaemia patients were not included as they are treated at a different hospital by a different group of clinicians. demographic information, tumour/treatment related factors e.g neutropenia, preadmission status and critical care diagnoses e.g. sepsis, were collected in addition to patient outcomes. results. patients were identified ( . % of all critical care admissions). itu mortality was . % (n = ), however only . % (n = ) survived to hospital discharge (comparable overall unit mortality: - %, hospital mortality: %). hospital survivors were younger (median . vs. years), and more non-survivors had pre-existing comorbidities, sepsis, ali and required more organ support (all ns). there was no difference between the groups regarding cancer treatment. non-survivors had a longer stay in critical care and treatment withdrawal/limitation decisions were more common suggesting these were often based on lack of medical progress whilst on icu rather than diagnostic nihilism. hospital mortality in patients with malignancy is higher in our specialist centre than reported for a europe wide cohort ( . vs. % overall and % in the medical subgroup). the majority of our patients were medical and not post-surgical unlike in the soap study. this may account for the greater mortality as a larger proportion of our patients had ali, sepsis, neutropenia and required inotropes. numbers admitted to critical care are much smaller than the . % reported in the soap study, suggesting some referral and admission triaging by the oncologists and the icu team. our results are similar to single centre french (hospital survival rate . vs. . %) and brazilian studies ( . vs. %), although a majority of our patients did not receive mechanical ventilation. , a diagnosis of cancer or active treatment for it should not be the major determinant of critical care support, but the patient's general premorbid status and the extent of organ failures appear to be important factors in decision making as for any other critical care patient. figures from the soap study for non specialist centres do not appear to reflect the experience of specialist oncology centres. historically there has been a negative perception of the prognosis for patients with haematological malignancies requiring admission to the intensive care unit (icu). however, advances in chemotherapeutic regimes and haematopoietic stem cell transplantation (hsct), along with improved monitoring and supportive measures have suggested that outcomes for these patients have improved [ ] . establishing key prognostic indicators predictive of outcome may be useful in identifying patients most likely to benefit from icu therapy. the aim of this study was to describe clinical outcomes and identify prognostic factors in patients with haematological malignancy requiring admission to icu. following research approval, a retrospective cohort study was undertaken in a -bedded specialist cancer icu over a -year period (october -september . recorded patient variables included demographics, haematological diagnosis, reason for icu admission, hsct, apache ii, admission laboratory data, number of organ failure, use of invasive mechanical ventilation, renal replacement therapy (rrt) and vasopressors. the primary outcome was in-hospital mortality. key prognostic variables in determining inhospital mortality were identified using univariate and multivariate analysis. results. patients with haematological malignancies were admitted to the icu during the study period: mean age . (sd . ); . % female; haematological diagnosis ( . % leukaemia, . % lymphoma, and . % myeloma); . % emergency admissions and . % were post-hsct. mean apache ii was . (sd . ), mean number of organ failures . (sd . ), % required invasive mechanical ventilation, . % rrt and . % vasopressor therapy in the first h of icu admission. icu, in-hospital and -month mortality were . , . and % respectively. significantly higher mortalities were seen in patients who were mechanically ventilated ( vs. % non-ventilated patients p \ . ), on vasopressor support ( vs. % no vasopressor support p \ . ), neutropenic ( vs. % non-neutropenic p \ . ) and in multi-organ failure defined as c organ failures ( deaths vs. deaths in patients with b organ failure, p \ . ). univariate analysis revealed mechanical ventilation, vasopressor support, albumin \ g/l, neutropenia, platelet count \ /l and multi-organ failure were all significant with p values . , . , . , . , . and. respectively. multivariate analysis revealed that multi-organ failure was the only independent prognostic predictor of in-hospital mortality. conclusion. mechanical ventilation, apache ii, vasopressor support, albumin\ g/l, neutropenia, platelets \ /l and multi-organ failure all had a significant association with mortality; however multi-organ failure was the only independent factor that predicted poor outcome. c.y.c. michael , a. vasu , s. eillyne tan tock seng hospital, emergency department, singapore, singapore introduction. coronary heart disease is the leading cause of mortality and morbidity for both women and men. although men are affected in greater numbers, women have been shown to have worse outcomes and higher mortality. objectives. this study aims to examine gender differences in risk factors, angiographic severity, treatment and in-hospital mortality after stemi. methods. in this retrospective study, the medical records of patients with an admitting diagnosis of stemi from tan tock seng hospital, emergency department (ttsh ed) between st january and st december were reviewed. we extracted the data from the electronic records of the emergency case notes and inpatient discharge summaries. results. of the patients studied, ( . %) were women and ( . %) men. four hundred and forty-nine ( . %) patients underwent coronary angiography. one hundred and seventy ( . %) patients did not undergo coronary angiography, majority ( . %) were elderly aged c years (men . % and women . %). between women and men, there was no significant difference between the number and distribution of diseased coronary vessels (including triple vessel and left main stem diseases). regardless of age, men were frequently treated with a coronary artery stent ( . %). elderly women (aged c years) were more often treated conservatively ( %) while those younger women (aged b years) were frequently treated with a coronary artery stent ( . %). in-hospital mortality rate was significantly higher for women than men ( . vs. . %, p = . ). amongst the patients treated conservatively, elderly women had the highest in-hospital mortality when compared to the other patients (women c years . vs. women b years . %; men c years vs. men b years . %). compared to men, women were significantly older (p \ . ; % ci . - . ) , more likely to have a history of hypertension ( . vs. . %; p \ . ), diabetes ( . vs. . %; p \ . ), hyperlipidemia ( . vs. . %; p = . ), peripheral vascular ( . vs. . %; p = . ) or ischemic heart diseases ( . vs. . %; p = . ) and less likely to be smokers ( . vs. . %; p \ . ) or consume alcohol ( vs. . %; p \ . ). conclusions. elderly women who were treated conservatively had the highest in-hospital mortality during the early management of stemi. hôpital saint-louis, ap-hp, paris diderot university, hematology department, paris, france introduction. aml is considered as an oncology emergency as a proportion of patients experience life threatening complications within the first hours or days after diagnosis. early death had been shown to be statistically related to high white blood cell (wbc) and monoblastic leukemia - , with leukostasis and lysis syndrome as the most deadful events. objectives. to evaluate the relationship between timing of icu admission and outcomes in high risk aml patients at the earliest phase of the malignancy (before any chemotherapy) methods. retrospective study in a tertiary care teaching hospital. adult patients with newly diagnoses aml from to were included. patients admitted for an immediate life sustaining therapy (ventilation, vasopressors or renal replacement therapy) were excluded. patients admitted directly to the icu (early admission) were matched for age, wbc and fab subtype with patients primarily admitted in hematology ward. datasets were extracted from medical charts. results. patients were included ( early admitted to the icu and admitted first to the wards). median follow up was . months. median age was . years ( - ). fab m or m was retrieved in % of the patients. karyotype was favorable for % and poor for %. median wbc was l - . no statistical difference was seen for demographic and hematological parameters between early admitted patients and matched controls. among the patients admitted first to the wards (controls), were subsequently admitted to the icu (lately admitted) and remained in ward during the entire treatment course (never admitted). the median time between diagnostic and icu admission of this last group was ( - ) days. strikingly, patients lately admitted had more frequently dyspnea,oxygen requirement, high respiratory rate, low diastolic arterial pressure and lower first h urine output. lately admitted patients were less likely to receive the complete dose of induction chemotherapy ( vs. %) furthermore, late admission resulted in increased use of invasive mechanical ventilation ( vs. %) and vaso-active drugs ( vs. %). these differences resulted in longer stay in icu and decreased survival. conclusion. patients at the earliest phase of high risk aml who are lately admitted to the icu experience worse outcomes, with increased use of life-sustaining therapies and higher mortality, compared to patients early admitted to the icu. physiologic parameters at the time of aml diagnosis such as respiratory rate, diastolic blood pressure, spo , or oxygen need are likely to help clinicians distinguish those patients at risk of late icu admission and subsequent adverse outcomes. studies are needed to assess the right place for newly diagnosed aml with physiological abnormalities but no organ dysfunction. atrial fibrillation (af) is the most common sustained tachyarrhythmia in the community. it has a prevalence of * % in those over years of age ( ) . the chronic health consequences of chronic af are significant. it can cause impaired cardiac function, a fivefold increased risk of stroke and decreased life expectancy ( ) . af is also the commonest arrhythmia in the critically ill, though a recent systematic review ( ) was unable to recommend evidence based standards due to the heterogeneity of the studies. objectives. a retrospective cohort study to assess the impact that chronic af has on the outcome from critical illness. methods. all patients admitted with chronic af between / / and / / were identified. we recorded age, apache ii and predicted hospital mortality, actual icu and hospital mortality, past medical history, admitting diagnosis, medication, echo findings, anticoagulants given, therapy instituted, and any further events between icu and hospital discharge. the only data collected for the patients who did not develop af was their age, apache ii and predicted hospital mortality and actual icu and hospital mortality. data analysis using chi square test and mann-whitney u test were used where appropriate. results. patients were admitted to the icu over the study period, of which had a history of chronic af ( . %), the remaining results are shown in table . chronic af had a prevalence of . %, in keeping with previous studies, and the mean age in the chronic af group was significantly higher. interestingly, there was no difference in icu and hospital mortality between the groups. despite the chronic af group being older with significantly worse apache ii scores. indeed the hospital mortality ( . %) of those patients admitted with chronic af was over % less than predicted hospital mortality ( . %). why patients with chronic af are outperforming expectation is not clear. it could be that apache ii is over estimating the severity of illness in these individuals, or is there something about the way chronic af is treated that affects the response to critical illness, for example, anticoagulation therapy? one of the major outcome measurements in burns centers is still mortality after severe burns. there are many predictive factors in admission as well as factors that are related with all the course of the disease responsible for survival after severe burn. many centers have a minimum standard of burn survival or la (the body surface area that kills % of people) and also have generated computer models of death probabilities based on age and tbsa (total body surface area) burned. objectives. to evaluate the outcome of the severely burned patients treated in the burn center and to develop a predictive model for survival from major burns in albania. the medical records of all acute burn patients admitted to the burn center of the university hospital center ''mother teresa'' in tirana, albania are reviewed retrospectively. statistical analyses are conducted using spss version . logistic regression is used for the prediction of death probability for two risk variables, tbsa burned and age. based on the index of evidence the variables are grouped in significant strata, from to for each variable. logistic regression equation is: where z = , - , age - , age - , age - , age + , tbsa - , tbsa - , tbsa - , tbsa after calculating the probability of death for each record, we have done respective grouping according the mortality from - %. results. during - are admitted altogether , patients in the burn center. overall mortality in icu is . % with a significant reduction during the years, up to . in . row burn mortality is . for , persons per year. la for children is % tbsa; for adults % tbsa and for aged % tbsa. based on probability of death, we notice that older age and larger burn size are associated with a higher like hood of mortality. figure gives an overview of death probability in our burn center. conclusions. the mortality reduction speaks up for a better work of our staff toward the patients. the predictive model may assist all the burn team to identify the crucial determinants of clinical outcome to establish a real basis for treatment standards and to allow future comparisons of new treatment strategies. ( ) in mechanically ventilated (mv) critically ill patients. methods. prospective observational multicenter study during weeks in november . consecutive patients admitted to the participating icus and requiring mv for at least h were included. maximal, minimal and mean intra-abdominal pressure (iap), were recorded on day , , and . iah was defined as mean iap c mmhg/ h at least day. following risk factors were recorded if evident during the first icu day or immediately before: respiratory failure, abdominal surgery with fascial closure, damage control laparatomy, major trauma/burns, prone positioning, gastroparesis, ileus, colonic pseudo-obstruction, ascites, hemo/pneumoperitoneum, intra-abdominal fluid collection, acidosis (ph \ . ), hypothermia (core t°\ °c), massive transfusion ([ u of packed red cells/ h), massive fluid resuscitation ([ l/ h), coagulopathy, oliguria and sepsis. results. patients from icus were included; mean apache ii score on admission was . ( . ) and -day mortality %. mean number of iap measurements was . per day. iah occurred in patients ( . %). only pt ( . %) had none of the studied risk factors, nevertheless % of them still developed iah. of the patients with or more risk factors, only . % developed iah (table ) . objectives. to describe the icu admission of our hospital for serious complications of hematology patients in the last years. compare the characteristics of these patients throughout the study period. analyze mortality and their evolution from their admission to the icu. the evolution of hematologic patients has improved in recent years due to better supportive treatment, sometimes involving the use of specific treatments in the icu. a retrospective study of medical records of all patients with hematologic diseases were admitted to our icu from april until may . we excluded patients admitted for channeling central catheter, diagnostic tests and bone marrow transplants. we selected a total of patients ( % male) with a mean age of years (range - ). the main hematological diagnoses were the most common aml ( %), acute lymphatic leukemia ( %), lymphoma (non-hodgkin's lymphoma) ( %), coagulopathy ( %), myelodysplastic syndrome ( %) and myeloma multiple ( %). the principal reason for admission in the unit were: acute respiratory failure ( %), followed by sepsis ( %) and less cns and cardiac problems ( and %) respectively. as important risk factors of neutropenia and peripheral blood stem cells after transplantation. the icu mortality reached . %. the average stay was . days. conclusions. the transfer to the icu allows a high percentage of hematological patients survive severe complications and the benefit continues after discharge. the mortality of icu patients in our series has not changed over the past years, keeping both the characteristics of patients transferred. the consensus among the services of hematology and intensive care is essential to select and treat the best candidates to benefit from support in the icu and to improve current survival results. a retrospective (from to ) and prospective (from to ) analysis of obstetric patients (pregnant or postpartum admissions) admitted in our ccd was performed. results are expressed as mean (standard deviation) or frequency (percentage). chi and t student tests were used for statistical analysis according to the different variables (spss . , inc. chicago, il), accepting a p-value . as significant. results. obstetric patients were included. mean maternal age was . ( . ) years and mean gestational age was . ( ) weeks. apache ii score was . ( ) . ( . %) patients were admitted to ccd due to an obstetric cause. the main diagnosis of this group were thrombotic microangiopathies ( . %) and hemorrhagic shock ( . %). thrombotic microangiopathy included ( %) eclampsia-preeclampsia, ( %) acute fatty liver, ( %) hellp syndrome and ( %) ptt-shu. in the remaining . % ( patients) the main reason for ccd admission not related to the pregnancy was respiratory failure ( . %). from the whole population included, patients ( . %) required mechanical ventilation (mv) with a mean duration of . ( . ) days. furthermore, ( . %) patients required surgical intervention ( . % hysterectomy). the ending of pregnancy was made in patients ( . %), most cases by caesarean . % ( patients). mean length of stay in ccd was . ( . ) days. maternal mortality was . % ( patients), basically in the non-obstetric group ( vs. ) . conclusions. this is a large series of young obstetric critically ill patients with a low mortality. however, a non-depreciable part of the population included presented important morbidity. objectives. to identify the association of co-morbidities with mortality. methods. retrospective analysis of clinical process of diagnosing patients with severe sepsis/septic shock admitted to the intensive care unit (icu) in the period of november to october . we collected demographic data, co-morbidities, and mortality in the icu hospitalization. statistical tests used were student's t and chi-square. we analyzed patients admitted with this diagnosis, median age of years and females . %. in . % ( patients) appear co-morbidities, distributed as follows: hypertension . %, . % diabetes mellitus, cerebrovascular disease . %, . % chronic kidney disease; . % neoplasic disease and chronic obstructive pulmonary disease . %. the mean age ( . , p \ . ) was higher in this group. the overall mortality in the icu was . % that has not increased significantly to . % in the group with comorbidities, and the overall in-hospital mortality was . % and rise significantly to . % (p \ . ). conclusions. in our study, around - patients had co-morbidities and these facts and the age were those who contributed to higher mortality. the factors of greatest weight are those related to metabolic disease. the characterization of chronic illness in the icu is important in future larger epidemiological studies to better characterize this group of patients and the factors predictive of mortality to decrease the suffering of the patient and plan for admission to intensive care units. one year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. introduction. despite the advances in respect to the development of objective criteria for admission of patients with hematologic malignancies to intensive care unit (icu), no evidence exists that they contributed to a reduction in the mortality, which depends from the aggressiveness of the cancer itself, its complications and even as a consequence of therapy. since the decision to admit one of these patients in icus involves a complex decision-making process, it becomes imperative to identify predictors that may help the clinician to discriminate the patients who may benefit from intensive care than those in which intensive care will be associated with just a prolongation of an agony. objectives.: to identify early prognostic factors in the admission of patients with hematological malignancy, admitted in the icu of a central university hospital. analysis of data prospectively collected and registered in a database of patients with hematological malignancy, admitted to the icu between january and december . we collected for each patient demographic and clinical data (age, sex, length of stay, origin, previous treatment, stage of disease at admission, type of malignancy and aggressiveness, organ dysfunction at admission, co-morbidities, reason of admission), general severity scores (saps ii and apache ii) and organ dysfunction scores (sofa at admission to the icu, maximum sofa score and delta sofa). specific variables were correlated with mortality at the icu and hospital discharge. results. patients ( males and females) fulfilled the inclusion criteria. the average age was ± . years ( - years). the type of hematological malignancy was acute leukemia ( . %), multiple myeloma ( . %), myelodysplastic syndrome ( . %), chronic leukemia ( . %), low grade non-hodgkin lymphoma ( . %), high grade non-hodgkin lymphoma ( . %). the average length of stay in the hospital was . ± . days. most patients were admitted from the department of hemato-oncology ward of the hospital ( . %), . % of the emergency department and . % of another hospital. the icu mortality was . %, with a corresponding hospital mortality of . %. the discriminative capacity of the severity scores, as assessed by the area under the roc curve (aroc) was . for saps ii and . for apache ii. for the delta sofa calculated for each organ dysfunction, progression of respiratory dysfunction/failure and cardiovascular failure demonstrated the best discriminative power (aroc of . ). conclusions. none of the variables showed a statistically acceptable relationship with icu or hospital mortality. the general severity indices saps ii and apache ii demonstrated a better discriminative power than the multiple organ failure scores. however, in this group of patients,it is still difficult to know objectively what factor or combination of factors may be useful in deciding the admission of the patient in an icu. recently due to new developments in interventional gastroenterology and new therapeutic options for treatment, gastroenterological and hepatological (geh) admissions to acute care settings has been decreased. for general intensive care units (icu) gastroenterological and hepatological (geh) diseases consititutes the minority of icu admissions. so we planned to find the incidence and clinical course of admissions due to geh complaints in a medical icu. objectives. main objective is to analyze clinical and epidemiological features of patients admitted to icu with geh disorders. other objectives are to analyze the mortality rate and the factors contributing mortality in these patients. and who stayed for more than h were included. the prospectively developed data including demographics, prognostic scores and clinical features of patients were analyzed retrospectively. patients with geh disorders consituted % of patients admitted to icu. one hundred thirthythree patients with an age of [ - ] years and gender of % male were included. more than half of these patients ( %) did not have any chronic geh disease. the patients were admitted most often from the emergency department ( %). the most frequent admission diagnosis was gastrointestinal bleeding ( %) followed by hepatic diseases including hepatic failure and acute hepatic encepahalopathy, biliary tract infection ( %), pancreatitis ( %) and enteric diseases including massive diarrhea and bowel obstruction ( %). on admission median apache ii and glasgow coma scores were [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , respectively. acute kidney injury (defined by rifle criteria risc, injury or failure) was found in (% ) patients. the most common rifle class was class failure ( %). during icu stay patients ( %) needed renal replacement therapy and patients ( %) received mechanical ventilation. nosocomial infection developed in ( %) patients and icu aqıired severe sepsis occured in ( %) patients. icu and hospital mortality were % and % respectively. length of icu and hospital stays were [ ] [ ] [ ] [ ] [ ] [ ] and [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] days respectively. respiratory failure requiring mechanical ventilation, acute renal failure on admission and severe sepsis in the icu were found to be the independent factors determining mortality in these patients (p = . , p = . and p = . respectively). patients with geh constitued % of patients admitted to icu. they usually do not have any chronic geh disease. gastrointestinal bleeding is the most frequent admission diagnosis. respiratuar and renal failure on admission and severe sepsis occured in the icu are the major determinats of mortality in these patients. introduction. in recent years described series with hematological patients in icu, but these studies are often limited because they are retrospective, single center in a few patients divided over many years. to determine the characteristics of mortality in this group is very important to assess their management in the icu. objective. to analyze prognostic factors associated with icu mortality of patients (pts) with hematologic malignancies admitted to the intensive care unit (ptu). method. an observational, transversal, prospective, multicenter oct conducted between june and october . we conducted a descriptive analysis, chi-square, bivariate and logistic regression including variables with a value of p \ . with the sas statistical pauet to assess the factors influencing mortality in icu. we included patients from icus. the mean age was years. the apache ii at admission was . ± . ) and the first day sofa ± . . ( . - . ). the crude mortality icu was . % ( pts). we divide related mortality by infectious etiology ( %) versus other causes ( %). in univariate analysis the variables significantly associated with mortality were: males p \ . , hematology plant from . , . multiple myeloma, respiratory failure at admission . , tachycardia, . , . hypothermia, tachypnea , apache ii c , more than two organ failures . , presence of ards \ . , invasive mechanical ventilation (imv) \ . , niv . , . transfusion (of all products: red cells, platelets and plasma), acquisition intrauci infection . , days longer stay in icu . . the presence of neutropenia was not associated (p = . ) at a significantly higher mortality, or personal history, septic shock, bone marrow transplant or other reasons for admission to the icu. table describe the independent factors associated with mortality in logistic regression analysis. variables classics such as septic shock or neutropenia not associated with mortality. and the independent variables associated with increased icu mortality were: vm, ards, severity and need for transfusion of blood products. results. patients were identified. major haematology diagnoses were acute leukaemia %, nhl % and lymphoma %. mean time to icu admission was . days with % admitted within h. the commonest reasons for icu admission were respiratory failure %, sepsis % and acute renal failure %. the mean number of organs supported was . . % of patients had c organ failure. mean apache ii score was . . increasing organ failure correlated with increasing mortality. patients with or organ failure had % mortality. mean icu stay was days with % having an icu stay of less than h. icu mortality rate was . %. . % received invasive ventilation, . % failed non-invasive ventilation (niv) and required invasive ventilation, . % had niv only and % received no respiratory support. vasoactive support was given to . % and rrt to . %. invasive ventilation and niv were associated with a higher mortality; and % versus % in spontaneously ventilating patients. vasoactive support was associated with more organ failure, longer icu stay and higher mortality. rrt was associated with a higher mortality versus %. patients with a documented poor haematological prognosis had a higher mortality but also more organs supported. conclusions. from this study invasive ventilation, cardiovascular support and multiorgan failure are strongly associated with increased mortality. the need for rrt was not an independent predictor of mortality. close collaboration is needed between the specialities to allow early resuscitation and critical care support to avoid delayed admissions with multi organ failure. introduction. the prescription of stress ulcer prophylaxis (sup) in critically ill patients is relatively commonplace due to the association between physiological stress and gastrointestinal (g.i.) bleeding. however, recent guidelines recommend that only patients who are mechanically ventilated, and/or have a coagulopathy warrant prophylaxis. they also state that histamine receptor blockers (h rb's) can be used primarily for sup ( ). objectives. the aim of this audit was to compare prescription practice of sup at the itu/hdu at mayday hospital with those set out in the guidelines and to calculate the potential cost savings resulting from following these guidelines. methods. data prospectively collected from consecutive admissions to mayday hospital itu/hdu between october and november . . data was collected on patients, had a g.i. bleed on admission, and were already on sup so were excluded. of ( %) patients with major risk factors were prescribed sup, compared with of ( %) patients with no major risk factors. proton pump inhibitors (ppi's) were prescribed preferentially to h rb's; versus . the cost of sup during the audit period was £ , . if we had only prescribed it to those at high risk the cost would have been £ , . , and if we had only used h rb's the cost would have been £ . . prescribing of sup in our unit does not reflect quenot's guidelines. this not only represents an increased cost but there are increased rates of nosocomial pneumonia and c. difficile diarrhoea associated with sup ( , ) . there is little evidence showing the superiority of ppi's over h rbs in the prophylaxis of bleeds; and there is evidence of an increased rate of the aforementioned infections with ppi's as compared to h rb's ( ). we prescribed ppi's to a significant majority of our patients; however, it is our opinion that our current unit practice is not dissimilar to that of the rest of the uk. we would encourage all critical care units to review their sup prescribing as our results show that significant savings can be made with judicious prescription of these drugs. . surprisingly little is published on the cost of drug treatment for critically ill patients. critical care is expensive, mainly due to the high staff ratio, expensive equipment but also due to a significant reliance on pharmacological management, which is usually funded with a limited drug budget. objectives. to explore the relationship between drug expenditure, patient acuity and outcome. methods. data was generated by retrospective analysis of consecutive patients admitted to our bedded general adult icu/hdu in a london teaching hospital, during february . patients were excluded from analysis if they were present in icu for less than h. the first and final ccu days stay were not included so that only full days were analysed. daily drug-use per patient was manually extracted from the computerized icu management system (cis, qs, ge medical). costs of prescribed drugs, fluids and parenteral nutrition (pn) were calculated from the pharmacy computer system and analyzed using regression analysis (spss ver ). results. the patient characteristics and outcomes of the patients are described in table table patient characteristics and outcomes age ( - )* gender (male n and %) ( %) apache ii score . ( . )** tiss score/patient . ( . )** length of ccu stay (days) ( - )* ccu survival (n and %) ( . %) daily drug cost for each patient's stay £ . (£ . - . )* daily drug cost for ccu and hospital survivors n = £ . ( . - . )* daily drug cost for ccu survivors who died in hospital n = £ . ( . - . )* daily drug cost for ccu non-survivors n = £ . ( . - . )* *median (interquartile range), **mean (standard deviation) the median daily drug cost was £ . . of note, the drug cost was highest for ccu nonsurvivors compared with survivors and also compared with patients who died in hospital after ccu discharge (p = . ). multivariate regression analysis demonstrated that median daily drug cost/patient = - . + . (mean tiss score) + . (apache ii score), r = . %; i.e median daily drug cost/patient was positively associated with tiss and apache ii score explaining % of the variation in cost seen. conclusions. this is the first study to show that daily drug expenditure in all general ccu adult patients correlates with patient acuity. median daily drug costs/patient were found to be £ . . this parameter would make an interesting comparison with other units both nationally and internationally. daily drug costs can be predicted on the basis of apache ii and tiss scores. furthermore, this may be further refined to develop a quality marker of daily drug cost in relation to survivors and non-survivors. material, methods and results. all patients admitted to the icu of neurotrauma, which underwent a tracheostomy after admission. data were collected: affiliation, cause of admission, average stay, indication of tracheostomy, tracheostomy time delay from its indication, place of performance of the procedure (icu or operating room), perioperative complications (event during transfer to operating room, event during surgery: hypoxia, hypotension, arrhythmia, bleeding, premature extubation, false cannulation, cardiac arrest, pneumothorax or death), and postoperative complications in the first week (bleeding, difficulty in changing cannula, stomal infection, pneumothorax, death conclusions. tracheostomie is a simple surgical technique and . % of tracheostomíes could be safely performed in the icu, saving hours of scheduled interventions in the operating room. there were no serious event during the transfer to the operating room or during the performance of tracheostomy. tracheostomized patients in icu, had a higher incidence of hypotension during surgery, although this complication in any case was serious or required treatment with vasoactive amines. when the tracheostomy is performed in the operating room, the delay shows a tendency to be higher, although this difference is not ss introduction. the concept of tight glyceamic control in critically ill has led to the rise of number of insulin infusion protocols designed to keep the blood sugar (bs) in predefined range. at the same time monitoring practices and patients populations vary greatly between intensive care units and thus so do the results. the matter is complicated by the absence of a widely agreed common glyceamic control indicators against which protocols can be evaluated and compared ( ). to establish the quality of glyceamic control in two different intensive care units. to compare the quality of glyceamic control between two intensive care units, with different glyceamic protocols and blood sugar measurement practices. we conducted retrospective non-randomized population study comparing quality of glyceamic control in two independent and non-related intensive care units. time spend in pre-defined glyceamic range was chosen as a quality indicator for both units ( , ) . data was collected from the electronic database and point of care bs measuring devices. the frequency distribution was analyzed to establish the patient-to-patient variability and a degree of bs deviation from the target value. results. units were different in method of sampling, frequency of sampling, target for optimal glyceamic range and instigated insulin protocol. data was collected on patients ( , bs measurement) in itu and patients ( , bs measurements) in itu . mean bs was . (sd = . ) mmol/l in itu and . (sd = . ) mmol/l in itu . conclusions. the performance of both protocols were satisfactory- . and . % of the time patients spend with bs less than mmol/l in itu and itu respectively. the quality of glyceamic control on both itus is similar in terms of proportion of time spend in different glyceamic bands, with the exception of the longer time spend in a hyperglyceamic state in itu . this study confirms the notion for a need of unified approach for evaluating quality of glyceamic control for in-patient populations. with an icu mortality of . % and in-hospital mortality of . %. the median transfusion threshold was a platelet count of /l with yearly medians ranging from . /l to /l. the % of platelet transfusions complying with bcsh guidelines increased from . to . % during the year study period. the specialties with the highest platelet requirement were general surgery ( . %), haematology ( . %) and general medicine ( . %) as a % of total units transfused. the yearly median threshold for haematology patients fell from . /l in to x /l in , increasing guideline compliance from . introduction. numerous protocols (e.g. glycaemic control, hhh, renal rescue) have been introduced into icu. these protocols involve blood sampling to assess gases, haemoglobin, glucose and electrolytes. this may result in anaemia and subsequent transfusion and adverse clinical outcome ( , ) . reducing blood loss due to sampling is an important blood conservation strategy ( ) . currently, our icu processes over , blood samples per month. objectives. to study the indications for blood gas sampling in our icu and identify strategies to reduce sampling. methods. we performed a prospective, observational study over week in . the nurses completed a questionnaire per shift per patient to assess the primary and any secondary reasons for each sample. subsequent management changes, haemoglobin levels, active bleeding, and transfusion were also recorded. results. blood samples from patients and questionnaires were analysed ( % of the nursing shifts). the range was - samples per patient per h shift with a mean of . the secondary reasons showed that many samples were also being used for potassium ( %) and glucose ( %) monitoring. only % of samples changed management (potassium %, ventilatory settings %, glucose %). haemoglobin levels dropped by an average of g/dl per week per patient with no active bleeding. units of blood were transfused during the study period. conclusions. our study shows that reasons for sampling are often relatively weak and sampling is promoted by icu protocols. frequent sampling does not change management for a large proportion of samples and may cause anaemia. there are financial implications to frequent sampling-at the time of the study each sample cost £ . (€ . ) to process. each unit of blood transfused cost £ (€ ). we have considered ways to reduce sampling including changing the glucose protocol to capillary sampling, using ml syringes, increased use of end tidal co monitoring, protocol redesign and education of staff. reference(s it has been reported that tight glyceamic control is associated with net savings in terms of length of stay on the itu and critical care bed occupancy ( ) . whilst it might be true for the overall length of stay, there is as yet, an un-quantified effect of frequent blood sugar measurement on the overall available nurse-patient time ( ) . there is finite amount of nurse-patient time within any given shift and so prioritizing nursing care will be an important factor in critically ill and high dependency patients. this is specifically important for any saving to be realized from the introduction of automated blood sugar measurement devices ( ). objectives. to quantify the amount of nursing time devoted to glyceamic control on itu or post-operative critical care environment based on data from four cohort studies on quality of glyceamic control in three intensive care units. a mathematical model, which takes into account frequency of blood sugar measurements and time to take each measurement was developed. stochastic analysis was used to calculate interdependency between quality of glyceamic control and the frequency of blood sugar measurements. introduction. introduction of trans-catheter aortic valve implantation (tavi) has been the latest technological advance in minimizing surgical stress and improving the chances of high-risk patient undergoing a successful aortic valve intervention ( ) . the latest technology comes at considerable cost, which relates to both-the cost of the tavi valve and to it's delivery system. currently, there are no randomized controlled trails addressing the issue of cost-effectiveness of tavi versus surgical avr ( ) . to build a cost-effectiveness model for patients undergoing either a tavi procedure or a surgical avr based on the level of care: level (ward based care), level (high dependency unit) and level (intensive care unit) during in-hospital stay, taking into account the rate of post-operative complications in both groups. methods. tavi patients were matched against patients who had previously undergone surgical avr. the groups were matched for demographic and physiological risk factors, as well as euroscore. a decision analytical tree was constructed based on the length of stay in hospital and post-operative complications. a markov model was built and the effectiveness was measured in terms of improvement in nyha class, which was translated into the quality adjusted life years (qaly) ( ) . results. the average in-hospital cost for tavi was £ , versus £ , for the surgical avr. the cost did not include the theatre time cost. in the surgical avr group the in-patient mean cost was greater than respective cost of the tavi group due to longer overall length of stay as in-patients. patients in the avr group spent more days in level and level care as compared to the tavi group. conclusions. the shorter length of stay and reduced rate of post-operative complications in the tavi group has got the potential to substantially reduce the overall in-patient cost and offset high cost of the valve. the effectiveness arm of the models did not differ for both groups, due to the lack of published literature, and raises a need for a qaly assessment for the effectiveness of tavi. the rate of post-operative complications in surgical avr group (higher rate of stroke and need for cardiac pacemaker) substantially affected the projected long-term cost. objectives. to determine if interventions for permanent pacing (ppm) and change of generator are more efficient in small hospitals. retrospective, transversal, observational study, measured through five diagnosis related groups (drg) that make up the casemix of pacemakers from the spanish minimum basic data set in , descriptively analyzing demographic variables (age, gender), clinical (number of secondary diagnoses (nsd) and procedures (np), mortality) and management (total, preoperative length of stay, access, discharge, hospital size), defining inefficient stays exceeding days the average. a bivariate study contrasting quantitative variables and comparisons between nominal and categorical, evaluating the independent association between short stay and different covariates studied building a binary logistic regression model, introducing as independent variables those that were significant in the bivariate as well as those considered that might be associated with the dependent variable. introduction. blood products are in short supply and with an ageing population the demand is likely to increase. blood use has been shown to be declining within the surgical specialties and intensive care, however overall use has remained unchanged. this audit looks at the use of packed red cells amonsgst medical inpatients to determine appropriateness. to determine if red cell use is appropraite among medical inpatients methods. medical blood transfusions were examined between august and august . patients were selected and pre and post transfusion haemoglobins were determined along with chronicity of anaemia. transfusions with haemoglobins of c . g/dl triggered a case note review. over months , patients were transfused , units. , units ( %) were given to medical patients ( %), of which patients were reviewed receiving transfusions. average age was . in patients pre transfusion haemoglobin was b g/dl ( %) and in patients c . g/dl ( %). in the group b g/dl patients had acute anaemia and had chronic anaemia. in the group c . g/dl patients had acute anaemia and had chronic anaemia. patients were not transfused and had absent data. out of case notes only were available. patients were transfused for acute anaemia, for chronic anaemia of which patients had cardiac disease, had haematological disorders, patients had iron deficiency anaemia and patient was folate deficient. conclusions. chronic anaemia in the over s accounted for the majority of transfusions. documentation was substandard. transfusions in chronic anaemia may be reduced by up-to-date guidance on transfusion triggers and alternative strategies to the use of blood products. ( ) results. the commonest indication for pct was long-term mechanical ventilation ( %) followed by airway protection ( . %). . % patients had platelets count\ lac while . % had severe thrombocytopenia (\ , ). . % patients had an additional coagulopathy (hepatic failure and multiple organ failure), with inr [ . was present in . % and deranged aptt in . % patients. pct was safely performed in all these patients. the patients received platelets or fresh frozen plasma(ffp) before the procedure to optimize coagulation. only . % had minor bleed through stoma, which was stopped in - min requiring gauze compression. conclusions. pct under videobronchoscopic guidance has low haemorrhagic complication rate in patients with deranged coagulation profile. platelets/ffp should be transfused before the procedure in these patients. introduction. blood components transfusion is common in the critically ill patient, as in the acute bleeding or the acute illness with multiorganic failure context. as any medical intervention, it has clinical indications and associated risks. clinical guidelines have evolved in a restrictive direction, suggesting that decision should be based on particular clinical situation and not only on analytical results. objectives. understand our transfusional practice and how close it is to clinical recommendations, as a quality indicator of our intensive care unit (icu). retrospective study using the icu patients data base. the population consists of patients with more than h icu stay in . the variables analysed are sex, age, diagnostic class (medical, surgical, trauma), saps ii score, mortality, number of transfusional events (erithrocyte concentrate, platelets, fresh frozen plasma and albumin) and the concordance to our hospital clinical guidelines. results. the population is of patients, % of male gender, with an average age of years-old. the admission diagnostic is medical in % of patients, with an average saps ii score of , median icu stay of days and a mortality rate of %. % (n = ) of patients received any kind of blood component transfusion, mostly erithrocyte concentrate ( % of patients), followed by albumin ( %). the populations of transfused patients is older ( vs. years-old), has a longer icu stay ( vs. days), higher saps ii score ( vs. ) and mortality rate ( . vs. . %) . pretransfusional values are hemoglobin of . g/dl, , platelets/ul, and albumin of . g/dl. the level of concordance with recommendations is high for erithrocyte concentrate ( %), platelets ( %) and fresh frozen plasma ( %) but not for albumin ( %). conclusions. the level of transfusion is high in icu patients. the population who received transfusion has a more severe clinical condition and higher mortality rate. the level of concordance with recommendations is high with the exception of albumin, which use is still less standardized. with increasing acuity due to escalating icu bed demand, but the impact on patient safety is unclear. sdu continuous non-invasive physiologic monitoring of hr, rr, bp and spo identifies cardio-respiratory instability often unnoticed by caregivers. causes may be alarm fatigue and/or high sdu nurse-to-patient ratios which make bedside monitoring insensitive. instability may become more resistant to intervention the longer it occurs. the impact of instability duration upon sdu patient outcomes is understudied. objectives. the study purpose was to determine the impact of cardiorespiratory instability duration experienced by in-patients being cared for on a monitored sdu upon hospital length of stay (los) and hospital charges. prospective study of monitored patients on a -bed trauma sdu over weeks. noninvasive continuous monitoring data were downloaded from bedside monitors and analyzed for vital signs (vs) beyond local instability criteria: hr\ or [ , rr\ or [ , systolic bp \ or [ , diastolic bp [ , spo \ % . vs time plots of unstable patients were further assessed to judge instability as mild or serious. instability duration categorized as: none, [ ] [ ] [ ] [ ] [ ] [$ k) . relationships between instability duration and outcomes analyzed with chi-square for mild and serious instability. conclusions. there has been a marked improvement in the overall recording of sews since the previous study. it is of concern that respiratory rate was again the least well recorded parameter as this has been shown to be the best physiological predictor of impending cardiopulmonary arrest , . this may be because respiratory rate is not provided by the automated monitoring devices available on the general wards in our hospital, and must be calculated manually. it demonstrated an increase in mortality even when tiss scores were taken into account as an independent risk factor. since these publications critical care outreach and the use of early warning scores have become common place; however it was felt that time of discharge was still impacting on patient outcome. to review our post-unit mortality and readmission rate, with particular focus on the time of discharge. conclusions. our mortality and readmission data compare favourably with a recent publication. there is a clear difference in mortality related to time of discharge; however this is for evening discharges as compared to night discharges in previous papers. [ ] [ ] [ ] [ ] the time of discharge may represent logistical issues of planned discharges or early discharge decisions due to pressure for beds. overnight discharge is an uncommon occurrence in our unit; this evidence suggests that previous concern about night discharges should be extended to evening discharges. transferring critically ill patients is a challenging task in the day to day activities of the critical care team. safe accomplishment of these transfers relies on skills of the persons accompanying and the resources available. guidelines have been produced by various professional bodies [ , ] to safely accomplish these transfers. the competency document released by the royal college of anaesthetists, uk requires that junior trainees have appropriate knowledge, skills, attitude and behaviour in the principles of safe transfer of critically ill patients [ , ] . to obtain information about trainee's perspective, experience and knowledge in transfer of critically ill. a web based online survey was sent to all the anaesthetic/itu trainees in the west midlands region of the uk. results. total number of respondents were . of these, . % had less than months of anaesthetic training before undertaking a transfer. only % had formal training on transfer of critically ill patients. % of the trainee's didn't have any competency based formal assessment of their skills, attitudes and behaviour in transfer of critically ill patients. majority of them ( %) felt that every one should undergo formal training before undertaking transfers. while % of the respondents have undertaken transfers during their training, only % have experienced some form of critical incident during these transfers. more than % of these adverse events were related to equipment failures while % were due to patient deterioration. nearly % of the trainees were not aware of terms and conditions of the insurance cover for these transfers. conclusions. this survey highlights the deficiencies involved in training the trainee's for transfer and the transfer itself. the results demonstrates that majority of the trainees would prefer to attend specific transfer courses before venturing out on an actual transfer. we hence recommended the following for implementation: improvement of training process for those undertaking transfers; regular monitoring of this process; regular analysis of critical incidents and acting upon it; making the insurance compulsory for those undertaking the transfers. greek hospitals, including initial management of critically ill patients and primary care for a growing proportion of the population. the impact of ed length of stay (los) on patient outcome has not been covered adequately by existing surveys so far. objectives. the aim of this study was to determine the association between ed overcrowding and outcomes for critically ill patients. in the present study, we included medical and surgical pts that all of them were intubated promptly to ed of general hospitals of athens gr, for months. pts survived [ h were divided into groups: ed boarding \ h (group a) and ed boarding c h (group b). demographics, apache ii, diagnosis, los, and icu and hospital mortality were recorded. ed boarding time was measured in min. groups were compared using chi-square, mann-whitney, unpaired student's t tests and stepwise regression analysis. the collection of data lasted months. results. in the ed, critically ill patients with a mean age . ± . years and apache ii score . ± . were intubated. pts were males and were females with a mean age . ± . and . ± . years, and apache ii score . ± . and . ± . respectively. main diagnosis was multi trauma ( ) objectives. we sought to assess the baseline characteristics and outcomes of the patients presenting af as a cause of met call activation. using the met database of one tertiary teaching hospital, we retrospectively reviewed all patients for which the met diagnosis was atrial fibrillation. we reviewed their clinical history, immediate treatment and outcome. these data were compared to those of a control group of randomly selected met calls with patients being matched for age, gender and ward of origin (surgical or medical). objectives. to ascertain the proportion of preventable in-hospital cardiac arrests occurring at university hospital lewisham. furthermore, to identify any common predictors of poor outcome that were apparent prior to those arrests and whether these are potentially modifiable. a case note review was performed on the cohort of patients who suffered inpatient cardiac arrests and who were admitted for icu (level- ) care post-resuscitation. these patients were identified using our quarterly feedback from the intensive care national audit and research centre (icnarc) case mix program dataset between april and september . we found that half ( out of ) of our in hospital cardiac arrests resulted in death despite level- care post arrest within the audit period. of these in-hospital arrests were deemed preventable from case note review and trust cardiac arrest call audit forms when available. in addition, in the preventable sub-group an arterial blood gas sample was not obtained in out of , %. in all of these cases, the icu outreach team was not aware of the patient prior to the arrest. conclusions. in keeping with widely published data regarding survival to discharge after in-hospital cardiac arrest, the high mortality rate of % for this cohort of patients emphasises the importance of early recognition of abnormal physiology and timely intervention. with the sensitivity, specificity and validity of ews yet to be validated and no clear benefit proved from the introduction of met/outreach teams, an alternative strategy for earlier recognition of critically ill patients is needed. our data suggests that arterial blood gas sampling, an essential investigation central to the recognition of critically ill patients is being consistently overlooked and is an important factor influencing outcome. results. attended patients were , , with mean age of , years, and women represent , % of them. most demanding services were internal medicine ( %) followed by general surgery, haematology and nephrology. global data may be seen in table . with regards to admissions to the icu of these patients, table depicts the proportion between requested admissions, and refusals. introduction. tradicionally, critical care interventions are highly intensive, expensive and brief. critical illnesses and interventions that we use, can both contribute to posticu disability: catheter-related bacteraemia, polineuropathy, resistant organism, nutricional problems, complications of tracheostomy, prolonged analgesic. all these factors and a premature discharge from an ever full icu, can even have an impact on occult mortality after discharge from icu (between and %). in our unit a follow up program have been implanted. when patients are about to be discharged from icu, icu clinicians selected those considered to be recoverable but fragile enough to have poor prognosis. objectives. to quantify the workload that a after icu follow-up entails, and to determine if this program impacts on mortality posticu. prospective and interventional study carried out during a months period. at a beds medical uci of a teaching hospital in malaga icu, patients were enrolled in the follow up program. we assessed prognosis with sabadell score and severity of illness with apache ii score; and registered our interventions after discharge from icu. the final endpoint was status at hospital discharge: survivant or dead. we did interventions in patients: we changed a venous catheter ocasions ( % of patients), changed analgesic schedule times ( . %), stopped antibiotics times ( %), modified parenteral nutrition times ( %) . we searched and treated sources of sleep deprivation (delirium, anxiety or insomnio) in patients ( %); treated tracheostomy complications in patients. mortality of patients enrolled in this program was . % ( patients) even if the mean expected mortality by apache ii score was [ %. conclusions. in our study, implementation of a continued follow-up program after icu discharge in selected patients, carried out by icu staff, was associated with an important decrease of mortality. encouraging clinical results and a non-excesive workload for icu staff justify continuing this follow-up. objectives. various therapeutic protocols were used for the management of sepsis including hyperbaric oxygene (hbo) therapy. it has been shown that ozone therapy (ot) reduced inflammation in several entities and exhibits some similarity with hbo in regard to mechanisms of action. thus, we designed a study to evaluate the efficacy of ot in an experimental rat model of sepsis and to compare these effects with hbo. methods. forty male wistar albino rats were divided into sham, sepsis+cefepime (control), sepsis+cefepime+hbo (hbo), and sepsis+cefepime+ot (ot) groups. sepsis was induced by an intraperitoneal injection of . cfu escherichia coli; hbo was administered twice daily at . -atm pressure for min; ot was set as intraperitoneal injections of . -mg/kg ozone/oxygen gas mixture once a day. the treatments were continued for days after the induction of sepsis. at the end of experiment the lung tissues and blood samples of the study animals were harvested for biochemical and histopathologic analyses. results. lung tissue myeleperoxidase activities and oxidative stress parameters, and serum proinflammatory cytokine levels, il- b and tnf-a, were found to be ameliorated by the adjuvant use of hbo and ot when compared with the antibiotherapy alone group. histopathologic evaluation of the lung tissue samples confirmed the biochemical outcome. some measures indicated significantly more efficacy of ot than hbo. conclusions. our data presented that both hbo and ot reduced inflammation and injury in the septic rats' lungs; a greater benefit was obtained for ot. these findings suggest that it may be possible to improve the outcome of sepsis by using ot as an adjuvant therapy. objectives. to investigate the regularity for change of paf, tm and vwf in septic rat, and the protective effects of statins on vascular endothelium. methods. fifty-four male sd rats were randomized into simvastatin with lps group (group a, n = ) and lps group (group b, n = ) and control group(n = ). they were respectively accepted ml/kg normal saline (ns) abdominal injection for both control group and group b, ml/kg simvastatin abdominal injection for group a, then h later, total male sd rats from group a and group b were respectively accepted lps ( mg/kg weight) abdominal injection to establish sepsis model and ml/kg ns abdominal injection for control group. thereafter, detected the serum concentration of von willebrand factor (vwf), thrombomodulin(tm) and antithrombin (at-iii) at different point of time ( , , and h after lps abdominal injection) in both group a and group b by elisa, the endothelial cells from thoracic aorta was observed with electron microscope. under electron microscope scanning, endothelial cells in septic rats from group b were found disarranged. under transmission electron microscope, endothelial cells were found to be in prophase of apoptosis characterized by unclear cell membrane, thickened cellcell conjunction, disappeared desmosome and microfilament, dissolved or vacuolized organelles and agglutinated and evaporated chromatin gathering under the karyolemma, but the karyorrhexis were not found. no similar changes were found in group a. ( ) introduction. sepsis induced lymphocyte apoptosis is believed to play an important role in the pathogenesis of sepsis and in the development of the immunesuppresion observed in septic patients. lymphocyte apoptosis not only decreases the number of functional lymphocytes but may also modify the immune response towards an anti-inflammatory state. erythropoietin (epo) has recently been recognized as a multifunctional cytokine with antiinflammatory, antioxidative, and antiapoptotic properties. objectives. this study aimed to test whether epo could mitigate peripheral blood mononuclear cell (pbmc) apoptosis and whether epo could modify the dynamic changes in lymphocyte-subsets in a porcine model of acute endotoxemia. methods. twenty-eight anesthetized and mechanical ventilated pigs were randomized to one of three groups: ) epo group, epo administered h prior to endotoxemia (n = ); ) placebo group, vehicle administered h prior to endotoxemia (n = ); ) sham group, animals only anesthetized and mechanical ventilated. endotoxemia was induced by an infusion of lipopolysaccharide (lps). after h the lps infusion was reduced to a maintenance dose and the animals were fluid resuscitated. pbmc were isolated at time , , , and min of endotoxemia. apoptosis in pbmc and relevant lymphocyte subsets were assessed by staining with -amino-actinomycin d ( aad) and annexin v using multicolor flow cytometry. apoptotic lymphocytes in spleen were quantified by immunohistochemical staining for activated caspase- . endotoxemia increased the number of apoptotic mononuclear cells in both blood (p = . ) and in spleen (p = . ), but with no significant modifying effects of epo. the numbers of both cd + (t-helper) and cd + (cytotoxic) t-cells declined during endotoxemia. cd + cells, defining b-lymphocytes, demonstrated a biphasic response with an immediate decline followed by an increase in number of b-cells. the dynamic changes in the lymphocyte subsets were not modified by epo. , and reduced the number of circulating leucocytes. epo had no modifying effects on these dynamic changes. furthermore, epo did not mitigate apoptosis in pbmcs analyzed by flow cytometry or in spleen lymphocytes analyzed by immunohistochemistry. this study does not support that epo confer protection against lymphocyte apoptosis. objectives. aim of this study was to investigate the effects of combined, recombinant human activated protein c (rhapc) and ceftazidime (cef) in our established model of acute respiratory distress syndrome (ards) and septic shock methods. thirty sheep ( - kg) were operatively prepared for chronic study, and were randomly allocated either to sham, control, rhapc, cef, or rhapc/cef groups (n = each). after tracheostomy, acute lung injury and sepsis was produced in all groups, following an established protocol ( , ) , except the sham group that received the vehicle. the sheep were studied for h in an awake state and were ventilated with % oxygen. pao /fio ratio was determined intermittently. cef ( g) was administered intravenously and h post injury. rhapc was given as a continuous infusion ( mcg/kg/h), starting h post injury. the animals were resuscitated with ringer's lactate solution to maintain filling pressures and hematocrit. lung tissue was obtained during necropsy and analyzed for myeloperoxidase (mpo) using a commercially available kit. statistical analysis: two-way anova and student-newman-keuls post hoc comparison. data are expressed as mean ± sem. significance p \ . . . mpo levels (mu/mg protein) were ± in sham and significantly increased in the control group ( ± *). the rhapc ( ± *) and cef group ( ± *) increased significantly vs. sham and tended to be lower than controls, but not statistically significant. mpo levels of combined rhapc/cef ( ± *) showed no difference to sham, but were significantly lower than controls or rhapc or cef alone. conclusions. combined administration of rhapc and ceftazidime in ards associated with septic shock improved oxygenation more than cef or rhapc alone, and prevented the onset of ards. seleno-compounds, such as sodium selenite (na seo ) show conflicting clinical results in the treatment of sepsis. efficacy, as well as mechanism of action of na seo , are unclear, with prevailing opinion that it acts as an anti-oxidant. however, na seo has also oxidant properties that could have a paradoxical therapeutic role in septic shock by reducing over-activated phagocytic cells. indeed, in septic sheep, high dose na seo injection as bolus rather than continuous administration resulted in a beneficial effect on survival time, macro and microcirculation ( ). objectives. to investigate at the endothelial level the mechanism of action of a bolus injection of a high oxidative dose of na seo . in male wistar rats, lipopolysaccharide (lps, mg/kg) or normal saline were injected intraperitoneally, followed h later by either an intravenous bolus injection of na seo (corresponding to . mg/kg se) or normal saline. after h of lps, extravasation of fluoroisothiocyanate-dextran and leukocyte-endothelium interaction in venules of the cremaster muscle were quantified by intravital microscopy. results. na seo did not alter systemic haemodynamic variables as compared to lps rats. there were no intergroup differences in fluoroisothiocyanate-dextran extravasation. lps significantly decreased leukocyte rolling when compared to control animals (p \ . ). bolus injection of na seo did not alter leukocyte rolling but decreased leukocyte adhesion and extravasation levels to control values. our results in endotoxemic rats suggest that a toxic dose of na seo may have a beneficial effect of on leukocyte-endothelium interaction without a significant effect on plasma extravasation. objectives. to design a model of sepsis in pigs characterized by an unchanged q t over time. methods. after a h fasting, pigs (weight - kg) were sedated with ketamine ( mg/ kg) and midazolam ( . mg/kg) i.m. animals were tracheostomized and anesthetized (propofol mg/kg iv bolus, followed by mg/kg/h), atracurium ( . mg/kg/h) and fentanil ( lg/kg/ h). the internal jugular vein, carotid artery and pulmonary artery were catheterized for iv fluid administration and monitoring. a lumbotomy was performed and an ultrasonic blood flow and a laser-doppler microvascular flow probes were placed in the left renal artery and on the kidney surface to measure renal artery blood flow (rabf) and renal cortical blood flow (rcbf), respectively. a cystostomy was performed to collect and measure urine output (uo). sepsis was induced by the iv administration of live e. coli ( . our previous study showed that citrulline (cit) supplementation during endotoxemia improved microcirculatory flow and endothelial function, and prevented glycocalyx degradation as a consequence of increased arginine (arg)-dependent vascular nitric oxide (no) production. during sepsis the availability of arg, the substrate for endothelial no production, is tempered as a consequence of increased inflammatory no synthase (inos) activity. the reduced endothelial nos (enos) activity and vascular no production is believed to result in endothelial and vascular dysfunction. a shortage of arg availability for enos is considered the main cause of the dysfunction. previous studies have indicated cit as an important, if not exclusive, mediator for enos-derived no production. cit is a substrate for argininosuccinate synthetase, an arg-producing enzyme that co-localizes with enos in the caveolae, thus directly and exclusively supplying arg to enos. objectives. we investigated whether cit supplementation during an ongoing endotoxemia rescues the enos-derived no production in endothelial cells, thereby providing a mechanistic explanation for its positive in vivo effects. mice received a continuous intravenous endotoxin (lps, lg total) infusion for h alone or an h lps infusion with cit ( . mg total) during the last h of endotoxin infusion. after the h infusion, the mice were sacrificed, arterial blood was sampled and the carotid arteries were removed. no production in the carotid arteries was measured ex vivo with -photon fluorescence microscopy, using a fluorescent copper-based no probe. amino-acid concentrations in plasma were measured by hplc. results. both cit and arg plasma concentrations were significantly increased in the lps-cit group compared with mice treated with lps alone (p \ . ). in vivo cit supplementation led to detectable levels of no production ex vivo in carotid smooth muscle cells (smc) and endothelial cells (ec) by using the no-probe with -photon fluorescence microscopy. while ec-derived no production was absent in the carotid arteries of mice treated with only lps, the smc-related no signal was undisturbed. no production in the ec of the lps-cit group was not blocked by the inos inhibitor , w, suggesting enos to be responsible for the observed effect. furthermore, ex vivo incubation of the carotid arteries of the lps-cit mice for min with extra cit ( mg/ml) resulted in prominently increased no production in the carotid ec, whilst this effect was not observed in the carotid arteries of lps without cit treated mice. conclusions. cit supplementation during murine sepsis rescues the enos-derived no production in carotid artery endothelial cells, providing a mechanistic base for the positive effect of cit supplementation on endothelial no synthase during endotoxemia. grant acknowledgment. objectives. investigated the mechanism involved in the clearance of bacteria observed after rpaf-ah treatment in sepsis model. mice were subjected to clp model, after min, the mice were treated with rpaf-ah. the cfu counts and measured of mediators were determined. results. the numbers of bacteria (cfu) recovered in the peritoneal fluid was inhibited in rpaf-ah treated group ( . / . ), suggesting a more efficient clearance of bacteria after rpaf-ah treatment. direct incubation of s. typhimurium, e. coli and s. aureus failed to affect bacterial growth indicating lack of a direct effect of paf-ah on bacteria. administration of rpaf-ah in ccr (receptor for mcp- /ccl ) deficient mice failed to increase bacterial clearance after clp, suggesting that mcp- signaling is involved in this phenomenon. rpaf-ah treatment also failed to increase bacterial clearance in inos deficient mice and no levels were found to be elevated ( . ± . / . ± . ) in peritoneal fluid of the mice treated with rpaf-ah after clp surgery. synergism for no production was also seen when macrophages stimulated with e. coli were treated with rpaf-ah+mcp- and correlated with better bacterial killing by macrophages. peritoneal macrophages from knockout mice for mcp- , stimulated from lps+ifn inhibited no levels when compared to wt mice ( . ± . / . ± . ). this results indicating that, excessive mcp- favors macrophage production of no and hence the ability of macrophages to deal with invading bacteria. conclusions. we conclude that the increase in bacterial clearance is important for the protective effect of rpaf-ah in sepsis and that exist a signaling involving mcp- /ccl and no in this system. introduction. disturbances within the microcirculation represent an important factor in the pathogenesis of multiple organ dysfunction during systemic inflammation and sepsis [ ] . dehydroepiandosterone (dhea) has immunomodulatory effects and improves survival in several animal models of trauma, hemorrhage and sepsis but also causes potent vasodilatation [ ] . to maintain efficient microcirculation we combined dhea with sodium orthovanadate (sov), which augments vascular contraction. furthermore, sov has been identified to attenuate tissue injury and improve survival related to inflammatory response [ ] . objectives. we investigated whether the combined administration of dhea and sov has beneficial effects to microcirculation in experimental sepsis. we divided sixty male lewis rats into six groups: control group; ethanol (solvent) treated control group; dhea ( mg/kg) + ( . mg/kg) treated control group; endotoxemic group (lps mg/kg); dhea + sov treated endotoxemic group; dhea ( mg/ kg) + sov treated endotoxemic group. two hours after lps challenge we performed intravital fluorescence microscopy of the intestinal wall in order to study leukocyte adhesion and functional capillary density (fcd). tnf-a, il- a, il- and infc, gm-csf and mcp were measured at baseline and following h of endotoxemia in all experimental groups. in comparison to untreated rats subjected to endotoxemia the treatment with dhea (both dosages) and sov resulted in a significant reduced number of adhering leukocytes in intestinal submucosal venules. furthermore, the mucosal functional capillary density was significantly improved. we did not identify any changes in cytokine plasma levels. conclusions. the study demonstrated beneficial effects of combined treatment with dhea and sov within the intestinal microcirculation in experimental endotoxemia. concomitant administration of sov permitted to reduce dhea dosage and prevent potential vasodilation without affecting anti-inflammatory dhea action. . spronk pe, zandstra df, ince c: bench-to-bedside review: sepsis is a disease of the microcirculation. crit introduction. sepsis is a disease of the microcirculation and impairment of the intestinal microcirculation during sepsis may cause a breakdown of gut barrier function thus releasing bacteria and their toxins into the systemic circulation [ ] . consequently, the protection of the intestinal microcirculation represents a pivotal therapeutic target in severe systemic inflammation. cannabinoids that interact with cannabinoid receptors (cb r and cb r) have been shown to have immunomodulatory properties in in vivo and in vitro studies and the endocannabinoid system has been shown to be involved during systemic inflammation [ ] . objectives. the aim of the present study was to examine the effects of cb receptor modulation on the intestinal microcirculation in experimental sepsis (endotoxemia) using intravital microscopy (ivm). we studied four groups of animals (lewis rats, n = per group): healthy controls (con), endotoxemic animals ( mg/kg lipopolysaccharide; lps), endotoxemic animals treated with cb agonist, hu ( mg/kg iv), and endotoxemic animals treated with cb antagonist, am ( . mg/kg iv). intravital microscopy of the intestinal microcirculation was performed following h lps/placebo administration. leukocyte adhesion and functional capillary density (fcd) were measured offline in a blinded fashion. results. following h of endotoxemia, a significant increase of leukocyte adhesion in the intestinal submucosal venules (e.g., v venules: con . ± . n/mm , lps . ± . n/mm , p\ . ) was observed. capillary perfusion of the muscular and mucosal layers of the intestinal wall was significantly reduced (e.g., circular muscular layer: con . ± . cm/cm , lps . ± . cm/cm ). treatment of endotoxemic animals with the cb receptor agonist, hu , further increased leukocyte adhesion (v venules: . ± . n/mm ), whereas cb receptor inhibition by am significantly reduced leukocyte activation (v venules: . ± . n/mm ) and restored capillary perfusion (circular muscular layer: . ± . cm/cm ). conclusions. the data support the hypothesis, that cb receptor signalling is involved in the impairment of the intestinal microcirculation during sepsis. blocking cb receptor signalling reduces leukocyte activation and improves capillary perfusion in acute endotoxemia in rats. the long-term effect of modulating cb receptors in more clinical sepsis models needs further investigation. [ ] . this study compares dobutamine and levosimendan for the treatment of circulatory failure in septic shock and assesses survival benefits. objectives. in this controlled randomized doubleblinded study anaesthetized and ventilated pigs ( . ± . kg) were enrolled after approval by the local governmental commission. methods. by continuous infusion of endotoxin (escherichia coli serotype :b , sigma-aldrich; . ± . lg/kg/h) over a time period of . ± . h, septic shock was induced. hemodynamic stabilization was performed by either use of the vasopressor norepinephrine alone (control group; n = ) or in combination with levosimendan ( . lg/kg/min; n = ) or dobutamine ( . lg/ kg/min; n = ). in a setting of h of measurements and treatment heart rate (hr), map, central venous pressure (cvp), pulmonary artery pressure (mpap) and cardiac output (co) were recorded continuously and evaluated hourly. beside norepinephrine requirement and mixed venous oxygen saturation (svo ) mean survival time and survival rate within the measurement period were analysed. results. after endotoxinemia septic shock was marked by reduction of co and svo [p \ . ]. mean survival time and survival rate were superior in levosimendan treated animals ( table ). norepinephrine consumption was lowest in the levosimendan group. after h, co of surviving animals was highest in the levosimendan group and statistically different compared with the control group. comparison of parameters hr, map, cvp and mpap showed no differences between treatments. conclusions. the complementary use of the calcium sensitizer levosimendan provides potential survival advantage in endotoxemic septic shock. beside an increase in co, improvement of regional organ perfusion or protection could be an explanation and has to be shown by further analysis. reference(s methods. the study group consisted of patients with shock on vasopressor support and control group had normotensive patients. arterial and capillary samples were taken simultaneously and were tested immediately at the bedside. the results of the paired measurements were analysed as a scatter plot by bland and altman method and were expressed as a correlation coefficient. values were considered to disagree significantly when the difference exceeded %. results. mean arterial and capillary sugars (mg/dl) in study and control groups were . ± and . ± . , and . ± . and . ± , respectively. on bland-altman analysis, % in study group and % in control group were out of range (acceptable limit \ %) [ figures , ] . correlation between capillary and arterial values was less in the study group (r = . , p . vs. r = . , p \ . ). in addition, the disagreement between capillary and arterial values was more than % in % of the patients in the study group vs. % in control group (p = . ) (iso standard \ %). conclusions. capillary blood glucose monitoring can be applied reliably to patients in icu. however, caution must be exercised in patients with shock in whom arterial blood may be preferred. rd esicm annual congress -barcelona, spain - - october objectives. our primary objective was to evaluate the safety and efficacy of a single oral high dose vitamin d supplementation in an intensive care setting over a one-week observation period. methods. , iu (corresponding to . mg) of cholecalciferol (d) dissolved in ml herbal oil or matched placebo (pbo) were given enterally (via nasogastric feeding tube or swallowed) to patients with vitamin d deficiency [ (oh)d b ng/ml] in the medical icu. results. baseline characteristics including age, sex and saps ii were balanced between the two groups (mean age ± years, % male, saps ii ± ). mean serum (oh)d levels at baseline were ± ng/ml in both groups. the mean serum (oh)d increase in the intervention group was ng/ml (range - ng/ml). two patients showed a small ( ng/ml) or no response ( ng/ml) attributable to gastrointestinal dysfunction after prolonged hypoxia and gastrointestinal gvhd after allogeneic stem cell transplantation. the time course of the (oh)d response is given in figure . introduction. considerable controversy has emerged as to whether tight glucose control (tgc) is warranted in all critically ill adult patients. recently, a new blood glucose upper limit ( mmol/l) has been assessed as more appropriate. rather than blood glucose target ranges, algorithms used to achieve tgc should be numerically evaluated before initiating clinical trials (preclinical validation test). our purpose was to assess performances of tgc algorithms in realistic virtual icu patients. we compared numerically the nice-sugar algorithm (n-s) and the cgao system (cgao) used in the ongoing cgao-rea study [clinicaltrials.gov, id:nct ] . a set of virtual patients constituting the test bench was built with ) real data coming from patients controlled with cgao before starting cgao-rea and ) a non-linear pharmaco-dynamic glucoseinsulin system model where patient endogenous glucose clearance and insulin-sensitivity were time varying parameters. in order to anticipate how algorithms would manage glycaemic control in clinical settings, delayed controls and inaccuracy of glucometers were implemented. the overall performance of each algorithm over the whole stay was assessed according to standard scores. results. the percentage of time in the target range [ . - . mmol/l] with n-s was less than % for almost all patients. in insulin-sensitive patients, glycemic fluctuations and sometimes severe hypoglycemia are induced by n-s (fig. ). the mean time in the target range with cgao was about % and variability scores were significantly lower than with n-s. mean glucose and standard deviations were always lower with cgao than with n-s. a numerical test bench constituted of realistic virtual icu patients, whose features were defined from real data obtained in patients under glycemic control, enabled to determine the best algorithms candidate for further evaluation in clinical settings. according to this approach, the algorithm used to achieve tgc in nice-sugar would not have been selected for such a large clinical trial while cgao reached the first validation step in simulation. we recommend that further glucose control studies focus not only on the target range but also on the algorithmic properties. introduction. there has been much debate in recent years about the appropriate level of blood glucose for intensive care patients with proposals of different levels of glucose control using insulin infusions. one risk of intensive glucose control is hypoglycaemia and this has been proposed as a measure of quality of care given by delivering the protocol safely. the nice-sugar trial found that intensive glucose control increased mortality among adults in intensive care. objectives. the aim of our study was to record hypoglycaemia and study it's relation to insulin therapy. insulin therapy on our unit follows the recommendations of the nice-sugar trial. methods. hypoglycaemia was recorded as a blood glucose level\ mmol/l. levels were detected using the blood gas analyser (radiometer m). data was recorded at the time of hypoglycaemia to provide an explanation using the innovian system which is the paperless patient record system on our unit. data was obtained over a period of months between october and december . data recorded included adverse events which were defined as worsening shock and/or increasing inotropic support. feeding status at the time of hypoglycaemia was recorded. results. there were a total of admissions over this period and there were a total of , blood glucose measurements. incidents of hypoglycaemia were recorded, of which patients were on insulin and were not. of the patients who were on insulin, had adverse events at the time of hypoglycaemia. all these patients died within h of the adverse event. all except one was on full feed. the others had minimal feed due to poor absorption. of the patients who did not have adverse events, were discharged and one died days after the hypoglycaemic event due to worsening sepsis. of the patients on insulin, there were iatrogenic errors where feeding was stopped and the insulin was left on. none resulted in any adverse outcome for the patients. of the patients who were not on insulin therapy, had adverse events at the time. died within h of the adverse event and died days later. the remaining patients were discharged. none of the patients were on full feeding protocol. conclusions. our findings suggest that hypoglycaemia in our unit is not primarily related to insulin therapy. it is related to adverse events and possibly inappropriate feeding at the time of hypoglycaemia. hypoglycaemia, in the absence of insulin therapy, is associated with a poor outcome. use of hypoglycaemia as a quality indicator should be interpreted with caution. introduction. vitamin d deficiency seems increasingly prevalent. pleiotropic effects of vitamin d like immunomodulation and effects on muscle strength may be of special importance to critically ill patients [ ] . however, vitamin d deficiency has only been studied in small and selected groups of icu patients [ ] . objectives. to prospectively determine the prevalence of vitamin d deficiency in winter and summer and relate vitamin d status to outcome in cohorts of critically ill patients. results. vit d was measured in patients admitted in winter and patients admitted in summer (table ). mean vit d was significantly lower in winter than in summer. in winter, % was deficient, % severely deficient. in summer, % was deficient, % severely deficient. predicted mortality was higher in winter and higher in vit d deficient patients. observed mortality was lower than predicted in all groups, but not different between groups. including both vit d and season in a multiple regression analysis, winter (p = . ) and not vit d (p = . ) was related to predicted mortality. introduction. glucagon-like peptide- (glp- ) lowers blood glucose via stimulation of insulin and suppression of glucagon secretion, as well as slowing gastric emptying. we have previously shown that exogenous glp- attenuates hyperglycaemia in non-diabetic critically ill patients [ , ] . however, islet cell function in critically ill diabetic patients may be so disturbed that pharmacological doses of glp- have no effect in this group. objectives. the aim of this study was to evaluate the effect of exogenous glp- on glycaemic excursions during intraduodenal nutrient infusion in critically ill patients with preexisting type- diabetes mellitus. methods. nine critically ill, mechanically ventilated, patients with pre-existing type- diabetes ( m: f, age ± years, hba c . % ± . %, bmi ± kg/m , apache ii on day of study ± , days in icu on day of study ± ) received iv infusions of glp- ( . pmol/kg/min), and placebo, from t = - min on separate days in a randomised, double-blind, fashion. between t = - min a liquid nutrient (ensure) was infused intraduodenally at a rate of kcal/min via a naso-enteric feeding catheter. blood glucose concentrations were measured by glucometer at min intervals. data are mean±sem and comparisons are using student's t test. results. prior to the commencement of iv infusions there was no difference in blood glucose between the groups (at t- min: glp- : . ± . mmol/l vs. placebo: . ± . mmol/ l; p = . ). during fasting, glp- had no effect on glycaemia (at t = min: glp- : . ± . mmol/l vs. placebo: . ± . mmol/l; p = . ). however, glp- attenuated the overall glycaemic response to the nutrient (auc - min : glp- : , ± mmol/l.min vs. placebo: , ± mmol/l.min; p \ . ), as well as the peak blood glucose (glp- : . ± . mmol/l vs. placebo: . ± . mmol/l; p \ . ) conclusions. exogenous glp- is effective in reducing the glycaemic excursions that occur with enteral nutrient critically ill patients with pre-existing type diabetes mellitus. these data indicating that further studies using glp- , or its analogues, are warranted in this group. , , , , whilst raising concerns regarding an increased risk of hypoglycaemia. , , . locally most units adopt a protocol that reflects the practice of the original study. objectives. this study was conceived due to concerns around the safety of tight glycaemic control (tgc). our objectives were to measure adherence to our local policies and ascertain our true rates of hypoglycaemia. methods. this study was designed as a retrospective audit on four critical care units in the cheshire and mersey critical care network. each site used the same audit tool but adapted it to allow for differences in local practice and protocols. data pertaining to the prescribing and administration of insulin was collected daily over a week period (the time of data collection varied from day to day). the doctors and nursing staff were unaware of the audit and the data was collected by the ward pharmacist who suggested modifications to therapy if it was deemed inappropriate or unsafe. results. patient days worth of data was collected with blood glucoses checked in this period. % of patients receiving insulin had insulin prescribed. only % of blood glucoses were within the target range set by the local protocol. however, of all the results only . % were ''low'' as defined by the local protocol, and only . % ( / ) were hypoglycaemic episodes as defined in the greet van den berghe paper of (\ . mmol/l). conversely, . % were above the target range. in the trusts that recorded how many of these levels were[ mmol/l (a proposed alternative upper limit), the rates were and %. in response to a blood glucose the policies suggest dosage adjustments/maintenance. on only % of occasions were the adjustments made correct. insulin infusions appeared to be managed safely by nursing staff. insulin, if given, was always prescribed and hypoglycaemia (blood glucose \ . mmol/l) occurred on only one occasion. although safe, adustments often didn't follow the protocols and the patients' blood glucose were within the target range only % of the time, potentially negating many of the perceived benefits of tgc. reasons for non-compliance with the protocols was difficult to objectively establish reference(s). introduction. diabetes mellitus has been associated with an increased risk of adverse outcomes after coronary artery bypass grafting. hemoglobin a c is a reliable measure of long-term glucose control. it is unknown whether adequacy of diabetic control, measured by hemoglobin a c, is a predictor of adverse outcomes after coronary artery bypass grafting. material and method. we evaluated consecutive diabetic patients who underwent primary, elective coronary artery bypass grafting at the anadolu medical center. hba c levels of all patients with diabetes mellitus were measured and value of % or greater was used as a threshold for uncontrolled hyperglycemia. all the peroperative variables were recorded and then, statistically evaluated. the statistical analysis was realised by t test for parametric variables and chi-square test for nonparametric variables. results. there were consecutive patients that underwent elective coronary artery bypass graft surgery between january and april . among them, patients had diabetes mellitus and others not. there were no significant differences between groups regarding each adverse outcomes (table ) . although, ( . %) of total surgical site infection in patients had been seen in diabetic patients, there were also no significant differences between groups regarding the rate of infections (table ). there was no early postoperative mortality in diabetic patients. insuline treatment (iit) , by implementing a completely nurse driven protocol as in the leuven i study, to achieve tight glucose control in our -bed medical(cardio-)surgical icu and non-ventilator beds. in the last year, the benefit of iit and the possible detrimental effects of hypoglycemia on survival have been heavily debated. objectives. the goal is to analyze our daily practice in all icu patients and compare this with the intensive treated groups from the leuven , visep en nice-sugar trial. methods. we compared mean morning blood glucose levels and the percentage of patients who had a hypoglycaemia, defined as glucose below . mmol/l, from to . the frequency of control and the insulin dosage was comparable to the leuven study. enteral or parenteral feeding was started at admission. no standard intravenous glucose was used. glucose was measured with arterial blood samples on the abl flex radiometer as poct. results. in our patients, the mean morning blood glucose was higher than in the leuven study and comparable to the visep and nice-sugar. the percentage of hypoglycemia on our icu was lower in comparison with the visep and nice-sugar. this may be explained by the availability of a poct on our icu which allows quick adjustments of the insulin dosage. conclusions. effective tgc with sprint resolved organ failure faster, and for a greater percentage of patients who had similar admission and maximum sofa scores, compared to a matched retrospective conventional control cohort. these morbidity reductions mirror the reduced mortality seen with sprint. these results suggest that reduced organ failure, assessed by sofa, is a fundamental element in reduced mortality when tgc is implemented effectively. introduction. tight glycaemic control was reported to reduce mortality in selected surgical critically ill patients and lowering of blood glucose (bg) levels was recommended as a means of improving patient outcomes ( ) . however, this approach has been linked with significant risk of hypoglycaemia. recently, several studies have confirmed significant associations between variability of bg levels and patient outcomes ( ). objectives. to evaluate the association between bg variability and hypoglycaemia in a mixed adult icu. methods. retrospective analysis of the prospectively collected and stored bg measurements over a year period, during which tight glycaemic control was targeted in all patients. every day we have calculated the bg coefficient variation as expressed by sd/mean bg level. we have divided the patients into low, medium and high variability groups ( - , - and [ , respectively) . hypoglycaemia was determined if bg was below . mmol/l. for statistical analysis chi-square test and pearsons correlation test was used. results. patients were admitted over the -year period, providing daily data points. bg variability was high in daily measurements ( . %), medium in ( . %) and low in ( . %). hypoglycaemia occurred in measurement points ( . %). hypoglycaemia was observed at all points ( %) when bg variability was high vs. . % when bg variability was medium and . % when bg variability was low and this difference was statistically significant (p = . ). we observed a significant correlation between increased bg variability and hypoglycaemia (r = . , p = . ). conclusions. increased bg variability as expressed by coefficient variation is associated with hypoglycaemia, when measured daily in a mixed icu population employing tight glucose control. decreasing the variability of the bg concentration may be an important dimension of glucose management. if reducing swings in the bg concentration is a major mechanism behind the beneficial effects of glucose control, it may not be necessary to pursue lower glucose levels with the associated risk of hypoglycemia. ). there were two major outliers which may skew the results in favour of the hypothesis. if these two results are removed (fig. ) the statistical significance remains strong (n v * p \ . ; **p = . ; ***p = . )). standard multiple regression analysis found the most useful predictors of t [mid] were 'time with aki' and 'serum urea' (beta coefficient . and . (p \ . ) respectively). crcl, serum creatinine and urine output did not add further predictive statistical power. conclusions. this study demonstrates a reduction in the hepatic metabolism of midazolam associated with aki. this effect is related most strongly to the length of time the patient has suffered with aki. our results are similar to the ncepod report. even with multiple recommendations by ncepod and the national institute for clinical excellence (nice) recognition of the critically ill remains poor. detection of organ failure risk is vital to implement preventative strategies. we found a delay in aki recognition and a lack of risk assessment. observations, included in admission protocols, were recorded, but investigations outside of these, were often absent. nice suggest management should be physiologically and not diagnosis based but few patients had a documented physiological plan. we suggest improving under and postgraduate education to increase awareness of aki. this could occur as an extension to the national, acute life-threatening events recognition and treatment course. an aki admission protocol may allow identification of at risk patients and instigate appropriate monitoring, investigation and management. improved ward based fluid monitoring and management would reduce deterioration. incorporation of a physiological monitoring plan on the icu observation chart may reduce preventable aki. there was no effect in patients with extensive stroke and high severity of a glasgow score ( - points in an observational prospective study, a total of patients who admitted during months in a medical and surgical intensive care unit and didn t have any recent history of renal replacement therapy were included in the study. ( %) of all patients was in aki (acute kidney injury) group according to the akin (acute kidney injury network) definition. the mean of age in aki group was more than non-aki ( . ± . , . ± . respectively; p \ . ); and had worse condition according to apache ii (acute physiology and chronic health evaluation ii) score ( . ± . vs. . ± . ; p \ . ). the aki patients stayed longer in icu rather than non-aki patients ( . ± . vs. . ± . days respectively; p \ . ); with more mortality rate ( . vs. %; p \ . ). also the mechanical ventilation days, time of vasoacive drugs and the use of dobutamin were more in aki group (p \ . ; p = . and p = . respectively). the aki was a significant predictor for mortality using the multivariate logistic regression (or adj = . ; %ci: . - . ); and had the same sensitivity as the apache ii score in prediction of mortality (sen. = . ). objectives. the purpose of this study was to evaluate renal function in children with congenital heart disease (chd) undergoing cardiac surgery with cpb. we conducted prospective, non randomized observational study at the tertiary care university children's hospital -bed surgical icu. study protocol was approved by hospital ethics commission. the study included patients with chd with body weight from . to kg (mean . ± . kg) and age from days to years (mean age months). there were patients with ventricular septal defect (vsd), patients had atrioventricular septal defect (avsd), two had total anomalous pulmonary venous drainage (tapvd), one had tetrology of fallot (tof), one had transposition of great arteries (tga), and one had aortic stenosis, requiring ross operation. urine was collected in the postoperative period during the first h after surgery for determination of clcr. the serum creatinine (scr) level was determined by jaffé s method (cobas analyzer, roche). harrison am et al. [ ] shows that estimated creatinine clearence (clcr) using schwartz formula does not accurately predict clcr. therefore we used standard formula for clcr calculations. urine output, inotrope score, duration of aortic cross clamping and cardiopulmonary bypass was recorded. we applied rifle criteria to assess renal functions, using clcr as a variable reflecting glomerular filtration rate (gfr). objectives. evaluate whether a real-time alert of worsening of rifle class, through the physicians' dect telephone system, would affect therapeutic interventions for aki and progression of rifle class. single centre, prospective intervention study during a -month period in our bed surgical and medical icu. three study phases were compared: a . -month control phase (con ) where physicians were blinded for the electronic alerts, a -month intervention phase where electronic alerts of worsening rifle class were made available to the physicians through the dect telephone system (int), followed by a second . month control period (con ). pasw statistics was used for statistical analysis and a double sided p value of . was considered as significant. at study entry, before and after to receive antioxidant or placebo concentration the blood was drawn, to posterior determination of thiobarbituric acid reactive species (tbars), protein carbonyls, total nitrite concentration and il- . results. the use of nac+dfx decreases oxidative damage parameters. patients at antioxidant arm have, despite not reaching statistical significance, a decrease on plasma il- levels h after the start of treatment. as observed to oxidative damage parameters, il- returned to the placebo levels after the end of antioxidant administration. the nitrite levels increased h after nac+dfx, returning to placebo levels and h. the incidence of arf using the rifle criteria was not significantly different in the two arms, and this was also true to a number of secondary end points, none of which showed significant differences between the treatment arms. analyzing the subgroups of the sofa score we observed at day a worse cardiovascular sofa in the nac+dfx arm ( . ± . vs. . ± . , p = . ) and a better renal sofa in antioxidant treated patients ( . ± . vs. . ± . , p = . ). conclusions. we demonstrated that nac + dfx administration was able to decrease plasma markers of oxidative damage and to a minor extend il- plasma levels. we believe that the use of antioxidants could be an alternative adjuvant therapy to prevent arf in critical ill patients with hypothension. table were found to be independent risk factors for postoperative aki: objectives. we aimed to access prospectively whether the use of antioxindants has beneficial effects in renal function of critical-ill patients undergoing imaging studies with intravenous radio-opaque agents (ivca). patients were recruited from those hospitalized in a tertiary intensive care unit between and . inclusion criteria were: a) requirement for imaging studies with ivca b) no use of renal replacement therapy. patients were randomized to receive before and after imaging, either antioxidants (n-acetyl-cysteine , mg and ascorbic acid g and ml ns . %) (sg) or cc ns . % (cg). renal function was assessed by serum levels of creatinine and cystatin c assessed before and at , h following administration of ivca. patients were followed until discharge. systatin c was measured by elisa. conclusions. the results of this study suggest that the use of preventive antioxidant therapy may protect critical-ill patients from contrast-induced nephropathy. our preliminary results have to be confirmed in larger cohorts. acute coronary occlusion is the leading cause of cardiac arrest. because of limited data, the indications and timing of coronary angiography and angioplasty in survivors of out of hospital cardiac arrest are controversial. objectives. using data from the parisian region out of hospital cardiac arrest (procat) prospective registry, we performed an analysis to assess the impact of an invasive strategy on hospital survival. between january and december , survivors of out of hospital cardiac arrest were referred to a tertiary center in paris, france. in survivors with no obvious extra-cardiac cause of arrest, an immediate coronary angiogram followed if indicated by coronary angioplasty was performed at admission. the prognostic value of pre-hospital and in-hospital characteristics on in-hospital mortality was evaluated using logistic regression analysis. results. at least one significant coronary artery lesion was found in ( %) therapeutic hypothermia has been shown to improve survival and neurological outcome in patients who have suffered out-of-hospital cardiac arrest and in whom the initial rhythm was ventricular fibrillation (vf) [ , ] . international guidelines now recommend the use of therapeutic hypothermia as part of post-resuscitation care in patients fulfilling the above criteria [ ] . objectives. we surveyed current practice regarding the use of therapeutic hypothermia for post resuscitation care in northern ireland (ni) intensive care units. a questionnaire was devised, reviewed and agreed by each author prior to posting to the lead clinician in each of northern ireland's adult intensive care units. a % response rate was obtained. we asked about the existence of a protocol for cooling, which patients were cooled, duration of cooling, by what particular method(s) cooling was achieved and how temperature was monitored during cooling. results. out of ( %) adult icus in ni institute therapeutic hypothermia routinely as part of their post-resuscitation care. only out of the units ( %) have a protocol for institution and maintenance of hypothermia. all units that utilise hypothermia do so regardless of the initial cardiac rhythm. out of ( . %) icus target a temperature of - °c with out of ( . %) targeting a temperature of - °c. all units utilise surface cooling methods with out of ( %) also using cold intravenous fluids occasionally. out of ( %) units cool for - h, ( . %) unit - h and unit - h. all units use more than one method of temperature monitoring during cooling. all units sedate patients during cooling and out of ( . %) also routinely curarise patients during cooling. the units that do not currently use therapeutic hypothermia cited lack of resources/funding as the main obstacle to adopting this evidence based practice. conclusions. the practice of therapeutic hypothermia post cardiac arrest has been embraced by the majority of icus in ni. there appears however to be variation in the target temperature and duration of hypothermia once instituted. icus that cool patients appear to do so regardless of initial cardiac rhythm. regional protocolisation of this therapeutic modality may help standardise practice across ni icus. reference(s we compared our data with those from retrospective audit [ ] . the method of th was via surface cooling technique together with cold intravenous saline infusion but not ivcd. total patients presented with cardiac arrest: underwent th ( ooh vf/vt and ooh non-vf/vt). in , there was an overall improvement in adherence to the audit standards, as shown in table : table : table hospital survival rate of th % gcs of the survivors at icu discharge / ( %) / ( %) / ( %) / ( %) conclusions. introduction of ivcd has led to an improved compliance with local and ilcor th guidelines. although the total numbers are small, there has been an increase in the patients discharged with gcs from our icu using ivcd. there are areas that require further improvement, notably the time to reach target temperature and prevention of rebound hyperthermia. work continues on protocolised evaluation of neurologically damaged survivors. rd esicm annual congress -barcelona, spain - - october s target temperature management after out-of-hospital car-diac arrest, an international, multi-centre, randomised, parallel groups, assessor blinded clinical trial-rationale and design of the ttm-trial n. nielsen , , and the ttm-trial study group helsingborg hospital, department of anesthesia and intensive care medicine, helsingborg, sweden, lund university, department of clinical sciences, section of anesthesia and intensive care medicine, lund, sweden introduction. experimental studies and previous clinical trials suggest an improvement in mortality and neurological function with induced hypothermia after out-of-hospital cardiac arrest (ohca). previous trials have included highly selected populations and the optimal target temperature is not known. objectives. to evaluate differences in efficacy and safety with target temperature management at and °c for h after ohca of presumed cardiac cause. methods. intervention: patients will be managed with h of temperature control at versus °c according to randomisation. temperature control will be delivered with temperature management equipment at the discretion of the trial sites. to facilitate cooling, when applicable, and to stabilise the circulation all patients will be treated with ml/kg of crystalloid infusion ( °c or room temperature according to treatment arm). design. randomised trial with : concealed allocation of ohca patients to temperature control for h at versus °c with blinded outcome assessment. sample size is based on a relative risk reduction of % with a risk of type- error of % and a power of % with a % loss to follow-up. conclusion. this study demonstrated that health care professionals, despite guidelines, are hyperventilating simulated cardiac arrests patients. suboptimal ventilation was a problem across all the backgrounds investigated; although doctors performed best here, they were still found to be hyperventilating to an unacceptable level. hyperventilation has a number of deleterious physiological effects and is associated with poor outcomes. increased training, awareness and recertification may be the answer, and certainly improves short term compliance with guidelines. however, these effects may be short lived and other changes may be needed. a reasonable course of action may be the use of paediatric ( l) self inflating reservoir bags as a first line device. this simple measure may ensure delivery of more guideline consistent ventilation, independent of the level of experience. extracorporeal life support (ecls) has been proposed as the ultimate heroic rescue measure in prolonged cardiac arrest unresponsive to conventional cardiopulmonary resuscitation. ecls effectiveness in out-of-hospital cardiac arrest remains to be addressed. decision to discontinue cpr due to medical futility is based upon presumed prolonged anoxia, with existing guidelines for termination. however, even when ecls is implemented, failure to maintain stable hemodynamic conditions due to marked capillary leak frequently results in patient's death. to evaluate the usefulness of routine laboratory parameters in the decision to treat refractory cardiac arrest patients with ecls . methods. sixty-six adults with witnessed cardiac arrest of cardiac origin unrelated to poisoning or hypothermia undergoing cardiopulmonary resuscitation without return of spontaneous circulation (duration: min [ - ], median, [ - %-percentiles]) were included in a prospective cohort-study. ecls was implanted under cardiac massage, using a centrifugal pump connected to a hollow-fiber membrane-oxygenator, aiming to maintain ecls flow c . l/min and mean arterial pressure c mmhg. introduction. due to the human lifespan increasing, people are living longer. cardiac arrest (ca) in old people could be seen as a natural end of life process and cardio-pulmonary resuscitation (cpr) in this setting as a disturbance. therefore, the question of prognosis in patients has been raised when performing cpr in the elderly. data from the s found month mortality in % of patients over suggesting that cpr in elderly people could be futile ( ) . the recent progresses in the management of resuscitated patients, such as mild hypothermia, were not evaluated in patients older than years ( , ) . in a recent study, we found that age [ years was an independent pejorative prognostic factor ( ) . hence there is virtually no data of prognosis factor of elderly patients after ca. our aim was to determine the prognosis factors in patients older than years successfully resuscitated. methods. all patients admitted to icu for ca with successful rosc were consecutively included between and . ca data were prospectively entered in a registry according to utstein recommendations. patients were managed following standardized procedures. good prognosis was defined as cpc or at icu discharge. factor associated with a good outcome were identified using multivariate analysis. results. among , patients admitted for ca, were older than years. median age was . years ( - ), ca was from cardiac origin in % of patients and . % had a vt/vf initial rhythm. mean no flow (nf) and low flow (lf) were . (± . ) and . min (± . ). mean blood lactate and creatinine level at admission were . mmol/l (± . ) and lmol/l (± ). . % of patients presented post-resuscitation shock (prs) and . % were treated with hypothermia. conclusions. ca in elderly patients is associated with an in-icu % good outcome rate. this should promote the cpr in non-severely disable elderly patients with ca regardless of their age. we plan to collect the -month mortality and the functional status of survivors. introduction. post-resuscitation phase is often characterized by a ''sepsis-like'' syndrome, which may be associated with the development of organ dysfunction. microcirculatory abnormalities play a key role in sepsis-related organ failure; however no data are available on microvascular function after cardiac arrest (ca). objectives. the aim of this study was to investigate peripheral microcirculation during and after therapeutic hypothermia (th) in ca patients. methods. this prospective, observational study included patients treated by th after ca. sublingual microcirculation was evaluated using sidestream dark-field (sdf, microscan, the netherlands) videomicroscopy at hypothermia and normothermia in all patients. at least images of s each from separate areas were recorded at each time point and stored under a random number to be analyzed, using a semi-quantitative method, by an investigator blinded to time and condition. thenar oxygen saturation (sto ) was measured using a tissue spectrometer (inspectra ; hutchinson, usa). a vaso-occlusive test was performed at hypothermia and normothermia by rapid inflation of a pneumatic cuff around the arm to evaluate sto reperfusion rate, reflecting microvascular reactivity. results. compared to hypothermia, measurements at normothermia showed a significant increase in functional capillary density (fcd) from . ± . to . ± . n/mm (p = . ), the proportion of small perfused vessels (ppv) from ± to ± % (p = . ) and mean flow index (mfi) from . ± . to . ± . (p = . ). fcd and ppv values were significantly correlated with body temperature. sto reperfusion rate was largely decreased when compared to healthy volunteers, but it did not change over the study period (from . ± . to . ± . %/sec) and showed large inter-individual variability. the same was found for sto (from ± to ± %). conclusions. mild hypothermia is associated with decreased fcd and ppv in the sublingual area when compared to normothermia. microvascular reactivity is decreased but changes are unpredictable. introduction. acute posthypoxic myoclonus (phm) occurs in deeply comatose patients, soon after a hypoxic episode. it is characterized by generalized, severe body jerks with violent flexor movements, but more focal myoclonus is reported too ( ) . acute phm and status myoclonus are considered to have a poor prognostic outcome ( , ) . although the cerebral cortex is known to be the most common origin of myoclonus in ambulant patients ( ) , the origin of acute phm is uncertain ( ) . to determine whether acute phm originates from damage in cortical or subcortical structures. for this study patients with myoclonus in the first h after admission were selected from the propac ii study, a prospective cohort study including patients admitted after cpr and treated with hypothermia. exclusion criteria: pre-existing disease with life expectancy\ months and severely disability before cpr. baseline characteristics were used from the main database. additional data of eeg and ssep recordings made after rewarming were collected. eegs were evaluated for presence of epileptic activity, status epilepticus, generalized periodic discharges, burst suppression pattern, iso-electric or low voltage amplitudes and reactivity of the background pattern. data collected from sseps: n potential, giant potential (defined as a potential five times the size of a normal potential) and p /n amplitudes (done by jhk). the glasgow outcome scale (gos) was used to assess outcome after months, poor outcome was defined as a gos of - (death, vegetative state, severe disability), good outcome as a gos of - (moderate disability, good recovery). . from a total of patients included in the propacii study, ( %) patients developed myoclonus. baseline characteristics of this group: age , % male, time to rosc min, primary cardiac arrest in patients, hypoxic arrest in . ssep recordings were available from patients. n potentials were present bilaterally in % ( ) and giant potentials were seen in % ( ) of the patients with a present n potential. eegs were made, epileptic activity was seen in % ( ) and a status epilepticus in % ( ), thus % of the eegs did not show any type of epileptic activity. good outcome was seen in % of the patients, poor outcome in %. mortality was %. conclusions. the results of this study show that acute phm is found in % of patients admitted after cpr and treated with hypothermia. it did not necessarily lead to a poor outcome, but we did not have information about the type of myoclonus. the available data seem to support the idea that the myoclonus originates mainly from subcortical structures, given the low number of patients with eegs showing epileptiform activity and sseps with giant potentials, which can be seen in cortical myoclonus ( ). introduction. the international liaison committee on resuscitation, the american heart association and the european resuscitation council recommend that mild therapeutic hypothermia improve neurological outcome in unconscious adult patients with return of spontaneous circulation (rosc) after out-of-hospital cardiac arrest (ohca) due to ventricular fibrillation (vf) or ventricular tachycardia (vt). in our intensive care unit (icu) we use mild hypothermia in all patients following cpr with successful rosc regardless of initial rhythm. in this study we compared the effect of mild therapeutic hypothermia at neurological outcome and mortality between the patients who had ohca due to vf or vt and them who had ohca due to a different initial cardiac rhythm as asystole or pulseless electrical activity. the study protocol was approved by the local ethics committee on human research. a total of patients were admitted to our icu with rosc after ohca between may and december . therapeutic hypothermia was initiated after admission in icu by intravenous infusion of cold saline ( °c , ml bolus) followed by intravenous cooling device (coolline catheter, coolgard alsius corporation irvine, ca, usa). the target temperature was °c maintained for h followed by slow active re-warming over a minimum period of h ( . °c per hour). intravenous anesthesia was induced in all patients by a combination of propofol and remifentanyl with dose adjustment as needed. to prevent shivering, patients received muscle relaxation by iv administration of sisatracurium every h. the primary end point was the neurological outcome at months according to the pittsburgh cerebral performance category (cpc). secondary end point was mortality at months. prehostital cooling procedures were not applied. nine of the patients ( %) of the group of the patients who had ohca due to vf or vt had favourable neurological outcome cpc or as compared with of ( %) of the group of the patients who had ohca due to a different initial cardiac rhythm. mortality at months was % ( of patients died) in the group of the patients who had ohca due to vf or vt as compared with % ( of patients died) in the group of the patients who had ohca due to a different initial cardiac rhythm. in patients who had ohca due to vf or vt mild therapeutic hypothermia inproves the neurological outcome and reduces mortality as compared with the patients who had ohca due to a different initial cardiac rhythm. objectives. we aimed to compare therapeutic hypothermia using either surface or endovascular techniques in terms of efficacy, complications and outcome at our institution, a bedded tertiary referral icu. a local research ethics committee reviewed the proposed study and waived the need for a full ethics submission, as the study met the national criteria for service evaluation. data were collected from patients undergoing therapeutic hypothermia following cardiac arrest over a . year period by retrospective casenote review and interrrogation of the carevue (phillips uk) database. therapeutic hypothermia was initiated in the icu using iced hartmann's solution, followed by either surface (n = ) or endovascular (n = ) cooling; choice of technique was based upon endovascular device availability. the target temperature was - °c for to h, followed by rewarming at a rate of . deg h - . the mean age was ± years; % of arrests occurred out of hospital, and % were ventricular fibrillation/tachycardia. endovascular cooling provided a longer time within the target temperature range (p = . ), less temperature fluctuation (p = . ), better control during rewarming ( . ), and a lower -h temperature load (p = . ). endovascular cooling also produced less cooling-associated complications in terms of both overcooling (p = . ) and failure to reach the target temperature (p = . ). after adjustment for known confounders, there were no differences in outcome between the groups in terms of icu or hospital mortality, ventilator free days and neurological outcome. conclusions. endovascular cooling provides better temperature management than surface cooling, as well as a more favorable complication profile. the equivalence in outcome suggested by this small study requires confirmation in a randomized trial. introduction. ventricular assist devices (vads) are successfully used in patients with end stage heart failure, usually as a bridge to transplantation or recovery, but increasingly as destination therapy as well. a major threat for patients with a vad is the frequent occurrence of, mainly thromboembolic, stroke, with a reported incidence of up to %. manufacture guidelines for anticoagulation therapy are based on relatively small observational studies and common sense rather than evidence, and as a consequence anticoagulation protocols vary widely between centers. objectives. the aim of this systematic review was to provide more evidence in order to determine the optimal anticoagulation protocol to prevent stroke in patients supported with a vad. a systematic search in pubmed and embase was performed in which we included all types of vads. all types of anticoagulation drugs applied to prevent thromboembolism were included and divided in three categories; heparin, coumarins and antiplatelets. we included references with a full text available, written in english, dutch, german or french, and which described patients with a stroke or tia. our primary outcome measure was defined as the onset of any type of stroke. two authors evaluated independently the results of this search; doubtful references were evaluated by two other authors. after critical appraisal articles were selected as relevant, which include cohort studies, case-control studies and trials, totaling patients with vad support between and . the mean age was years (range - ) and the mean duration of support was days ( - ). stroke occurred in - % patients supported by vad, with an incidence of - /patient-year. the majority of strokes occurred within the first year. six types of anticoagulation protocols were used that combines drugs from one or all three categories. most protocols used a combination of all categories ( , patients with a total follow up of , days) and had an average stroke incidence of . events/patient-years. the lowest average stroke incidence was reported in studies that used only antiplatelets ( . events/patient-years) and the highest in which only heparin was used ( events/patientyears). we could not detect a decreased risk for stroke in patients with vad support when coumarines or heparin were used instead of or in addition to antiplatelets. antiplatelets should be part of an anticoagulation protocol to prevent stroke in patients supported by vad. a.m. de la torre , c. marco , d.j. palacios , a. pedrosa , i. lopez de toro , v.a. hortigüela hospital virgen de la salud, toledo, spain objectives. to analyze the difference between two groups of patients with ich considering severity, treatment, evolution and mortality. methods. description retrospective study of admitted patients between st of january of to st of december and st of january of to st of december in the icu of virgen de la salud hospital (toledo) with the diagnosis of ich. there are patients in the group of - and patients in the groups of - without any difference of age. regarding comorbidity between the two groups no differences can be found regarding the previous presence of hta, but regarding diabetes and dislipemy, we do find a higher prevalence on the second group ( . vs. . %, p \ . and . vs. . %, p \ . respectively). reviewing the presence of anticoagulated patients, no differences of significance can be found, but a trend ( . vs. . %, p \ . ). regarding the location of the hemorrhage, the most frequent is the basal ganglia ( . vs. %), existing no differences amongst the two groups. we don't find differences either in the presence of a intraventricular component, whether it is neither supratentorial nor infratentorial. there are differences between the ich score of both groups with p \ . : with a score of ( . vs. conclusions. an increase in the comorbidity can be observed in the included patients, which can be due to a better screening of these pathologies. we also find that the ich score is higher than in the - sample, which is attributed to the admittance in the icu of patients with the ultimate goal of organ donations. in the evolution, it can only be observed a longer stay in patients from the second sample, likely because they are more serious patients with a higher ich score. the analysis of the two groups has not been conclusive when it comes to assessing the improvements that might have come out in these last years, although it is necessary a deeper analysis of the data. introduction. sodium dysbalances are frequent medical complications in patients with subarachnoid hemorrhage (sah). hyponatremia is more frequent but it is associated with better outcome than hypernatremia. the aim of this study was to observe differences in outcome between hyponatremic and hypernatremic patients with sah. we performed the prospective years study in incidence of hyponatremia (serum sodium \ mmol/l) and hypernatremia (serum sodium [ mmol/l) in patients (pts) with sah. we compared the incidence of cerebral complications, glasgow outcome scale (gos) upon discharge from the neurointensive care unit (nicu) and in mortality nicu. results. there were ( %) pts with dysnatremia, more patients had hyponatremia ( , %), less hypernatremia ( , %). between these groups there were no diferences in stay in nicu (p = . ), duration of dysnatremia (p = . ), fluid intake (p = . , ml/day), daily sodium intake (p = . , mmol/day) and fluid output (p = . , ml/day). hyponatremia was more frequent on admission (p \ . ) and connected with higher diuresis (p \ . ). hypernatremic pts received more antiedematic therapy (p \ . ). hypernatremia was arised in pts with significantly lower glasgow coma scale (p = . ). these pts had more cerebral complications (p = . ), worse glasgow outcome scale upon discharge from nicu (p \ . ) and higher mortality in the nicu (p = . ). conclusion. dysnatremia is frequent in patients with sah ( %). hyponatremia occurs more often, but hypernatremia is connected with worse outcome. objectives. to analyze clinical, epidemiologic and outcome differences and to identify predictor factors of mortality at discharge from icu of patients admitted after craneoencephalic trauma (cet) according to glasgow coma scale (gcs) score. observational prospective study of patients admitted in the intensive care unit (icu) after cet. we classified the traumatic brain injury, according to gcs score of b or c points groups. we analyzed clinical and demographic data during icu stay, as well as physiological, functional and emotional data measured with paecc scale (project for the epidemiological analysis of critical patients) at discharge from icu. qualitative variables are expressed as a percentage and quantitative variables as mean and standard deviation. we used chi test, t-student and multivariate analysis as required with a maximum alpha error of %. we analyzed patients, . % male. at admission . % had gcs b . traffic accidents ( . % in gcs c and . % in gcs b ) were the most frequent cause of cet. there was a higher rate of out hospital hypotension in the gcs b group (p = . , or . , % ci . - . ). cranial computed tomography (ct) scan findings in the gcs c group were diffuse injury i and ii ( . %) after marshall classification versus . % in the gcs b group (p = . ). fewer complications were detected in patients in the gcs c vs. gcs b group ( . vs. . %, p = . , or . , % ci . - . ). icu mortality rate was significantly lower in the gcs c group than in the gcs b group ( . vs. . , p \ . ). predictors of mortality were gcs at admission (p = . ), ct findings type iii, iv and v (p = . , . and . respectively), complications (p = . ), tracheotomy (p = . ), days on ventilator (p = . ), apache ii (p = . ) and the length of icu stay (p = . ). best overall score in paecc questionnaire at discharge from icu was better in the gcs c vs. gcs b group. ( . ± . vs. . ± . , p = . ). conclusions. patients with lower gcs at admission presented higher rate of prehospital hypotension, more severe ct findings, more complications at icu, worse physiologic, functional and emotional outcome, and higher rate of mortality, than patients with gcs c . factors associated with increased mortality were coma level, type of findings in ct, complications, prolonged mechanical ventilation, length of icu stay, apache ii, and the need for a tracheotomy. objectives. the aim of our study was to estimate the influence of hyperhaes infusion on haemodynamic regulation. we examined patients with severe brain trauma (gcs score \ , sedation, artificial ventilation). the bp, stroke volume (sv) and their variability (bpv, svv) were determined by the bioimpedance method. additionally we determined the peripheral pulse (pp) and its variability (ppv) using plethysmography curve registration. special attention were paid to the p ( . - . hz) and p ( . - . hz) bands of bpv, svv and ppv, connected with volume state, breathing, and autonomic regulation, especially baroregulation. all the comparisons were made before and after min. of the infusion of hyperhaes ( ml). all patients had the autonomic dysfunction: the waves of baroregulation (p ) had low power compared with healthy. hypovolemia was moderate: sv ( ± . ) and pp ( ± . ) were slightly decreased, but bp were ± . mmhg. the bp increasing was registered as the first reaction on the infusion of hyperhaes ( ± . mmhg). the same time pp increased more then twice and became ± . , and p of ppv decreased from ± . to ± . , that reflected the improving of the volume state. although sv did not rise significantly, the increasing of p were estimated in svv, as a marker of the baroregulation restoration. conclusions. the infusion of hyperhaes in severe brain trauma not only decrease the range of hypovolemia, but restore the baroregulation as a significant part of autonomic regulation, needed for cerebral perfusion support. introduction. continuous measurement of intracranial pressure (icp) using intraparenchymal sensors has become part of the standard management of patients at risk of developing intracranial hypertension. whilst reliability has been explored previously little is published on the accuracy of depth to which the sensor is placed. a difference in sensor location has been shown to affect the reliability of icp readings and could impact negatively on patient management ( ). to determine whether icp sensors (codman, j&j) placed by neurosurgical staff were within the optimum depth of cm from the cortex. methods. consecutive patients were identified from a prospectively collected neuro icu database who had had a ct of the head (cth) performed whilst an icp sensor was in situ during . the depth of the sensor tip on cth was measured and patients were stratified according to whether they had surgery or no surgery to determine any differences between open and percutaneous placement. of the icp sensors ( %) were placed deeper than cm. the greatest incidence of deep placement was in surgical patients / ( %) and in craniotomy patients % of these were deeper than cm conclusions. this investigation has shown that the majority of patients admitted to our neuroicu have less than optimally placed icp sensors. inappropriately deep sensors appear more common in surgical patients, particularly following craniotomy. the impact of this on patient outcome is unknown and would require further study. this study has highlighted we need to implement new methods to improve the accuracy of our icp sensor placement. graduated marks on the sensor sheath during manufacture may assist accurate placement. conclusions. if icp is largely used, it remains below %. % of the cases have been monitored with at least techniques suggesting an acceptance tendency for a multimodal monitoring. among these techniques, the control of pco seemed considered important as the use of tcd to assess perfusion and vessel tone. on-going analysis of these data will provide information on the therapeutic strategy performed and the impact on outcome. introduction. raised intracranial pressure (ricp) can be evaluated sonographically by measuring the optic nerve sheath diameter (onsd). a wide variation in the threshold measurement of onsd for ricp has been reported in literature. it is likely that exaggeration of the hypoechoic edge artifact around the dura by high frequency ([ mhz) linear transducers and uncertainty over whether to measure -mm behind the papilla or behind the globe (posterior margin of sclera) could have resulted in such differences. to determine the optimal site of measurement of onsd by correlating it with ricp determined clinico-radiologically. we also evaluated if different sonographic appearances of the onsd could be used qualitatively to determine the presence or absence of ricp. methods. initially, in order to precisely delineate the anatomical dura sonographically and assess optimal cursor placement, cadaver orbital preparations were studied before and after subarachnoid fluid insufflation. scans were then done by a single sonographer using a - mhz linear transducer on healthy volunteers and patients admitted to the medical/ neurosurgical intensive care units. onsd was measured at locations; -mm behind the papillae and -mm behind the globe. in each location measurement was made within the anatomical dura and another between the echogenic margins of retrobulbar fat as described in literature. four patterns (fig. ) of the nerve sheath were identified based on the appearance of the csf space and edge artifact. ricp was diagnosed by clinically correlated computed tomography of the brain. an independent sample t test was done to correlate measurements with ricp. classification of optic nerve sheath appearances results. / ( %) scans were done on patients with ricp. all measurements independently correlated with ricp (p \ . ); albeit cut-offs differed substantially ( table ) . the presence of a type pattern (fig.) in both eyes strongly suggested ricp ( % positive predictive value) whilst its absence in both eyes ruled out ricp ( % negative predictive value). methods. three years after the introduction of the concept of bs in our icu, a questionnaire was sent to people directly involved in the nursing of critically ill patients to study the current practice during the previous month. responses were received from persons, a % response rate. ( %) persons had practiced bs. only ( %) employees used calming bath and ( %) an invigorating bath. guided oral care and guided suction was performed respectively by ( %) and ( %) nursing persons. orientative positioning was used by ( %) nurses. everybody is very satisfied with the instruction manual which can be found in each room. ( %) persons estimated to be well informed about bs. others wanted more practice course and training at the bedside. conclusion. pattern suggested an increasing interest in bs since its introduction. initial touch is well implemented. more effort is needed for continuous education and training. introduction. admittance to hospital for surgical treatment, is often linked with insecurity and anxiety for many patients. to most patients, the postoperative care unit constitutes an unknown environment, and can represent a frightening experience. research has shown that preoperative information leads to subjective outcome as anxiety reduction, and objective outcome as shorter hospital stay and less intake of pain medication. few studies, however, have addressed patients' experiences with preoperative information about the early postoperative phase. objectives. the purpose of this study was to describe patients' experiences with preoperative information about events they may experience during their stay in the postoperative unit. patients' experiences may contribute to increased knowledge about this topic. the study design was exploratory-descriptive, and a semi-structured interview based on thematic guide was used. nine patients met the inclusion criteria, and they had an average age of years. they were admitted to elective surgery for cancer and their stay in the postoperative unit varied from to . days. the interviews were conducted - days after surgery and transcribed verbatim. the data material was subjected to qualitative content analysis. results. experience with information before surgery and in the early postoperative phase, was categorized into four themes: being prepared before surgery, reactions to differing experience, discomfort and pain, management of some self-care activities and experiences with the environment of the postoperative unit. conclusions. the patients received a fair amount of information before surgery, but only limited information concerning what to expect while in the postoperative unit. the patients' information needs differed and patients with former experience with surgery were more prepared for what to expect. the patients got mainly verbal information and most of this was given the day before surgery. o.m. peters-polman , m. van roosmalen , j.e. tulleken , j.g. zijlstra umc groningen, intensive care, groningen, netherlands, arup nederland, amsterdam, netherlands, umc groningen, groningen, netherlands background. who guidelines concerning sound levels in hospitals requires a maximum of db in daytime, a nighttime sound level below db to allow good sleep quality and peak levels that do not exceed db at all times. in an icu environment, apart from being critically ill, patients are exposed to typical icu environmental noise. sleeping cycles disturbed by illness are further disrupted by care providers performing procedures and taking vital signs and alarms with delirium as a common result. we describe the acoustic environment in our mixed icu. we conducted an observational study in which we continuously measured the sound level (db), frequency and repetition of sound in our icu. we used a splnet microphone and noise monitoring system which was placed, after informed consent, at the ear level of the patient. results. noise sources are numerous and consist of human voices, doors slamming, pagers, telephones, shoes and equipment alarms. there is a round the clock continuous background noise of - db, staff conversation with levels of - db and peak levels up to - db, mainly due to alarms. these levels of sound are comparable to loud conversation at meter distance ( - db), walking along a motorway ( - db) or standing next to a roaring engine ( db). conclusion. who guidelines clearly state maximum sound levels of db in daytime, db at night and peak levels of db. the sound level in our unit is exceptionally and unacceptably high throughout day and night and requires a behavioral intervention. further research on the influence of these noise levels on our patients is necessary. objectives. this study has been achieved in order to realize the comparison of efficiency of manual and mechanical compression techniques used for the maintenance of haemostasis after femoral sheath removal. methods. this study was planned and applied as a randomized controlled trial. the study was executed at a military education and research hospital in turkey between january and march . data collecting form was prepared by the investigators after the literature examination. the form consists of questions which are evaluating the demographic data of patients, the compression time, the pain level (before sheath removal, during the manual/ mechanical compression and after the sheath removal), the complications occurring in femoral zone, the mobilization/discharge period and the problems (bruise, oedema, hemorrhage and etc.) occurring the th day after the discharge. the patients have been called up in order to evaluate the problems occurring on the th day. the persons that were applied mechanical compression have constituted the experimental group and the patients that were applied manual compression have formed the control group. the patients volunteer to participate to the study have been informed in regard with the implementing procedures before the application. descriptive statistics were shown in numbers and percentages for the variables obtained by counting and in mean ± standard deviation for variables obtained by measurement. results. the average of age is . ± . in the experimental group and is . ± . in the control group. the average of compression time is . ± . min in the experimental group and is . ± . min in the control group (p \ . ). the average of mobilization time after sheath removal is . ± . min in the experimental group and is . ± . min in the control group (p \ . ). it has been observed a lower pain level during compression and after sheath removal in patient that were applied mechanical compression in comparison to the patients that were applied manual compression(p \ . ). when the groups were compared in terms of femoral zone complications while no haematoma was observed in the experimental group, haematoma has been occurred in the . % (n = ) of the control group. conclusions. the mechanical compression provides an earlier mobilization and earlier discharge of the patient. this study shows that mechanical compression is a method as safety as the manual method in order to obtain a haemostasis a correlational survey was conducted in public hospitals located in athens. critical care nurses completed anonymous questionnaires , , yielding a response rate of %. greek critical care nurses believe that open visiting increases family's satisfaction ( . %), exhausts family members ( . %) and provides emotional support to the patient ( . %); nevertheless the effects of visiting depend both on patient and family ( . %). furthermore open visiting hampers the planning of adequate nursing care ( . %) and is not a helpful support for the caregivers ( . %) while increases their physical and psychological burden ( . %). critical care nurses' attitudes toward visiting hours were rather negative and they didn't want to liberalize the visiting policy of their unit ( . %). there was a positive correlation between nurses' beliefs and attitudes regarding visiting (r = . , p \ . , r = . , p \ . ). the factors ''working experience'', ''adequacy in staff'' and ''the number of shifts'' were found to be independently correlated and they predicted the score of the scales of the questionnaire. greek icu nurses have rather negative beliefs and attitudes toward visiting and open visiting policy. this will be a challenging barrier to overcome when imposing new flexible policies in icus . objectives. our aim was to elucidate potential mechanisms for the beneficial effects of rhapc on ali, as assessed by microarray analysis of lung tissue after sepsis induced by clp in rats. methods. sepsis (n = ) was induced in rats by clp. a sham-operated group (n = ) underwent laparotomy and closure without clp. a clp group (n = ) received subcutaneous saline ( ml/kg) and a clp + apc group (n = ) additionally received mg/kg rhapc. twelve hours postoperatively, lung tissue was preserved in mrna later until mrna isolation by promega total rna kit and analyzed using illumina beadarray. data were log variance stabilized and quantile normalized using the lumi package in r and the limma package was used for group comparisons and false discovery rate correction. data were further analyzed using panther and david. the clinical outcomes of this study showed a marked attenuation of the sepsisinduced increase in lung permeability in rats treated with rhapc . although no formal statistical significance was reached for the gene expression changes between the clp and the clp + apc groups, there was a clear attenuating effect of rhapc on the changes in gene expression caused by sepsis reflected in generally lower fold change values and fewer significantly differentially regulated genes in the clp + apc versus sham group compared to the non-treated clp vs. sham group ( vs. genes). nevertheless, there were only genes of which the fold change difference between clp versus sham and clp + apc versus sham was more than one, indicating that although there was a large difference in the number of differentially expressed genes, the difference in fold change between these genes was small. conclusions. these data suggest that the rhapc treatment of septicemic rats does not only cause a down regulation of specific pathways as argued by previous investigators, but leads to a global reduction in the inflammatory response at a mrna level. introduction. septic shock guidelines recommends the use of recombinant human activated c protein (acp) in high risk mortality patients. the aim of our study is to describe the clinical characteristics, and the outcome of patients treated with acp in our hospital. methods. retrospective and descriptive study which includes patients with severe sepsis/ septic shock treated with pca in a tertiary hospital intensive care unit (icu) over years ( - ) . we analyze epidemiological data, reason for admission, infectious focus and agent, severity scores, organ failure, complications, stay and mortality. we used chi-square analysis to compare categorical data and student's t test to compare continuous variables. conclusions. in our study most patients were admitted from emergency department, with organic failure caused by pneumonia. we haven't detected deaths related with acp complications, even in patients undergoing surgery. we found as prognostic factors for mortality: organ dysfunction, acp indication, renal failure, pao /fio relation, amount of vasopressors, bicarbonate and base deficit levels, apacheii and icu stay. objectives. to analyze changes on hemodynamics in patients with severe sepsis treated with high volume hemofiltration ( ml/kg/h) vs. patients treated with very high volume hemofiltration ([ ml/kg/h). we conducted a prospective randomized trial from january to november in patients admitted into icu with a diagnosis of septic shock in which hf was indicated. patients were randomized to one of each group of therapy. the control group received high volume hemofiltration therapy and the experimental group received very high volume hemofiltration. the hemodynamic parameters were measured at the admittance in icu and every h onwards. results. data of patients were collected ( men and women) mean age ± years old. the hemodynamic parameters registered at the admittance and during the therapy had no significant difference between the groups. the control group received hf therapy during . ± . days and the intervention group . ± . days. there wasn't any difference either in the administration of vasoactive drugs between both groups. the most significant difference between the groups was the -day survival rate, . % of the experimental group against . % of the control group (p = . ). from these results we can conclude that very high volume hemofiltration therapy should be the therapy of election because it improves the survival of patients with severe sepsis without impairing the hemodynamic parameters. we have to point out the importance of the nursing staff in the assembly and management of the equipment as well as in the patient care and thus avoiding potential complications. introduction. the use of herbal products is increasing, and may result in increased drug-herb interactions or form a potential for adverse reactions in cardiovascular surgery patients. objectives. the aim of this study was to describe the utilization patterns for herbal products in patients with cardiovascular disease. methods. this was a descriptive study which was carried out among adult patients presenting to cardiovascular surgery department for elective cardiac surgery between september and april in a research and training hospital. after giving informed consent, patients were interviewed by researchers using a structured survey instrument in the preoperative period. results. interviews were conducted with patients (mean age . ± . , range: - years), % of them were married, % were men, and % of the patients had high school or university education. the majority ( %) had coronary artery disease and most of the patients ( %) had concomitant diabetes mellitus and hypertension. the most common used drugs were anti-hypertensives, nsai's, and anti-aggregants. most patients ( %) reported the regular use of drugs. eighty-nine ( %) among the surveyed patients reported the use of herbal products. the most common used herbal products were garlic ( %), apple vinegar ( %), lavandula stoechas ( %), cratageus ( %) and ginger-honey mixture ( %). the average educational degree of herbal product users was found to be higher when compared with the others. many patients report being informed about those products from television, internet, newspapers, herbal-stores personal communications, and report the use of those products after the diagnosis is made. none of those patients have informed physicians or nursing staff about the use of those herbs. the demographic variables of patients and the herbal-product usage has failed to show a statistically significant difference (p [ . ). conclusions. the use of herbal products is common among the patients with cardiovascular diseases. health professionals should be aware of the usage of those products in order to prevent possible adverse reactions and drug-herb interactions. introduction. nurses employed in the icu operate in a complex environment, under time pressure, and with limited information available. thus, errors are inevitable and, besides their adverse consequences, they offer the potential for learning . in this concept, properly copying with errors is a prerequisite for avoiding their recurrence and improving nursing practice. objectives. our aim was to investigate how error-copying strategies are associated with constructive and defensive changes in icu nursing practice. methods. questionnaires were completed (a % response rate) from nurses employed in the icus of adults, children, and the coronary care unit of two greek hospitals, between january-june . ''ways of copying'' scale as revised by wu et al. was used for evaluating copying strategies. this includes copying subscales, each ranging between and . constructive changes in response to error included items (paying more attention to detail, keeping better patient records, reading patient notes more carefully, seeking advice, discussing with colleagues about similar situations, devoting more observation on patients, reading for covering knowledge deficiencies), while defensive changes included items (getting more worried, feeling less confident at work, being more likely not to discuss errors, being less trusting of others, thinking to leave profession.). a four-point likert scale ( - ) was used for evaluating each item, and points were summed to estimate total scores of constructive and defensive changes. . . % of participants were female and . % were registered nurses. mean (±se) age was . ± . years and mean icu experience was . ± . years. multiple linear regressions with constructive and defensive changes in practice as dependent variables and copying strategies as independent variables are summarized in table . participants were more likely to make constructive changes if they coped by seeking social support (p = . ) and accepting responsibility (p = . ). at the same time, they were more likely to make defensive changes if they coped by escape-avoidance (p = . ). reasons for high risks are e.g. sedation and analgesia, immobility, malnutrition and hemodynamic or oxygenation problems as well as poor identification or unsystematic assessment of the risks. in our unit, we performed a months retrospective review of pressure ulcer risks for all patients (n = ) using jackson-cubbin calculator. the risk point level in this instrument is and below. patients of ( %) exceeded the risk limit already in the icu admission phase. objectives. to change care practices of pressure ulcer prevention and care with action research. with the measurement tool nurses are able to identify patients at risk of developing pressure ulcers during the whole icu in-patient time, and to prevent risks of pressure ulcer in an early stage. with the assessment tool, the measurement is systematic which enables the benchmarking and have effects on material recourse planning and cost caused by pressure ulcers. the study unit is a -bed icu for adults taking care annually circa , patients with multiple disorders. firstly, the jackson-cubbin pressure area risk calculator was translated into finnish. a few changes which have an effect on pressure ulcer risk were added; weight limits were also defined with bmi values, hyperbaric oxygen therapy was added in deducted points as well as h limit for blood transfusions and limits for hypothermia from celsius or under. secondly, standardized guidelines for different risk levels were developed; if patients have a high risk specialized mattresses should be used and changes of positions and beds should be stressed. thirdly, an electronic evolution form for patient information system was planned and implemented. finally, a systematic education program for icu personnel including special lectures, material demonstrations and familiarization by the nurse responsible for wound care was started. results. after the development project and systematic education the knowledge of personnel about pressure ulcer risks and care has increased. risk points are counted once a day for every patient using the electronic form. all the mattresses at the icu have been changed to medium and high risk mattresses and are chosen for a patient related to the risk assessment points. conclusions. a reliable assessment scale, systematic measurement and continuous evaluation and education are crucial for identification of high risk pressure ulcer patient at the icus. with a systematic measurement and recognizing high risk patients we can also improve patients' quality of life and reduce the cost caused by pressure ulcers. reference(s ) is considered to be one of the main agents in gram negative sepsis. in recent years several adsorption dispositives have been designed in order to achieve low blood endotoxin levels with a theorical clinical improvement. toramyxin (polymixine b fixed to polyesthirene fibers) and alteco lps adsorber (polyethylene discs) are two of these dispositives. both are used with h sessions for several days until patient clinical improvement. • design a nursery prothocol with the most important procedures in gram negative septic shock patients with acute renal failure that undergo adsorption cartridge therapy. • evaluate initial experience in the use of endotoxin adsorption cartridges. methods. nursery prothocol with special attention to the settlement and management of the cartridge therapy, based on library references and practice guidelines. once prothocol was stablised, prospective observational study was started from january till january . inclusion criteria were: patients admitted to our intensive care department with gram negative confirmed septic shock and acute renal dysfunction requiring continuous renal replacement therapies (crrt). adsorptive cartridge were added and several parameters were studied: heart rate, mean blood pressure, vasopressor support (norepinephrine), pao / fio , and lactate. the information was analyzed in excel. results. nursery protocol was correctly applied in all patients and showed to be basic in the maintenance and early complication detection. hemodynamic improvement that allowed norepinephrine lowering dose and normalized lactate levels with no changes in pao /fio . patient (toraymyxin): years man, acute pancreatitis with septic shock. patient (toraymyxin): years man, pneumococic pneumonia and klebsiella septic shock. patient (alteco): years man, acute pancreatitis with enterobacter cloacae septic shock. patient (alteco): years woman, acute peritonitis with e. coli septic shock. results of a program to reduce catheter-related blood-stream infection in the icu: two years' follow-up a systematic review comparing the relative effectiveness of antimicrobial-coated catheters in intensive care units benefits of minocycline and rifampicin-impregnated central venous catheters which antimicrobial impregnated central venous catheter should we use? modeling the costs and outcomes of antimicrobial catheter use when is hit really hit? anticoagulative management of patients requiring left ventricular assist device implantation and suffering from heparin-induced thrombocytopenia type ii -hit happens: diagnosis and evaluating the patient with heparininduced thrombocytopenia informe del registro mami - grupo de trabajo de la sociedad europea de cardiología (esc) sobre marcapasos y terapia de resincronización cardíaca moreno millán e. variación de la estancia preoperatoria en españa según grupos de edad, sexo y modo de acceso hospitalario reference(s). . association of anaesthetists of great britain & ireland. safety guideline on interhospital transfer intensive care society: guidelines for the transport of the critically ill adult competency-based st st training and assessment. a manual for trainees and trainers. royal college of anaesthetists training and assessment of competency of trainees in the transfer of critically ill patients adverse events experienced while transferring the critically ill patient from ed to the icu a modified mccabe score for stratification of patients after intensive care unit discharge: the sabadell score surviving intensive care. edicion taurine and niacin block lung injury and fibrosis by down-regulating bleomycin-induced activation of transcription nuclear factor-kappab in mice antioxidants and sepsis: can we find the ideal approach? post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. a scientific statement from the international liaison committee on resuscitation therapeutic hypothermia after cardiac arrest: unintentional overcooling is common using ice packs and conventional cooling blankets it's well known that normobaric hyperoxia (nh) increases arterial and brain oxygen tension. however the influence of nh on intracranial pressure (icp) and cerebral metabolism in patients to investigate the dynamics of icp, jugular bulb saturation (svjo ), brain oxygen tension (pbro ) and cerebral metabolism during nh in patients with ich icp monitoring and tissue microdialysis were used in all patients, svjo monitoring -in , pbro -in . microdialysis and pbro catheters were placed in lesioned (les) and intact (int) brain tissue. icp, svjo , pbro , glucose and glycerol levels, lactate/pyruvate ratio dynamics during fio ) to ± mmhg (ð \ . ) (fio . ) and ± mmhg (ð \ . ) (fio . ) cerebral metabolism didn t change significantly, except glycerol level increase in lesioned brain tissue from ( ; ) mlmol/l (fio . ) to ( ; ) mlmol/l (fio . ) and ( ; ) mlmol/l (fio . ). fio . : glucose (int) - . ( . ; . ) mmol/l, glucose (les) - . ( . ; . ) mmol/l, lactat/piruvat (int) - . ( . icp was stable during investigation ( . ± . mmhg nh is accompanied by pao and pbro increase and doesn't influence icp and cerebral metabolism in ich patients with normal vo /do relationships effects of anesthetics oc cerebral blood flow and cerebral metabolic rate isoflurane preconditioning improves long-term neurologic outcome after hypoxic-ischemic brain injury in neonatal rats this no-profit trial has been supported by depuy/ hemedex, providing the probes. no other economical support has been received effect of equiosmolar solutions of mannitol versus hypertonic saline on intraoperative brain relaxation and electrolyte balance a comparison of % hypertonic saline and mannitol for brain relaxation during elective supratentorial brain tumor surgery hypertonic resuscitation and blood coagulation: in vitro comparison of several hypertonic solutions for their action on platelets and plasma coagulation effect of the combination of mannitol and ringer acetate or hydroxyethyl starch on whole blood coagulation in vitro no well defined threshold for transfusion or target hemoglobin (hb) level for these patients exists. objectives. to examine associations of anemia and transfusion with adverse outcomes in patients with sah, and better define hb level thresholds associated with these. methods. retrospective, observational study of consecutive patients with sah admitted to icus at mayo clinic in jacksonville and rochester, usa, over -year period. data included demographics, nadir hb, blood transfusion, ali/ards, vasospasm, radiographically confirmed cerebral infarction, apache and wfns. primary outcome was association of anemia and transfusion with death and secondary outcomes were vasospasm, cerebral infarction and ali/ards. results. we identified patients, mean age was (± ), ( %) were females. mortality was %. seventy-two ( %) of patients were transfused. ( %) patients had vasospasm and ( %) cerebral infarction. there was a strong association between transfusion and increased mortality (p = . ), vasospasm (p = . ), cerebral infarction (p \ . ) and ali/ards (p \ . ) outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than ct abnormalities comparison of simultaneous continuous intracranial pressure (icp) signals from a codman and a camino icp sensor therapeutic actions may correct abnormal values and perform potentially cerebral blood flow/oxygen extraction coupling. objectives. aim of this study was to describe the incidence and the type of bedside icu monitoring devices used in the management of patients with severe tbi in french icu's. methods. multicentric observational study including patients having severe tbi (glasgow coma scale (gcs) \ ) picked on scene by a mobile medical unit for pre-hospital care (samu). inclusion period: months general hospital of athens, department of intensive care unit o poder na relação enfermeiro-utente relacionamento enfermeiro, paciente e família: factores comportamentais associados à qualidade da assistência investigação qualitativa em enfermagem: avançando o imperativo humanista the experiences of families of critically ill patients in greece: a social constructionist grounded theory study. intensive and critical care nursing visiting hours policies in new england intensive care units: strategies for improvement this study was supported by a post graduate programme in nursing surviving the nursing shortage: developing a nursing orientation program to prepare and retain intensive care unit nurses clinical utility of apc-pci (activated protein c-protein c inhibitor) complex as predictors for severity and prognosis in sepsis: preliminary study republic of korea introduction. recently human recombinant activated protein c (drotrecogin alfa [activated]) has been shown to reduce mortality in severe sepsis. in severe sepsis, conversion of protein c to apc (activated protein c) is impaired due to endothelial dysfunction. apc level is related to coagulation cascade known to be important in sepsis pathophysiology. objectives. in this preliminary study, we checked apc-pci (activated protein c-protein c inhibitor) complex level to evaluate protein c activation using apc-pci elisa kit they were admitted asan medical center (seoul, korea) medical intensive care unit (icu) between sep and . , respectively. apc-pci level had no statistically difference among sepsis, severe sepsis, septic shock ( . , . , . ng/ml, p = . ). between hospital survivor group and non-survivor group there was also no difference in apc-pci level ( . , . ng/ml but apc-pci level was tended to decrease in severe sepsis, septic shock group as compared to sepsis group activated protein c versus protein c in severe sepsis endogenous protein c activation in patients with severe sepsis efficacy and safety of recombinant human activated protein c for severe sepsis septic critical patients to evaluate the experience with drotrecogine alfa (da) in septic critical patients (scp) in a analysis of scp admitted in an icu unit between december and which received treatment with da. patients were included or excluded on the approved specifications fda and emea. inclusion criteria were septic patients and apache ii score c and/or two or more organ dysfunction (od) thirty-eight patients were eligible od: respiratory %, renal %, cardiovascular %, metabolic %, hematologic %; sdra . , vmc . , vni, . , all patients received empirical antibiotic treatment in the first h according to epidemiologic characteristics. microbiology: some germens were isolated in patients ( %) mortality (%) by presumed site of infection day /day : respiratory / , abdominal / , urologic / ; skin / . average hours drug administration was h. da was administrated at % of the patients between hour and hour , the other % between hour y critical septic patient treated early with empirical antibiotics, the best standard care and da have a low mortality rate. more early da administration was associated to lower mortality the treatment of severe sepsis in france: overview of a -year survey period bichat hospital, surgical intensive care unit lariboisière university hospital, medical intensive care unit cochrane database leptin is an adipocyte-derived cytokine regulating energy homeostasis, metabolism as well as immune-inflammatory processes. leptin also has thermogenic actions and regulates enzymes of fatty acid oxidation. leptin is significantly increased in response to acute infection and sepsis and exerts direct effects on cd + t-lymphocyte proliferation, macrophage phagocytosis, and secretion of inflammatory cytokines such as il- and tumor necrosis factor (tnf) a. we measured leptin in blood of septic patients we measured leptin serum levels in septic patients leptin levels in septic patients (mw = , . ng/ml ± sem = , . ng/ ml) are significantly higher compared to healthy controls (mw = , . ng/ ml ± sem = , . ng/ml, p \ . ). serum levels of leptin were significantly higher on day (mw = , . ng/ml ±sem = , . ng/ml) and day (mw = , . ng/ ml ± sem = the aim of this multi-centre retrospective observational study was to resuscitation bundle the above preliminary data indicated that an experienced use of rhapc, when compared to other survey ( ), was associated with a reduction of serious bleeding events, a more frequent off-label use and a similar mortality rate. the concomitant adherence to evidence-based guidelines improved significantly the patient survival ) macias et al. sources of variability on the estimate of treatment effect in the prowess trial: implications for the design and conduct of future studies in severe sepsis use of drotrecogin alfa (activated) in italian intensive care units: the results of a nationwide survey acute lung injury (ali) is one of the most frequent complications of sepsis. although coecum ligation and puncture (clp)-induced sepsis is a frequently used model, we found only three microarray studies of clp-induced sepsis - , of which one looked at lung tissue . none of them had examined the effects of recombinant human myocardial transcriptional profiles in a murine model of sepsis: evidence for the importance of age molecular signatures of sepsis: multiorgan gene expression profiles of systemic inflammation sepsis gene expression profiling: murine splenic compared with hepatic responses determined by using complementary dna microarrays endothelin- in endotoxin-and sepsis-induced lung injury activated) in real-life clinical practice for management of severe sepsis in surgical patients in patients with severe sepsis and multiple organ dysfunction, major surgery is not a contraindication for early ( - h after surgery) daa administration retrospective, observational, descriptive cohort study in patients with severe sepsis and multiple organ dysfunction treated with daa the principal focus of sepsis differed between the two groups (p \ . ): in the surgical group it was the abdomen ( . %) followed by the skin and soft tissues %) followed by the urinary tract ( . %) in the perfusion period, the distribution of severe/ moderate hemorrhages in the surgical group was %/ . vs. . %/ . % in the medical group. we found no differences between groups in death from any cause at days ( . vs. . %; rr ; % ci . - . ; p = . ). nevertheless, at days overall mortality had increased in both groups, although this difference was not statistically significant: the percentage of increase with respect to the -day mortality was % in the surgical group and % in the medical group in patients with severe sepsis and multiple organ dysfunction, major surgery is not a contraindication for early ( - h after surgery) daa administration. given our findings at days, studies including a wider period from the initiation of daa administration are necessary to evaluate the cost-efficacy efficacy and safety of recombinant human activated protein c for severe sepsis recombinant human activated protein c, package labeling and hemorrhage risk reference(s). iom. to err is human incidence of adverse events and negligence in hospitalized patients matrix metalloproteinase- promotes repair after ventila-tor-induced lung injury supported by the parker b. francis foundation, physician services incorporate, ontario thoracic society and canadian lung association sepsis-induced immuno-endocrine dysfunction impact of arginine-vasopressin (avp) and apelin (apl) exogenous administrations in a rodent model because the corticotrophic pathway is disturbed during circi, with acth-cortisol dissociation, alternative physiologically nondominant pathways such as the vasopressinergic/apelinergic axis, become essential to the hpa adaptation to stress. objectives. seeking the impact of arginine-vasopressin (avp) and apelin (apl) exogenous administrations on: acth & corticosterone blood contents, and respective pituitary and adrenal gland receptor expression (v b, apj) in a rodent model of endotoxin challenge. methods. a rodent model of endotoxin (lps e. coli :b , mg/kg i/p)-induced hpa axis has been selected to study the committment of avp/apl and related receptors (v b/ apj). rats (n = ) were equipped with subcutaneous osmotic minipumps (alzet, ) containing: saline, apl- ( , , , lg), or avp ( . , lg) for h. results. without lps challenge, exogenous apl administration did not alter acth & corticosterone blood contents whereas high dosage of exogenous avp significantly increased corticosterone blood content (p \ . vs. control). lps i/p challenge induced a huge increased of blood acth & corticosterone, both culminating at . h ( -and -fold increases respectively, p \ . vs. baseline), which was normalizing at h for acth whereas corticosterone remained high. this dissociation validates the model, matchs with human observations, and suggests non acth-dependent corticosterone release after lps challenge apl administration completely reversed the above down-regulation while avp also partially restored apj pituitary expression by almost % in a dose-dependent manner, and to a lesser degree in the adrenal gland (p \ . vs. lps). selective non-peptide v b (ssr ) and peptide apl antagonists (f a) substitutions confirmed the above effects were directely mediated. conclusions. apl and avp pituitary neuronal and bloodstream contents behave differently, and blood acth & corticosterone contents were dissociated, after acute lps challenge. apl as well as avp exogenous administrations were able to reverse (partially for the later) the lps-induced apj down-regulation in both pituitary and adrenal glands. reference(s) supported by the esicm young investigator award from infection diagnosis to therapy an antimicrobial stewardship program (asp) is a method of optimizing antimicrobial prescribing, altering antimicrobial resistance, reducing costs, and improving patient care. the intensive care unit (icu) is an ideal environment for the application of an asp given the complexity of the patient population, the ecology of resistant organisms, and the fact that selection of inappropriate antimicrobials or delays to determine the impact of the introduction of an icu asp on prescribing, patient outcomes, resistance, and costs we implemented an asp in a -bed medical surgical icu of a university-affiliated hospital. the asp team used prospective audit with interaction and feedback providing suggested changes in therapy (e.g. antibiotic choice, dose, duration) on a daily basis. asp provided consultation on all icu patients not followed by the infectious diseases consult service. parameters collected included demographic data, details of antimicrobial regimens, culture results, defined daily doses (ddd)/ patient days and antimicrobial costs mean monthly antibacterial ddd/ patient-days post-asp was reduced by . % ( . vs. . , p \ . ). the implementation of the asp was associated with a . % decrease in mean monthly antibiotic costs/ patient-days ($ vs. $ ) for a total cost reduction of $ , . in terms of prescribing and resistance, the introduction of asp was associated with a reduction in the prescribing of anti-pseudomonal agents (compared with antibiotics not covering pseudomonas) (mean monthly ratio . vs. . ), mrsa vs. mssa covering antibiotics (mean monthly ratio . vs. . ) and improved susceptibility pattern for pseudomonas aeruginosa as demonstrated by increases of , and % to tobramycin, meropenem, and piperacillin-tazobactam susceptibilities, respectively. there was no difference in icu mortality rate the asp team worked collaboratively with the icu team to improve antimicrobial therapy and as a result improved overall antibiotic usage and resistance patterns of important icu microorganisms, and decreased antimicrobial costs. appropriate and judicious antimicrobial use guided by an asp is beneficial to the icu can pct and/or crp help identify associated bacterial infection in patients with influenza pneumonia? procalcitonin (pct) is a recognized marker of bacterial infection and might be a prognostic marker in lower respiratory tract infections. objectives. to determine if pct and/or c-reactive protein (crp) levels at admission in intensive care unit can help identify associated bacterial infection in patients with influenzae pneumonia. methods. a nationwide registry (reva) was set up in france during the h n influenza pandemic. levels of pct and crp at icu admission were compared between patients presenting with influenzae pneumonia associated or not with a bacterial coinfection. results. patients were included, of whom received antibiotics prior to hospitalization. of the remaining patients, ( %) had documented bacterial co-infection. the bacteria involved in the co-infections were streptococcus pneumoniae (n = , . %), staphylococcus aureus (n = , . %), streptococcus a group (n = , . %). figure shows the initial values of procalcitonin and crp. median values for both pct ( . vs. . ng/ml, p \ . ) and crp ( vs. mg/l, p = . ) were significantly higher in patients with bacterial coinfection. the area under the roc curve was . and . , respectively for pct and crp. a cutoff of[ . ng/ml for pct (sensitivity % and specificity %) best identified patients with bacterial co-infection. for crp, a cutoff of[ mg/l (sensitivity %, specificity %) best identified patients with bacterial co-infections. comparison of the h n pneumonia and bacterial pneumonia group revealed no differences except for a higher saps in the latter pro endothelin (pro et) and copeptin (pro vasopressin cp)) for diagnosing infection in patients with severe acute dyspnea. methods. we designed a prospective study of patients admitted in emergency department (ed) and medical intensive care unit (icu) in a university hospital. inclusion criteria were acute dyspnea with spo b % and/or respiratory rate c b/min. patients with obvious myocardial infarction or pneumothorax were excluded. all clinical and biological data were recorded and biomarkers sampled. an independent blinded expert panel classified the patients according to all the available data including response to treatment and outcomes blindly to biomarkers' results. the roles of biomarkers were assessed quantitatively and then using terciles of the distribution. the contribution of the biomarkers in the diagnosis was assessed using auc-roc curves and by multiple logistic regression taking into account other clinical and biological explanatory variables. results. consecutive patients ( % male, med age years, day mortality %) were enrolled. the final diagnosis was severe sepsis for ( . %) (pulmonary: n = , non-pulmonary n = ). the parameters independently associated with infection lead to a clinico-biological model with an auc = . and a good calibration (p (hlchi ) = . ) and included temperature, arterial pressure, cyanosis, stupor and coma, orthopnea, localized chest sound abnormalities, pao /fio ratio and localized infiltrate on chest x ray although new biomarkers were different between septic and non septic patients with severe acute dyspnea, only mid pro-anp may add a significant contribution. further analysis about the prognostic value of these biomarkers is ongoing grenoble university hospital and brahms diagnostic czech republic, st faculty of medicine charles university and thomayers' hospital, anesthesiology and intensive care medicine fluid management with cvp is still common despite lack of efficacy. objectives. implement stroke volume maximisation during major surgery using odm guided fluid challenges. assess impact of odm use on central venous line insertion rates. identify and overcome barriers to adoption of odm technology. methods. nhs technology adoption centre project (ntac) supported an implementation project at hospitals. the audit into central catheter use during major surgery was undertaken at manchester royal infirmary. fourteen anaesthetic consultants volunteered to champion odm use to guide targeted fluid challenges with hes / . (voluven, fresenius kabi) within a range of major surgical procedures (colo-rectal, hepatic, pancreaticobiliary, urological, reno-pancreas transplant and emergency surgery). prospective data was collected for patients who underwent major surgery between with no significant differences in preoperative risk, intervention patients had enhanced post-operative outcomes. cvc insertion reduced after anaesthetists had the opportunity to use odm to guide fluid therapy. reference(s) clinically used fluids modify in vitro phenotype and function of circulating immune cells peri-operative fluid loading, i.e. ''hemodynamic optimization'', reduces post-operative complications and hospital length of stay. mechanisms involving perfusion have been studied, but fluid could also alter phenotype and function of circulating immune cells, and consequently the systemic inflammatory response induced by surgery blood from control donors has been diluted in crystalloid fluid (isotonic saline, wsio), colloids (hydroxyethyl starch (hes kd, . %) and % albumin solution (alb)), or autologous plasma, which corresponds to clinical situations in programmed anesthesia and surgery. two dilution levels have been studied, to achieve - g/dl hemoglobin (dilution ) and - g/dl (dilution ) )* cd mono (sites/cell) , ( , ) , ( , )* , ( , ) , ( , )* , ( , )* cd b pmn (sites/cell) alb only increased ord, but not activation and adhesion markers. conclusions. wsio had clear anti-inflammatory properties, whereas colloids were more inflammatory, with a dissociation of the effects between different types of fluids. mechanisms have to be precised, especially regarding physico-chemical, immuno-inflammatory and metabolic regulations. reference(s). none. grant acknowledgment. plan quadriennal outcome-related factors federacion panamericana e iberica de sociedades de medicina critica y terapia intensiva (fpimcti) our aim was to conduct a multicenter study to evaluate the epidemiology of delirium in intensive care units (icu) a -day point-prevalence study was performed with the aim of describing in icus from countries in south and north america and spain % were admitted to the icu due to medical causes and sepsis was the main diagnosis (n = , . %). patients were sedated and only ( . %) patients could be evaluated with the cam-icu. the prevalence of delirium was . % (n = ). as compared to patients without delirium, those with the diagnosis of delirium had a higher severity of illness at admission as demonstrated by higher sofa increased use of invasive devices such as central venous catheter (p \ . ), arterial catheter (p = . ) and urinary catheter (p = . ) were more frequent in patients with delirium. on multivariate analysis, delirium was independently associated with increased icu mortality in this one-day international study, delirium was frequent in icu patients and associated with increased mortality and icu los. the main modifiable risk factors associated with the diagnosis of delirium were the use of invasive devices and sedatives the study was funded by the federacion panamericana e iberica de sociedades de medicina critica y terapia intensiva (fpimcti). the fpimcti has used in part an educational grant from hospira recent studies suggest that increased blood glucose variability (bgv) is associated with icu mortality . hypothermia is known to induce insulin resistance, thus potentially increasing bgv. no studies however have examined the effect of therapeutic hypothermia (th) on insulin requirements and bgv. objectives. to examine the effect of th on bgv and its relationship to all patients were treated with intravenous insulin (blood glucose target - mm), according to a written algorithm, with nurse-driven adjustment of insulin dose. for each patient, standard deviation of repeated blood glucose samples was used to calculate bgv. two time-points, comparable in duration, were studied: th (stable maintenance phase, i.e. - h, core temp ± °c) vs. normothermia (nt, i.e. after rewarming, stable normothermic phase, core temp ± °c). mortality and neurological recovery (glasgow-pittsburgh cerebral performance categories, cpc, dichotomized as good = cpc - vs. poor = cpc - ) were assessed at hospital discharge. statistical analysis was performed with anova for repeated measures therapeutic hypothermia is associated with increased insulin requirements and higher blood glucose variability, which in turn correlates with worse prognosis in patients with post-ca coma. strategies aimed to maintain stable glycemic profile and avoid blood glucose variability might contribute to optimize the management of th and may translate into better outcome glucose variability is associated with intensive care unit mortality therapeutic hypothermia post cardiac arrest has been shown to improve survival and neurological outcome . there are approximately , treated cardiac arrests in the uk each year with one-eighth we aimed to establish if implementation of an agreed care bundle including therapeutic hypothermia reduced mortality and improved neurological outcome patients were categorized according to initial cardiac rhythm, ventricular fibrillation/tachycardia (vf/vt) or non-vf/vt. we recorded the degree of implementation of the post cardiac arrest care bundle, comprising; coronary reperfusion, haemodynamic optimisation, control of ventilation, blood glucose, temperature and seizures. data was compared with survival to discharge and neurological function there were ihas, male (mean age . years) and female ( . years) and oohas, male ( . years) and female ( . years). the predominant presenting rhythm in oohas was vf/vt ( . %) compared to ihas which was non vf/vt ( . %). underlying co-morbidities included - °c) was achieved in % of vf/vt oohas compared to . % of vf/vt ihas. the complete care bundle was delivered to . % of oohas and . % of ihas survival rates were higher in all patients with complete bundle of care versus those with an incomplete bundle independent of location or rhythm ( . vs. . % p = . ). this improval in survival was also demonstrated in vf/vt arrests receiving the complete bundle of those patients who had a vf/vt arrest, survival with full neurological recovery (gcs on discharge) was higher in those receiving therapeutic hypothermia . versus % where therapeutic hypothermia was not achieved adherence to the post cardiac arrest care bundle led to significantly improved outcome following both vf/vt and non vf/vt arrests. there was a trend towards therapeutic hypothermia improving neurological outcome on discharge reference(s). . the hypothermia after cardiac arrest study group. mild therapeutic hypothermia to improve the neurological outcome after cardiac arrest royal sussex county hospital intensive care unit, brighton, uk for patient data h. altemimi , s. altaf , j. brown , s. al-juboori , v. jadhav queen elizabeth hospital, kings lynn, medical assessment unit, kings lynn, uk introduction. the medical assessment unit (mau) in our district general hospital (with beds) provides assessment and treatment of acute medical patients from general practice (gp) referals and the emergency department (ed). patients arriving in mau are first triaged by the nurses before assessment by junior doctors. the early warning score (ews) is an indepenently verified scoring systems used to prioritise patient assessment. appropriate referal to critical care outreach teams and intensive care units can be triggered by nurses or doctors according to the ews score. clear and seemless referal pathways and communication between those involved with acutely unwell patients is essential. objectives. to measure key performance indicators in the mau and identify specific areas for improvement. methods. retrospective audit of all admissions to medical assessment unit during week in . the following parameters were recorded for patients admitted. patient ages ranged from to : [ . of these, only were reviewed within h. . % of patients reviewed within min. conclusions. in the uk, early warning scores have been developed to trigger early review. the most sophisticated intensive care becomes unnecessarily expensive terminal care when the pre-icu system fails to refer in a timely manner. our results showed that when a patient was recognised as being unwell, they were seen rapidly by the outreach team. however, not all new admissions had their ews documented, overlooking an important opportunity to risk stratify patients before formal medical clerking. our critical care outreach team have prominent role in education to identify abnormal physiology early, and take action as appropriate. immunological host reactions are primarily believed to determine the clinical course of this disease. an overwhelming inflammatory response to microbial invasion may be involved in the pathogenesis of sirs, sepsis and multiple organ failure. it is important to block the inflammatory response and stop or alleviate sepsis injuries. immunotherapy is regarded as effective approach to improve the immunological function. objectives. immunomodulation in the critically ill is an appealing notion because of the abnormal immune responses. the aim of this study is to evaluate the immunomodulation and its mechanism to improve immune function and prognosis in sepsis. methods. experimental part:clp model were divided into three groups including sham group, control group and experimental group. control group only used antibiotic and experimental group used antibiotic plus immunomodulation. blood collection were made after clp model in , , and h. lymphocyte counting, cd +, cd + t lymphocyte and cd /cd ratio were checked. the apoptosis of lymphocyte in thymus and spleen and survival rate were checked. clinical part: prospective analysis seventy patients conformed to the enrolled standard. it was divided into two groups at random. one was control group with regular therapy, the therapy group with ulinastatin plus thymosin-a in a week. the immune index before and after therapy in the , st, rd, thday was observed. results. experimental part: lymphocyte, cd + t lymphocyte and cd /cd ratio in experimental group increased more significant than in control group (p \ . ). lymphocyte apoptosis index of thymus and spleen in control group increased more significant than in experimental group (p \ . ). h-survival rate in experimental group was higher than in control group. clinical part: cd + t lymphocyte, lymphocytes and hla-dr cd + had more significant increase in therapy group than in control group (p \ . ). twenty patients died in the control group and thirteen patients died in the therapy group (p \ . ). conclusions. immunomodulation in sepsis can improve immune function and alleviate the lymphocyte apoptosis and extend the survival time. in recent years, the antiinflammatory effects of niacin by reducing nuclear factor jb (nf-jb) activation have attracted attention. however, the protective effects of niacin on the development of acute lung injury and systemic inflammatory response during sepsis have not been studied.objectives. we performed this study to determine whether niacin attenuates acute lung injury (ali) and improves survival during sepsis and the beneficial effects of niacin are associated with the down-regulation of nf-jb pathway.methods. lipopolysaccharide (lps) at a dosage of mg/kg was injected into the tail vein to induce endotoxemia in rats. then, vehicle, low dose niacin ( mg/kg), or high dose niacin ( mg/kg) diluted in distilled water with same volume ( ml/kg) was administered once to the rats through orogastric tube, respectively. we observed the survival of the subjects. at h post-lps injection, we measured serum tumor necrosis factor-a (tnf-a), interleukin- (il- ) levels, lung cytoplasmic phosphorylated inhibitor jb-a (p-ijb-a), ijb-a, nuclear nf-jb p expressions, nf-jb p dna-binding activity, and ali occurrence.results. high dose niacin improved survival during sepsis. niacin induced dose-dependent reduction of serum tnf-a, il- levels, lung cytoplasmic p-ijb-a, nuclear nf-jb p expressions, nf-jb p dna-binding activity, and ali occurrence in endotoxemic rats. in contrast, niacin preserved lung cytoplasmic ijb-a expression dose-dependently in endotoxemic rats.conclusions. niacin attenuated acute lung injury and improved survival during sepsis in rats. the protective effects of niacin were associated with the down-regulation of nf-jb pathway. niacin can be considered as a therapeutic agent for sepsis. f. barbani , m. boddi , r. cammelli , a. cecchi , e. spinelli , m. bonizzoli , a. peris university of florence, postgraduate school of anesthesia and intensive care, florence, italy, university of florence, department of critical care medicine and surgery, florence, italy, careggi teaching hospital, anesthesia and intensive care unit of emergency department, florence, italy introduction. acute kidney injury (aki) is a frequent complication in critically ill patients. there is emerging evidence that aki can lead to chronic kidney disease and that even only partial renal recovery after aki is associated with a higher long-term mortality.objectives. we investigated whether measurement of renal resistive index (rri) by ultrasound could predict renal function recovery after aki.methods. rri has been determined in patients who had been admitted (jan -feb to our mixed intensive care unit (icu) and referral trauma center (careggi teaching hospital, florence, it) and developed aki. rri measurements were performed within h from aki diagnosis, according to rifle criteria. renal recovery was defined as the return to the normal renal function parameters.results. patients studied were ( male vs. female) with a mean age of . ± . years. aki was due to sepsis (n = ), shock (n = ), rhabdomyolysis (n = ), abdominal compartment syndrome (n = ) and major surgery (n = ). mean length of icu stay was ± days. at discharge patients showed a complete recovery of renal function, while patients had persistent altered renal function parameters or needed renal replacement therapy (rrt); mortality rate was . % ( / ) . rri measured at aki onset was significantly higher in patients with persistence of renal failure than in patients with complete renal recovery ( . ± . vs. . ± . , p \ . ). rri [ . had a sensitivity of % ( % ci - %), a specificity of % ( % ci - %) and a positive likelihood ratio of . ( % ) for persistent renal dysfunction at the discharge.conclusions. our findings suggest that doppler-based determination of rri at the onset of aki can identify those patients who are at greater risk for no complete recovery of renal function. further studies on larger populations are required to confirm these preliminary results so to promote therapies dedicated to this high risk population.conclusions. apache score on admission, hypothermia and mean arterial pressure are not statistically significant, but age approached significance at % level in ccu survival. blood sugar control is not statistically significant at % level but approached significance as p value was less than . for ccu survival. for hospital survival,age is significant at % level; apache score on admission and mean arterial pressure are significant at % level while cardiac index, hypothermia and glycaemic control are not statistically significant . in the intensive care society (ics) published a care bundle for the management of patients following cardiac arrest . the american heart association now recommends regionalisation of post-resuscitation care following out of hospital cardiac arrest (ohca), in a centre capable of providing rapid therapeutic hypothermia, h emergency angiography and percutaneous coronary intervention (pci) as necessary . objectives. the audit's purpose was to evaluate work load, treatment and outcomes of ohca on the icu following publication of the ics care bundle and inception of a h pci service in our hospital. methods. retrospective audit of ohca patients admitted to icu from / to / to examine number admitted, cause of arrest, treatment and mortality. predicted mortality from the icnarc model was used to calculated standardised mortality ratio (smr). comparison was made with an audit of ohca patients between / and / . the sample was subdivided into subgroups with cardiac and non-cardiac cause for ohca. the chi-square test was used in analysis. results. comparison conclusions. we demonstrated: . a significant increase both in the absolute number of ohca and the proportion due to cardiac causes, due in part to in-region transfers for emergency angiography/pci. . a significant increase in the use of angiography and pci, increasing use of therapeutic hypothermia and iabp. . improved survival from previous audit. . better than predicted survival, particularly in the 'cardiac' group. this audit lends support for the protocolised icu care of post-ohca patients in a regional centre able to offer h emergency pci. there is scope for increased use of cooling for arrests of all causes, and extending provision of angiography/pci to vf arrests and those of unknown cause . reference(s). . despite all the research, education and training that has gone into the field of cpr during the last years, survival rates remain bleak for the majority of patients . so, what is lost in translation? much of the problem is that what the medical community is being trained to do is not being replicated in clinical practice . given this discrepancy, along with the deleterious outcomes, we conducted a manikin-based study to assess the quality of ventilation delivered during simulated cpr, in a large uk centre. objectives. to demonstrate whether uk-based medical personal were adhering to ventilation guidelines and to see how this result varied across specialities. methods. a simulated cardiac arrest scenario was undertaken by (a- . , power- %) participants from a range of medical specialties. participants were asked to asynchronously ventilate our manikin for a period of min during which time tidal volumes (tv), minute volume (mv) and ventilation rates (vr) were recorded. to help limit outside influence, at no point during the trial was any feedback about ventilation technique or als principals discussed with the participant. results. the mean and sd across the sample population for the mv, vr and tv were . l min - (sd . ), . min - (sd . ) and ml (sd ) respectively. comparison of groups can be seen in table introduction. mild hypothermia reduces cerebral blood flow (cbf) without concurrent increase of cerebral oxygen extraction rate in the first h after cardiac arrest, indicating a lower cerebral metabolic activity with a preserved metabolic coupling.objectives. the aim of this study was to assess the cerebral blood flow and cerebral oxygen extraction in patients treated with prolonged hypothermia, as previously was performed in newborn infants with perinatal asphyxial encephalopathy . patients were included after restoration of spontaneous circulation (rosc) after asystole, pulseless electrical activity based circulatory arrest or after rosc after ventricular fibrillation based prolonged resuscitation. in this prospective observational study comatose patients after cardiac arrest were treated with prolonged hypothermia for h. after h patients were passively rewarmed. mean flow velocity in the middle cerebral artery (mfv mca ), reflecting cbf, was measured after , , , , , , , , and h after admission to the icu by transcranial doppler (tcd). jugular bulb oxygenation (sjbo ) and arterial oxygenation were measured at intervals of h. introduction. isoflurane is a volatile anesthetic known for its direct vasodilating effect on cerebral vessels, producing a cbf increase. moreover, it has been shown in animal studies that isoflurane has neuroprotective properties, inducing tolerance to ischemia when used as a preconditioning agent. at the present time, isoflurane is not used as a sedative agent in neuroicu because of the fear of an increase in intracranial pressure (icp) caused by the increase in cbf. however, sah patient at risk for vasospasm may benefit from an increase in cbf. the ischemic risk will peak at day - , leaving a window of opportunity for neuroprotection. objectives. we decided to measure rcbf during traditional intravenous sedation with propofol and during volatile sedation with isoflurane in sah patients not having intracranial hypertension. the clinical trial was approved by the hospital irb and registered on trial.gov (nct ). we enrolled sah (fisher - , wfns b ) patients, monitored with an intraparenchimal icp device and a thermal diffusion probe (tdp, hemedex) for the assessment of rcbf. an icp [ mmhg was an exclusion criteria. cerebral and haemodynamic parameters were assessed at steps:step during sedation with propofol - mg/kg/ h; step : after h of sedation with isoflurane . - % mac administered through an anesthetic conserving device; step after h of propofol re-started at the same infusion rate. in all patients sedation with isoflurane produced an increase of rcbf although not yet significant in the population (step : ± ml/ g/min; step : ± step : ± ). jugular vein oxygen saturation, sjo , was significantly higher at the end of the isoflurane step (step : ± %; step : ± ; step : ± ). icp did not change significantly and remained below the pathological threshold (step : . ± ; step : . ± ; step : ± mmhg).conclusions. the small population of this pilot study phase causes a lack in statistical significance, however our data already suggest that isoflurane induces a marked cerebral vasodilatation and an increase in rcbf compared to propofol. patients with a normal icp did not develop an intracranial hypertension. at short and long term and its correlation with severity scales, scales of quality of life and endovascular treatment m there is not a consensus about which scales should be used to define the outcome after aneurysmal subarachnoid hemorrhage. objectives. the purpose of this study was to determine the risk factors and impact on functional outcome and quality of life months after spontaneous sah due to ruptured intracranial aneurysms. methods. we performed a prospective study of patients with aneurysmal spontaneous sah admitted to our centre from july to august . diagnosis of sah was done by ct and ethiological diagnosis by brain angiography. we paid attention to previous pathological history, clinical characteristics at admission and radiological characteristics. the severity was measured by the hunt-hess (hh), wfns, graeb and fisher scales. the months outcome was assessed by the glasgow outcome scale (gos) and modified rankin scale. the basic activities of daily living were evaluated with the barthel index. moreover, patients were asked about their subsequent incorporation to their previous occupation. we divided our population into two groups depending on the clinical grade at admission (hunt-hess scale): group i, hh , or ; and group , hh or . long-term followed up continues. results. during the year of study a total of patients have been included. the mean age of patients was years with a prevalence of % in women, being arterial hypertension and smoking history the main factors of related risk. the angiography was performed in . % of the patients. an aneurysm was confirmed as the origin of the bleeding in . %. poor clinical grade at admission (hh or ) was associated with apache ii, sofa, glucose, more sah computed tomography on admission, and infection and icu stay. there is % mortality in the series. after a months period, group patients (hh or grade) had a severe disability and functional dependence to perform instrumental and basic activities of daily living (p = . ). only % of patients were able to return to their previous occupation months after the initial bleeding. scales and outcome by clinical grade at admission introduction. aneurysmal subarachnoid hemorrhage (asah) remains a therapeutic challenge due to unacceptably high levels of mortality and morbidity. for survivors of the initial insult, cerebral vasospasm and related delayed ischemic deficits are the major determinants of final outcomes. traumatic sah (tsah) occurs in as high as % of patients with tbi, and is associated with a twofold increase in risk of death. statins may be an alternative for conventional treatments of vasospasm due to their beneficial pleiotropic effects on cerebral vasomotor reactivity as well as absence of negative haemodynamic influence.objectives. the goal of our study was to examine the effects atorvastatin therapy on cerebral vasospasm after asah and tsah as well as on short term outcomes of icu patients (length of stay and severity of condition upon discharge from icu). hypertonic saline infusion is an alternative to mannitol to decrease intracranial pressure before craniotomy [ , ] . previous studies have demonstrated that both hypertonic saline and mannitol interfere negatively with various components of blood coagulation [ , ] . normal blood coagulation capacity is essential during craniotomy and, therefore, we created an in vitro model to examine the effects of hypertonic sodium chloride and mannitol solution on whole blood coagulation. fresh citrated whole blood, withdrawn from volunteers, was diluted with . , . or . % sodium chloride solution or % mannitol to make vol.% and vol.% hemodilution in vitro. the diluted blood and undiluted control samples were analyzed with thromboelastometry (rotem Ò ) using two activators, tissue thromboplastin without (extem Ò ) or with cytochalasin (fibtem Ò ). all the study solutions with the same vol.% hemodilution induced comparable decrease in hematocrit. in extem Ò analysis, alpha-angle was smaller in the mannitol group than in the . % or . % sodium chloride group after vol.% dilution (p. ). in vol.% hemodilution, alpha-angle was also more decreased, and clot formation time more delayed in the mannitol group than in the . , . or . % sodium chloride groups in extem Ò analyses (p \ . ). maximum clot firmness (mcf) in extem Ò analysis was similar with all the study solutions after vol.% dilution, but after vol.% dilution mcf was weaker in the mannitol group than in the other groups. mcf was also weaker in . % than in . % sodium chloride group after vol.% dilution. in fibtem Ò analysis, mcf was stronger in the . % sodium chloride group than in the mannitol group after both dilutions (p \ . ). a or vol.% dilution of % mannitol disturbs whole blood coagulation more than equiosmolar . % sodium chloride. this disturbance seems to be attributed to overall clot formation and strength but also to pure fibrin clot firmness. . % sodium chloride might be more favorable than mannitol before craniotomy in patients with high bleeding risk. introduction. delayed cerebral ischemia (dci) is a major complication after aneurysmal subarachnoid haemorrhage (sah), occurring in around % of patients and increasing case fatality . - -fold. induced hypertension, alone or in combination with haemodilution and hypervolemia (triple-h), is used around the world as a therapy in the treatment of dci, but its efficacy in improving outcome is not based on a randomised clinical trial. objectives. to investigate the outcome of induced hypertension versus no induced hypertension in patients with dci after aneurysmal sah. study design a multi-centre, single blinded, randomized controlled trial. study population patients admitted after recent sah with a treated aneurysm and dci based on the onset of a new focal deficit and/or a decrease of the level of consciousness of at least point on the glasgow coma scale with exclusion of other causes of deterioration, will be randomized to either hypertension (n = ) or no hypertension (n = ). interventions in the intervention group, blood pressure will be raised with norepinephrine or additional dobutamin in case of low cardiac output. when clinical improvement occurs, hypertension will be continued for h, after which the dose norepinephrine will be tapered daily, but resumed in case of clinical deterioration. when no clinical improvement occurs within h, induced hypertension will not be continued. patients in the reference group will be treated according to the standardised sah treatment protocol of the participating centre including oral nimodipine and normovolaemia without haemodilution. main outcome measurement the modified rankin scale at months after the sah, will be compared between patients who were randomized to induced hypertension and patients who were randomized to no induced hypertension. objectives. to investigate brain metabolism at different serum glucose levels.methods. six patients with aneurismal sah and vasospasm were enrolled in the study (age . ± . ; male/female / ; . cerebral microdialysis was used in all patients. microdialysis catheters were placed into ''lesioned'' (brain tissue perfused by involved artery) and ''intact'' brain tissue. glucose levels in arterial blood (glu art ) and in brain interstitial fluid were compared. we analyzed brain glucose levels, intracranial pressure (icp), lactate/pyruvate (l/p) ratio, pao , paco and cerebral perfusion pressure (cpp) at blood glucose levels b mmol/l (group i, n = ), . - mmol/l (group ii, n = ), . - mmol/l (group iii, n = ), c mmol/l (group iv, n = ). we found out tight correlation between glucose levels in arterial blood and in ''lesioned'' brain tissue (n = ; r = . ; p \ . ) and weak correlation between gluart and glucose levels in ''intact'' brain tissue (n = ; r = . ; p \ . ). pao , paco , icp and cpp were comparable between groups. glu art was . ± . mmol/l in group i, . ± . mmol/l in group ii, . ± . mmol/l in group iii and . ± . mmol/l in group iv. normal glucose levels in arterial blood (group i) were accompanied by low glucose levels in ''intact'' ( . ± . mmol/l) and ''lesioned'' ( . ± . mmol/l) brain tissue. arterial blood glucose elevation has led to significant increase in brain glucose levels. but brain glucose levels were in normal ranges during hyperglycemia. glucose levels in ''intact'' brain tissue: . ± . mmol/l (group ii), . ± mmol/l (group iii), . ± . mmol/l (group iv). glucose levels in ''lesioned'' brain tissue: . ± . mmol/l (group ii), . ± . (group iii), . ± . (group iv). we didn't find out any significant differences in l/p ratio at different blood glucose levels. however, low glucose levels in ''intact'' brain tissue (b . mmol/l; . ± . mmol/l; n = ) were accompanied by significant increase of l/p ratio ( . ± . vs. . ± . at normal brain glucose levels (c . mmol/l; . ± . mmol/l; n = )). we didn't notice any significant differences in l/p ratio in ''lesioned'' brain tissue at different brain glucose levels, opposite to intact brain tissue. l/p ratio was . ( . ; . ) at glucose levels in ''lesioned'' brain tissue b . mmol/l ( . ± . mmol/l; n = ) vs. ( . ; ) at glucose levels in ''lesioned'' brain tissue c . mmol/l ( . ± . ; n = ).conclusions. hyperglycemia is not accompanied by high glucose levels and brain metabolism impairment in ''intact'' and ''lesioned'' brain tissue in severe patients with aneurismal sah. low glucose levels in ''intact'' brain tissue are related with significant increase of l/p ratio. introduction. the national confidential enquiry into patient outcome and death report found that less than % of patients with a severe head injury received a standard of care that was judged to be good [ ] . our intensive care unit (icu) at the royal cornwall hospital, a large district general hospital, is one of the few non-neurosurgical centres in the uk to use intracranial pressure (icp) monitoring. we aimed to assess if the practice of icp monitoring in our non-neurosurgical centre was valuable and safe. retrospective audit of case notes and charts of all patients admitted with traumatic brain injury receiving icp monitoring over a year period from st january until st january . a total of patients who had icp monitoring for traumatic brain injury were identified. the codman tm strain-gauge catheter was used in all cases, ( %) were male, ( %) were female. mean age was years (range - ). median reported gcs at the scene of injury was (range - ), median gcs prior to intubation was (range - ). median apache score was (range - ). all patients were discussed with the neurosurgical referral centre. patients were monitored for a median of days (range [ ] [ ] [ ] [ ] . icp was raised in patients ( %). elevation of icp triggered the following interventions: patients ( %) received hyperosmolar agents, patients ( %) were treated with therapeutic hypothermia, patients ( %) with barbiturate coma and none of the patients received steroids. patients were transferred to a neurosurgical centre ( % of patients with elevated icp, % of total). complications comprised one minor intracranial haematoma and one monitor failure. review of documented care bundles for head-injury patients revealed: head-up tilt in %, gastric protection in %, normoglycaemia in %, early enteral nutrition in %, appropriate thromboprophylaxis in %, appropriate sedation in % and appropriate analgesia in %. % survived to hospital discharge.conclusions. in our audit the majority of patients received specific treatment for raised icp, which might have gone undetected without invasive icp monitoring. at the same time most patients were managed without neurosurgical intervention. in light of the paucity of neurocritical care beds [ ] this approach appears to help to select a suitable subgroup of patients needing transfer to a specialist centre. our data adds weight to the evidence that icp monitoring is a valuable and safe monitoring modality in a non-neurosurgical icu if used appropriately within established guidelines and in collaboration with a neurosurgical referral centre. introduction. assessment of injury severity and prediction of outcome represent major challenges following severe traumatic brain injury (tbi). objectives. this study was aimed to evaluate relationships between cerebrospinal fluid (csf) levels of purported biomarkers of tbi including glial fibrillary acidic protein (gfap), ubiquitin c-terminal hydrolase (uch-l ) and alpha-ii spectrin breakdown product (sbdp ), and partial pressure of brain tissue oxygen (ptio ) as well as brain temperature during the first h and up to days post-injury.methods. twenty-seven severe tbi patients with csf drainage and invasive monitoring (licox probe) have been studied with quantitative csf-elisa for sbdp , uch-l and gfap on admission and every h up to days. in the first h, biomarker levels decreased while those of ptio increased. all three biomarkers correlated with ptio (p \ . , p = . and p = . , respectively). after the first h, there were statistically significant changes in levels of the three markers as well as in levels of ptio (p = . , p \ . , p = . , p \ . , respectively). however, the correlation between biomarkers and brain tissue oxygenation was sustained and, for uch-l improved (p \ . ). no significant correlations between biomarker levels and brain temperature were found. the results indicate that cfs levels of sbdp , uch-l and gfap are related to ptio following severe tbi. future studies are on their way to unravel whether these biochemical markers and ptio measurement could serve the better care of the head injured. introduction. this was a pilot study to compare the cerebral neurochemical changes in patients with traumatic brain injury (tbi) who underwent conventional blood glucose level (bgl) control and intensive bgl control with continuous titrated insulin.objectives. to demostrate that intensive glycaemic control using insulin induced a decrease of cerebral glucose.methods. this prospective, randomized study was conducted in traumatic brain injury patients in a surgical and trauma intensive care unit. patients admitted over an -month period with tbi were prospectively divided into two groups according to the method used for bgl control: the intensive group consisted of patients who underwent continuous titrated insulin infusion to maintain a lower normoglycemic level of - mmol/l, and the conventional group consisted of patients whose bgl was maintained at between . and . mmol/ l using conventional sliding scale bolus subcutaneous insulin administration. data on cerebral haemodynamics, interstitial brain oxygenation (ptio ( )) and neurochemical monitoring were collected via microcatheters inserted in the penumbral region. we analyzed , cerebral microdialysis samples. in patients treated with intensive insulin therapy, there was a reduction in microdialysis glucose by % of baseline concentration compared with a % reduction in patients treated with a conventional blood glucose level control. intensive insulin therapy was associated with increased incidence of microdialysis markers of cellular distress, elevated glutamate ( ± vs. ± %, p \ . ), elevated lactate/pyruvate ratio ( ± vs. ± %, p \ . ) and low glucose ( ± vs. ± %, p \ . ), and increased global oxygen extraction fraction. cerebral microdialysis glucose was lower in nonsurvivors than in survivors ( . ± . vs. . ± . mmol/l, p \ . ).conclusions. intensive glycaemic control using insulin induced a decrease of cerebral glucose and an increase in microdialysis markers of cellular distress. in patients with severe brain injury, tight systemic glucose control is associated with increased mortality. introduction. we have previously used c-flumazenil positron emission tomography to show that selective neuronal loss in the thalamus is pervasive after traumatic brain injury (tbi) and correlates with functional outcome, findings that are concordant with previous post-mortem data. the mechanisms responsible are unclear, but may involved global hypoxia/ischaemia as well as retrograde degeneration.objectives. we hypothesised that early brain tissue oxygenation would correlate with late diffusion tensor imaging (dti) abnormalities in the thalamus, and therefore, help to provide an explanation for late neuronal loss. nine patients underwent brain tissue oximetry (pbo ) following acute tbi, using a licox pbo probe, sited in structurally normal frontal white matter. mean pbo was calculated for the duration of their intensive care admission. at a median of . months (range - days) they underwent magnetic resonance imaging, including dti. apparent diffusion coefficient adc (maps) were created, adc calculated in regions of interest in the frontal lobes, splenium of the corpus callosum and thalami, and correlated with mean pbo using spearman's rho. ethical approval was obtained from the local research ethics committee, and assent from next-of-kin was obtained in all cases.results. mean pbo was inversely related to adc in both frontal lobes (r = - . and - . ; p = . and . ), and with the adc in the thalamus bilaterally (r = - . and - . ; p = . and p = . ). in contrast, no correlation was seen between mean pbo and adc in the splenium of the corpus callosum, a common site of traumatic axonal injury (tai; p = . ).conclusions. the inverse correlation of mean pbo associated with adcs in the monitored brain region is unsurprising, but the correlations observed with contralateral regions and deep grey matter suggest that the burden of tissue hypoxia has a significant impact on secondary neuronal loss across the brain. in contrast, the lack of correlation with adc changes in an area at risk of tai suggests a less significant impact of hypoxia on the progression or maturation of tai. the correlations with measures of thalamic microstructural injury are particularly significant, since they establish a clear link between acute physiology, tissue fate in key brain regions, and clinical outcome. introduction. earlier studies have suggested that autonomic dysfunction is associated with poor outcome in traumatic brain injury (tbi).objectives. this study was performed to assess changes in baroreceptor sensitivity and heart rate variability as indices of autonomic dysfunction in relation to icu management variables during early tbi.methods. ten patients ( females/ males) with a median age of (interquartile range, iqr, - ) admitted to icu following tbi were prospectively studied for the first consecutive days. all patients were sedated and mechanically ventilated with icp monitoring in place. high fidelity signals at hz were sampled for ecg and invasive arterial pressure (radial) to monitor baroreceptor sensitivity (brs) based on three or more consecutive beats in which successive systolic pressure and rr intervals increased or decreased with the threshold set at mmhg and ms, respectively. heart rate variability (hrv) was analysed by fourier transformation in the low (lf, . - . hz) and high frequency (hf, . - . hz) domains. the lf/hf ratio and total power ( . - . hz) were also calculated for hrv. management variables included use of inotropes, vasopressors, icp, use of decompressive craniectomy, icu length of stay (los) and mortality. statistical significance was set at p \ . using mann-whitney one-way anova and spearman correlation tests. median days (and iqr) were . ( - . ) for inotropes, . ( - ) for vasopressors and . ( - . ) for icu los. brs and lf, hf, lf/hf ratio and total power were all depressed throughout early icu management with no significant changes in the first week. no significant correlations were found between brs/hrv and days on inotropes/vasopressors or icu los. four patients underwent decompressive craniectomy and one patient died while in icu. no correlation was found between these events and brs or hrv changes brs, hrv and icp data conclusions. both brs and hrv were depressed early following tbi but did not correlate to icu management variables. while autonomic dysfunction is evident early in the icu treatment of tbi, no evidence to support an association between severity of impairment and icu outcome was found in this pilot study. introduction. in neurocritical care, raised intracranial pressure (icp) is associated to a poor outcome and its detection still leads the therapeutic management of the patients suffering from head pathologies.objectives. although invasive devices are recommended to detect intracranial pressure (icp), we investigated the correlation and the reliability with non-invasive ultrasound techniques as the optic nerve sheath diameter (onsd) assessed by ultrasonography and the pulsatility index (ip) measured by transcranial doppler sonography (tcd). we included patients suffering from intracranial hypertension, sedated and mechanically ventilated and control individuals, chosen among healthy people. all the patients had icp measured invasively either by external ventricular drains (evd) or intraparenchymal catheter. everyone underwent non-invasive measurements of onsd bilaterally and simultaneous medial cerebral artery ip assessment at the side of the best window.results. onsd had a significant difference between volunteers ( . ± . mm) and patients ( . ± . mm). ip's were . ± . for the control individuals and . ± . for the patients (media icp = ± mmhg) and also revealed a significant difference. onsd strongly correlated with icp (y = . x + . , p \ . , r = . ) whereas ip had some correlation but without statistical significance (y = . x + . , p = . , r = . ). onsd was found wider (p = . ) within patients with both icp and ip abnormal. a strong correlation was found between onsd and ip (y = . x + . , p = . , r = . ). however, we could not find the best cut-off values of onsd and ip for predicting an icp [ mmhg.conclusions. ip and onsd correlated with icp with a stronger reliability results of the latter, suggesting the possibility to integrate their use in the case of icp invasive monitoring would be contraindicated or not available. we studied the effects of normothermic therapy during the acute phase of traumatic brain injury.methods. twenty patients ( males, ± years old) who were admitted in the intensive care unit due to traumatic brain injury (glasgow coma scale upon admission - , marshall scale ii to iv) were studied. if patients' core temperature was above . °c, a cool line Ò , alsius corporation, irvine, ca. usa intravascular heat exchange central venous catheter (coolgard Ò device) was inserted via the femoral or the subclavian route, in order to achieve and maintain a target temperature of °c. intracranial pressure (icp) was measured (a) invasively by means of a intraparenchymal catheter (camino, camino laboratories, san diego, ca, usa) and (b) noninvasively by means of transcranial doppler sonography (tcd), using a philips hd xe (philips medical systems; bothell, wa, usa) equipped with a mhz transducer and a mhz linear transducer. estimated icp was calculated by tcd using the equation proposed by czosnyka and colleagues and the pulsatility index (pi = vs -vd/vm) was assessed in the middle cerebral artery bilaterally. all measurements were conducted at baseline and repeatedly on a daily basis for the next days and the average values were used in the statistical analysis.results. target temperature (t: . ± . °c) was achieved within the next h of the catheter insertion. at baseline (t: . °c) pulsatility index (pimean) was . ± . , icpmean/invasive was ± . mmhg and icpmean/noninvasive was . ± . mmhg. invasive and noninvasive icp values correlated significantly (r = . , p \ . ). following ± h from the insertion of the catheter the above parameters were significantly decreased as compared to baseline values (pimean = . ± . , icpmean/invasive = ± . mmhg, icpmean/noninvasive = . ± . mmhg, respectively; all p \ . ). out of patients, progressed towards brain tamponade, remained in a persistent vegetative state and were discharged with normal consciousness and motor deficits. however, due to the small number of patients no analysis could be performed to estimate the possible impact of normothermic therapy on the survival of these patients. these preliminary results suggest that normothermia during the acute phase of traumatic brain injury may decrease icp and ameliorate cerebral blood flow. introduction. extracranial organ dysfunctions are extremely common in patients with severe traumatic brain injury (tbi). although it has been shown that development of tbiinduced multiple organ failure (mof) is associated with a poor outcome, the underlying mechanisms leading to mof after tbi have not been investigated.objectives. to investigate in vitro the effect of plasma from tbi patients developing different degrees of organ failure on human endothelial cells.methods. ten consecutive severe tbi patients were included. gcs, iss and sofa score were recorded at admission; sofa was also recorded after days. plasma samples were obtained at the same time points. adhesion of freshly isolated human neutrophils on spontaneously transformed human umbelical vein endothelial cells (ecv ) was evaluated after h in vitro stimulation with % of plasma collected from tbi patients days after admission. expression of intercellular adhesion molecule- (icam- ) was assessed by immunofluorescence. to determine the impairment of the endothelial cell barrier function, trans-endothelial electrical resistance (teer) and permeability to fitc-dextran were measured. plasma from healthy volunteers were used as control. data are expressed as mean ± sd. results from different experiments were compared by unpaired t test.results. ten male patients were enrolled, mean age ± , gcs ± , iss ± , sofa was . ± . on admission and ± . on day . plasma derived from tbi patients increased the adhesion of neutrophils on ecv cells ( ± vs. ± cells/field, p \ . ), induced a significant reduction of teer ( . ± . ohm/cm vs. . ± . ohm/cm , p \ . ) and caused a concomitant increase of endothelial permeability to dextran ( . ± . vs. . ± . %, p \ . ) compared to control (healthy plasma). a visual up-regulation of icam- expression was also observed. there was a significant correlation between delta sofa score (day -day ), calculated excluding gcs, and neutrophil adhesion on endothelial cells exposed to plasma from tbi patients (p = . , r = . ).conclusions. plasma from patients with tbi causes the increase of endothelial permeability and neutrophil adhesion, which correlates with the development of extracranial organ dysfunction expressed by sofa. these results suggest a mechanism potentially responsible for the development of mof after traumatic brain injury.grant acknowledgment. fondi universitari ex- %, regione piemonte-ricerca sanitaria finalizzata. objectives. the aim of this study is to describe indications of dc and outcomes in our unit.methods. it is a retrospective revue collecting patients who had a dc for severe icht between january and july . inclusion criteria were: icht refractory to medical management due to cerebral oedema. we define intractable icht as intracranial pression (icp) over cmh o, pupil modification, neurologic deterioration persisting more than min despite medical management or ct scan findings. exclusion criteria were imminent cerebral death, icht due to an acute hematoma, tumour, hydrocephalus and prediction of short life expectancy. objectives. historically, research has targeted problems experienced several months post discharge from critical care, namely using data from follow up clinics \ months after the critical illness. in contrast, this study aimed to review data from patients recently transferred from critical care to the wards. this data can then be compared with patients' progress after earlier rehabilitation. methods. this was a prospective, longitudinal study, involving long stay critical care patients ([ days), between april - . this cohort included all patients nursed within our itu/hdu, regardless of speciality, age or gender. all reviews took place whilst the patients were still hospitalised. the study used qualitative data, using specifically designed questionnaires which highlighted the type of long term problems our patients suffered. these were developed using data from previous informal patient interviews and the had (hospital anxiety and depression) questionnaire. the latter was considered too intrusive for the ward environment. a data base was used to list the frequency of these problems to provide quantitative data. a total of patients were reviewed over years. the qualitative data highlighted different, common morbidities, in addition to disease specific morbidities. between, april - , % of patients demonstrated at least physical or psychological problems and % displayed or more. the quantitative data showed the most prevalent morbidities were: poor mobility at %, nightmares %, loss of appetite % and insomnia %. year showed similar findings, plus global weakness at %.conclusions. this research showed significant post critical illness morbidities in this cohort which appeared to impact on the patients' recovery on the wards. the challenge for our follow up is to target support and rehabilitation whilst the patients are in critical care and then re-evaluate the results. if this expedites a return to a near normal quality of life, it will have improved the efficacy of our service and may impact on follow up care in general. . it may affect the balance of family and change their roles and responsibilities, mainly due to the separation from their relative imposed by hospitalization. this admission may also generate other discomforts to the family, as relationship problems, emergence of diseases, lack of financial resources for expenditures now installed, anxiety, depression, fear and irritability . objective. to get to know the discomfort that characterizes the changes experienced in the daily life of families who have a relative in icu. method. this is a qualitative study, conducted in a general icu of a large hospital in the city of salvador, bahia, brazil, from august to october of . nine relatives of people hospitalized for at least h in icu were interviewed. the data were analyzed by the use of procedures of analysis of grounded theory. results. the hospitalization of a family member in icu produced discomfort for her, as the uncertainty of recovery, the fear of loss and the sudden physical separation of the relative. the interaction between the huge discomfort of life threat and the separation from the relative, in turn, spawned other discomforts in the daily lives of families, expressed by two categories. the first one, having difficulties to answer psychobiological needs, meant for the family member the experience of sleep deprivation, loss of appetite and constant concern with the relative. the second one, suffering a discontinuity in the daily life, meant to the family the disruption of daily activities with the relative, irritability front other family members, removal of the routine of home, loss on work performance and studies and difficulties to enjoy the leisure and recreation.conclusion. the coping of illness and hospitalization of a relative in intensive care produced discomfort for family members, characterized by changing of the routine of the daily life and care for oneself. the family's attention is primarily directed toward the ill relative. it starts to experience the routine of a hospital and disrupts the organization of familiar and personal life, it finds itself suffering a break from daily life. the discomfort experienced by the family can be minimized by practices of the healthcare team, which provide care, information, support, safety and convenience. (fig. ). this is a unique opportunity to study the effects of nursing environment on sleep quality and quantity in icu patients. to study the effects of nursing environment on sleep quality and quantity in icu patients. a total of patients will be included in this ongoing study: ten subjects who were admitted to the old, ward-like icu (fig. ) , and ten patients who will be admitted to the new, single-room icu (fig. ) . objectives. in order to understand the family's perception of nursing care, the authors undertook this study, assessing the family satisfaction and use the results to increase the quality of care.methods. this is a qualitative study of inductive nature. data was collected along the time of the study by in-depth interviews, to six relatives of each patient, after discharge the intensive care unit. for data analysis we followed the steps of the phenomenological method, according to max van manen ( ) . results. from data analysis, the results were divided in categories: ) relative needs; ) icu environment; ) relative's feeling; ) nurses role and ) suggestions. all this categories were grouped in a central theme called ''being a relative in a general intensive care unit''. the results show that relatives of patients admitted to the intensive care unit often require complete knowledge of the medical condition of the patient, a specific area for that purpose and a comfortable waiting room. they express the need to be near the patient and participate in care. they feel fear and anger with the situation that inevitably are forced to live and think, mostly, that nurses are effective and efficient in meeting the needs of the patient and family. conclusions. it is essential to promote attitudes and behaviors that provide comfort, safety and privacy for relatives, and acknowledge that they have a role in the process of care, reinforcing their importance in decision making process.introduction. heart failure (hf) is a complex syndrome that commonly affects elderly patients in whom it has a major impact upon longevity and quality of life. it is usually associated with symptoms such as dyspnoea, fatigue, and fluid retention, and results in frequent episodes of hospitalisation.objectives. this study was planned to examine the relationship between self-care behaviors and quality of life in patients with hf.methods. this study was planned and applied as a descriptive and a cross-sectional study. introduction. the hospitalization of a relative in icu, especially when it's unexpected, is considered a too stressful experience for the family, usually compounded by the disruption of daily life. from the relative's hospitalization at the icu, the family will necessarily interact with health practices, the rationality that underlie it and institutional objects that may be a source of comfort or discomfort , .objectives. to understand the situations defined as comfort to relatives of people in critical state of health and the sense of comfort in this situation.methods. this is a qualitative study conducted in the general icu of a large hospital in the city of salvador, bahia, brazil, from june to october of . fourteen family members of persons hospitalized for at least h in icu were interviewed by a specific questionnaire. all recorded interviews were transcribed and the data were analyzed by the use of procedures to encode the data of grounded theory. seven categories expressed the experience and sense of comfort for the relatives who had a person hospitalized in the icu: ) security: confidence of relatives in technical-scientific and humanistic team and in the possibility of recovery of the person who is hospitalized, ) reception: comfort experienced by the family by being treated as a person by the professional of icu when they interact with a supportive attitude, ) information: comfort experienced by the family when it feels conscious of the reality of the health condition of their relative and to receive guidance about the unit s routine, ) social and spiritual support: comfort experienced by the receiving of help and support of the family, friends and religion, ) proximity: the comfort of being close of the relative and being able to enjoy the interaction established between them, ) convenience: comfort experienced in interacting with pleasant elements and support of basic needs of the family, offered by the environment and physical structure of the hospital; ) integration with itself and the daily: the possibility of the family member to take care of himself, to help the relative and to give continuity to the family routine as it did before the hospitalization.conclusions. the comfort is a positive, subjective and dynamic experience, which changes in time and space, which is the result of the interactions that the individual sets with himself, with those around him and with the situations he faces, without losing view that every family is unique and can experience this process in a proper way. to ascertain the perceptions of icu nurses' about the needs of families of critically ill patients methods. this is a transversal study. the data were collected in four icus in the city of feira de santana, bahia, brazil, after approval by ethics and research committees. all clinical nurses of icus were interviewed. the brazilian adaptation of the critical care family need inventory (inefti) was used for measuring the degree of importance of needs of family members, valued at increasing levels from to . descriptive statistics were used for analysis, needs with a mean score [ were defined as having the greatest importance.results. the nurses identified % of needs as important for family members. the items related to security ''to be sure that the best possible treatment is being offered to the patient'' ( . ± . ), and the information ''to talk to the doctor every day'' ( . ± . ), were pointed out as the most important, with consistent results with the literature. some needs of support ''to have general guidelines on the icu at the first visit'' ( . ± . ) and comfort ''to have a bathroom near the waiting room'' ( . ± . ) were also identified as important. however, the needs of proximity, like being close to their relative was not identified as important to the family for all nurses.conclusions. the nurses identified the need for security and information as important, however the wish that the family has to be near their relative was not considered important, as described in the literature , , . a movement of nursing towards the family can be perceived, so nurses should plan their interventions based on knowledge of the demands of the family in order to promote care for the relief of immediate distress and anguish, which will consequently encourage the recovery of the ill relative reference(s). nurse educator, realized that with an ongoing critical care nursing shortage world wide, even when retention is high, some turnover is inevitable necessitating an orientation tool to guide charge nurses in assigning new hires to critically ill patients. impetus for this clinical orientation tool arose from observations that new hires were often overwhelmed or disengaged at the bedside, and patient assignments did not consistently foster the development of critical care skills. the orientation tool reflected a staged approach to patient assignments; gradually exposing the new hire to progressive levels of complexity. embedded within the tool were guidelines specifying performance competency expected of new hires at month intervals in their first year of critical care practice. evaluation at this stage involved on the spot interviews. use of the tool began in january . since its introduction, this tool has guided patient assignments for newly hired nurses. in six cases, nurses moved through the stages more quickly than anticipated. reports from staff nurses, clinical educator, patient care coordinator and nurse manager suggest that anxiety and stress of novice critical care nurses related to the complexity of patient assignments have decreased, and that the tool's structure provides clear goals and has enhanced satisfaction with the consolidation experience. our goal was to ensure the tool facilitated an optimal learning experience, structured around orientation standards and leading to the development of confident, competent practitioners. future plans for on-going evaluation include: formal surveys with present msicu staff, and exit interviews with nurses new to critical care who have left their msicu positions prior to the introduction of the orientation tool. ( ) has previously been claimed to show an association between improvement of score (or lack of) over time and survival status ( ) . severe sepsis in patients is associated with considerable mortality. activated protein c (apc) is a mediator of the inflammatory and coagulation systems, which has shown decreased mortality in severe sepsis ( ) beyond h sofa scores showed further distinct improvement over the apc infusion period in the survivor group, whereas minimal improvement was seen in the non survivors.change in daily sofa scores conclusions. our analysis appears to agree with levy's previous findings of increasing sofa (albeit modified) scores and mortality. we, however, looked at a different treatment period, (apc infusion rather than first day of sepsis) but, nonetheless, found the same association of increasing score and mortality and decreasing score and survival. the mean age in survivor group was considerably less than that in non survivors and this age discrepancy largely accounts for the difference in mean apache score ( points) between groups. the depicted trend in sofa scores is more apparent beyond the initial h of treatment, and suggests that improving sofa scores and outcome prediction is possible beyond the previously reported h. our numbers are small, but lend support to the predictive potential of repetitive sofa scores and outcome.objectives. this real-life registry was implemented to describe clinical characteristics of patients treated with drotrecogin alfa (activated) (daa) in france and the use of this drug.methods. this national multicenter observational study, proposed to intensive care units (icus) which used daa, was conducted by data abstraction from hospital files of patients admitted in icus and treated by daa. two sets of data were obtained: a) retrospective data collected between january st, and beginning of the prospective phase in each site; b) prospective data for patients treated until november . this current analysis aimed to describe the patients retrospectively enrolled and treated between january and april . statistical analysis was mainly descriptive. conclusions. this study showed a good concordance between the target population and population treated by daa in terms of treating patients with higher disease severity. patients treated in real-life had a particularly severe sepsis as shown by the saps ii score of and high number of organ dysfunctions at time of infusion initiation. the -month observed mortality was lower than the predicted hospital mortality of % with this level of saps ii. introduction. mortality in severe sepsis is variously described, but is often up to % ( ) . activated protein c (apc), a mediator of the inflammatory and coagulation system has shown a decrease of hospital mortality from . to . % ( ) at year post apc we found that patients ( %) out of were still alive ( patients are still less than year post apc and therefore not eligible for consideration). conclusions. this study is limited in size, but demonstrates further favourable evidence to support the administration of apc for patients with severe sepsis, and appears to contradict the cochrane findings ( ) . we have shown that our hospital survival has improved since initial report ( ) . we attribute this improvement in smr to better targeting of apc to the more severely ill septic patients (as evidenced by the increased apache score).longer term survival data was also encouraging, % of our patients were alive at year, post apc. this should be considered against an initial predicted survival to hospital discharge (never mind year) of . %. we find this result very promising, it would appear that initial survival advantage with apc is in fact sustained beyond hospital discharge. objectives. medication errors reported in a self reporting medical incident system were systematically analyzed to identify root causes and obtain preventive measures methods. all medication incidents received within year in a -bed mixed icu, were analyzed by trained persons in analyzing medical adverse events. the systematic approach consisted of five steps. . description of the incident in a causal tree. . all causes were classified into the main categories according to the prisma incident analysis tool (technical failure, organization failure, human failure, patient related and non classified). . all medication errors were categories into the broad stages of medication process (prescription, transcription, preparation, dispensation and administration). . the recovery phase of all near miss were analyzed. . development of an action matrix based on the most suitable solution (equipment, procedures, information/communication, training and motivation) for each root cause. . incidents/near miss were recorded. % were medication or fluid therapy related incidents/near miss. human intervention ( %), verification ( %) and organizational/ protocol ( %) were the most common causes of medication incidents/near miss. % of all errors occurred in the administration phase and % in the prescription phase. the most suitable solution for the recorded medication errors are shown in fig. . conclusions. this systematic approach reveals that introduction of new equipment, such as a patient data management system (pdms), and improvement of the procedures are the most important actions to reduce medication errors in our icu. objectives. this study is a descriptive study which is carried out in order to determine the perspectives of newly graduate and experienced nurses on medication errors working in a military education and research hospital. methods. this study was planned and applied as a descriptive and a cross-sectional study. study was executed at a military education and research hospital in turkey between july and august . totally nurses were involved, of those were newly graduate and were experienced nurses. data collection form which has been prepared by the researches in order to determine the perspectives of nurses on medication errors consists of two parts. the first part consists of questions prepared in order to determine the ages, departments, educational levels, experiences and some informative characteristics of the nurses. in the second part there is questionnaire form on perspectives of the nurses on medication errors which was prepared by gladstone in . the study was applied after written ethical approval of the ethical committee of the military education and research hospital and application permission of the nursing department. the application was realized by surveying on volunteer nurses after making necessary explanations about the aim of the study and the application procedures to the participants. the data were analyzed using percentages, mean ± standard deviation, chisquared test and independent-samples t test. conclusions. in this study among the causes of drug errors; tiredness and exhaustion of nurses is stated in the first place. it is thought that rearrangement of working hours of the nurses, reduction of long working hours by the nursing administration will be effective on preventing drug errors. ( ). to test the basic knowledge and practical implementation of picco measurements by icu personnel. descriptive trial in which (para)medical icu personnel were asked to participate in a written or online survey ( questions based on the information found in the manual of the picco system).results. so far, persons have participated: nurses and medical doctors ( were residents in training), all of them actively working in an icu. in total, % of the respondents knew that a picco co measurement is performed intermittently by transpulmonal thermodilution and on a continuous basis by arterial pulse contour analysis. about % is convinced that a picco measurement is an invasive procedure, while in fact it is considered minimally invasive. opinions are divided upon the indications for picco measurement. some participants do not know that the measurement of extravascular lung water provides valuable additional information in pts with acute hypoxic respiratory failure and some even believe that picco can also measure pulmonary capillary wedge pressures. the basic knowledge on co calibration is insufficient: % do not know that the temperature of the injection fluid should best be below °c and only % know that the volume of the calibration fluid depends on the patients' weight. % faulty believe that the patient has to be in the supine position to perform a measurement and % is not informed on the fact that the co obtained should not differ more than % from the mean co value. only % of the respondents carry out a rapid flush test before each picco measurement and only % know that the calibration fluid has to be injected in less than s to obtain a correct measurement. finally, % believe that it is necessary to input the cvp value to calculate a correct co, although % of the respondents correctly knew what to do in case the delta t°is too small and % could correctly interpret the thermodilution curves displayed in the survey.conclusions. from these data we can conclude that a big variation exists in the knowledge on the basic principles and the practical implementation of picco measurements. some confusion exists with regard to the terminology used. we conclude that (as with any new technique) high quality education on picco measurements is necessary for icu personnel. this education can be facilitated by a good protocol, that can be implemented by nurses and doctors at the bedside to avoid human errors. a.c. beers vu university medical center, intensive care, amsterdam, netherlands health insurance companies in the netherlands sign exclusive contracts with hospitals. patients are more critical and independent. they consciously choose a particular hospital or treatment. this is why our management gave high priority to the subject of customer service in their long term policy plan.objectives. in january a project group was launched, which aimed for a number of specific improvements but also by increasing awareness and enthusiasm for customer experience amongst employees. the project is focused on the experience or perception of patients and visitors.methods. the first step was a baseline measurement by hcg (hospitality consulting group). this measurement included interviews with employees from different icu locations and an online survey that was completed by employees, next of kin and other visitors. this resulted in a high score for commitment of staff towards patients and visitors. remarkably, employees thought that aspects for example reliability, professional care and privacy would be valued higher by customers. they attach more importance to how they are received, to empathy and sympathy. respondents also mentioned other things for improvement for example better signage, improved telephone access, better information about rules and procedures, unambiguity in approach, a better visibility of staff and a pleasant and hygienic department. . several improvements such as product, behavior and environment were achieved: we employed family counsellors, developed an information folder and started a pilot for an improved name badge. we can still make improvements in awareness, behavior and addressing each other on this subject. this year we plan to come to an agreement on standards, competencies and control by means of several management training sessions and workshops for employees. we can measure changes in patient satisfaction by family evaluation surveys or an instrument called netto promotor score. the netto promotor score (nps) indicates how many respondents will recommend our ward or hospital to their family and friends. to quote fred lee: ''if a service is provided as expected, patients or visitors will not remember it, they are merely satisfied. satisfied patients will forget a service quickly, have no story to tell to their family and friends and are not really loyal to your organisation. therefore you must create an unforgettable experience, because an experience that remains in memory, is told to others.'' reference(s). critically ill medical, post-surgical, and trauma patients are at greater risk for hyperglycemia with associated increase in mortality and morbidity. tight glycemic control (tgc) has been well documented as a method to control hyperglycemia by managing blood glucose fluctuations through carefully controlled continuous insulin infusion. in order to determine the amount of time it takes within practice for nurses to implement effectively a tgc protocol within the critical care unit, we conducted a pilot time-in-motion study to elucidate the effect on workload. a time-and-motion study was carried out at a hospital located in london, uk in order to document the time associated with tgc activities. a timing workflow, used to capture the key steps involved with effective tgc implementation when utilizing blood gas analyzers for the determination of whole blood glucose (bg) and the time required to complete each step, was designed and then validated by ccu staff. ccu staff was trained on the timing workflow and mechanism. independent observers shadowed ccu nurses, observing when a blood glucose measurement was taken, which steps were completed, and the length of time required to complete each step. other data such as time of the previous bg measurement and status of the last bg test was collected for analysis purposes. during the past few years, the increased incident rate of medical errors occurring in hospitals under governing of hong kong hospital authority has contributed significant attention from the public and health care policy makers. in such a situation, promote patient safety culture becomes paramount for all health care professionals and hospital settings. interdisciplinary teamwork is important in the intensive care units. the benefits of good teamwork have been well documented in the literatures. they included fewer delays, increase in working moral, increased in job satisfactory and decreased in medical errors. in relation to patient safety, fewer errors occur when there is strong teamwork because patient care activities are planned, well organized and standardized. therefore, substantial attention should be given to decrease of medical errors and nurture patient safety culture within high-risk areas such as icus. objectives.• to examine the perception of teamwork and patient safety culture of doctors and nurses between icus and within icu • to investigate the relationship between teamwork and patient safety culture of icu doctors and nurses methods. a cross-sectional surveyed of doctors and nurses in three intensive care units with various size, level of care and staff to patient ratio of hong kong hospitals. totally icu doctors and nurses have been included in this study. a modification of safety attitudes questionnaire developed by sexton and colleagues in was adopted. results. the overall response rate was . %. there were no significant difference of perception of teamwork and patient safety attitude among studied icu's doctors and nurses. however, icu (a) and icu (c)'s doctors demonstrated more positively and showed significant different in perceptions of teamwork (p = . ; . ) than nurses. regarding patient safety attitude, icu (a)'s doctor also showed significant difference (p = . ) and rated more positively than nurses working in the same clinical area. a highly statistically significant association between patient safety attitude and teamwork was shown in the spearman rho statistics with r s ( ) = . , p = . . conclusions. the rate of agreement on teamwork and patient safety attitude were higher in icu doctors. they were more likely to perceive effective teamwork and patient safety in the working area. nurses tended to rate both items lower. as teamwork has been shown to have strongest relationship with patient safety issues, more attention should be given to improve teamwork for icu nurses. tnf is upregulated within the alveolar space early in the course of ventilator-induced lung injury (vili), and plays a major role in the pathogenesis. we previously found in knockout mice that two tnf receptors play opposing roles during vili, with p promoting but p preventing pulmonary oedema. this suggests that specific blockade of the p receptor within the alveoli is a potential therapeutic strategy for vili. domain antibodies (dabs) are the smallest antigen-binding fragments of the igg molecule, which may have advantages over complete antibodies due to their small size (short half life, enabling regional delivery) and monovalent binding (no receptor cross-linking). objectives. we tested the effects of an intratracheally (i.t.) delivered dab that binds to and inhibits the mouse p receptor (biopharmaceutical r&d, glaxosmithkline), on pulmonary oedema and inflammation during vili. methods. c bl mice were ventilated with a high-stretch protocol (plateau pressure . - . cmh o, tidal volume - ml/kg, peep cmh o, o with - % co ). immediately after the start of high-stretch, mice were given an i.t. bolus of non-specific 'dummy' dab or p -specific dab ( lg in ll) and ventilated for up to h ( -hit model). as a -hit model, ng lps was included in the dab bolus. respiratory elastance (ers) and blood gases were monitored, and bal performed at termination. in the -hit model, lung cell suspension was analysed for intravascular margination of neutrophils (pmn), and bal fluid (balf) assessed for pmn infiltration and alveolar macrophage (am) activation using flow cytometry. results. high-stretch ventilation produced deteriorations in ers and po , and high balf protein in both models. treatment with the p -specific dab substantially attenuated all of these changes in the -hit model (table ). in the -hit model, p blockade prevented deteriorations in ers and po , and significantly decreased pmn margination, intraalveolar pmn infiltration and icam- expression on ams (table ) . introduction. ventilator-induced lung injury (vili) triggers a variety of molecular responses within the lungs. however, the contribution of these pathways to lung repair has not been identified.objective. to identify the molecular mechanisms involved in lung repair after vili.methods. vili was induced in mice by ventilation using high pressures ( cmh o) without peep for min. after this, pressure was decreased to cmh o and peep increased to cmh o for h more to promote lung repair. we quantified histological damage, protein content in alveolar lavage (balf) and different molecules in lung tissue (collagen, matrix metalloproteinases- and - , tnfa, ifnc, il- , il- , mip- and lix) in the different conditions (baseline, after injury and after repair). additionally, survivors and non-survivors to the repair phase were compared. the effects of the differentially released mediators were studied in a wound model using murine alveolar cells cultured in presence of balf obtained from ventilated animals, and human alveolar cells and balf from ventilated patients. results were compared using an anova, with a significance level of p = . . . mice were studied ( at baseline, after injury and after repair). high pressure ventilation caused lung tissue injury, with significant increases in balf protein content, mmp- , mmp- , tnfa and mip- , and a significant decrease in il- . during the repair phase, tissue injury was partially reverted, balf proteins and levels of tnfa decreased, but mmps and mip- persisted elevated. mortality during the repair phase was %. survivors showed lower levels of collagen and higher levels of mmp- ( ± vs. ± units, p \ . ) and mip- ( ± vs. ± pg/mg protein, p \ . ).blockade of mmp- , but not mip- , delayed wound closure in both murine and human alveolar cells cultured in presence of balf from ventilated mice or patients respectively.conclusions. vili is partially reversible by decreasing airway pressures and increasing peep. mmp- promotes epithelial repair.grant acknowledgment. universidad de oviedo (unov- -becdoc), ficyt (cof- - ). introduction. critically ill survivors present significant long-term brain-related morbidity. excessive end-inspiratory stretch during mechanical ventilation (mv), even in healthy lungs, may promote alterations in the local and the systemic inflammatory cascade. the effects of ventilator-induced systemic inflammation on brain structures are unknown. to characterize the role of the ventilatory pattern (high vs. low tidal volume (vt)) in the development of local or systemic inflammatory response and regional neuronal brain activation in rats. brains were processed for c-fos immunohistochemistry, as a cellular marker for activated neurons, in the following regions: thalamus, cerebral cortex, amygdala, hippocampus, hypothalamus, and caudal striatum. data were analyzed using one-way anova (p \ . ). results. map and lung compliance remained stable and in the normal range in both groups. pao decreased and paco increased at h in lvt. mv animals presented high levels of systemic and lung inflammatory mediators compared with baseline levels. hvt significanly increased tnfa and il- in plasma when compared with lvt group. in the lungs mv increased il- , il- , il- b and mip- proteins, irrespective of the vt level (lvt or hvt). mcp- only increased in hvt lungs, while tnfa lung levels are similar in ventilated and non-ventilated animals. a significant increase in the number of c-fos immunopositive neurons was only found in retrosplenial cortex and thalamus in hvt animals as a sign of neuronal activation of those areas. none of these two areas were activated in lvt or in control animals. mechanical ventilation produced a moderated systemic and lung inflammation in the context of a preserved lung function. high tidal volume ventilation promoted differential neuronal activation in the brain compared with lvt animals. these findings suggest a novel cross-talking mechanism between lung and brain in the context of experimental acute lung injury.grant acknowledgment. mec bfu - /bfi, fundació parc taulí. jl-a is senior researcher program i isciii, and ciberes. ( ).in an ex vivo perfused human lung preparation injured by e. coli endotoxin, allogeneic human mscs or the conditioned medium restored normal fluid balance ( ).objectives. we wished to evaluate the potential for mscs to modulate inflammation and enhance repair after ventilator induced lung injury (vili). adult male sprague-dawley rats were anaesthetised, orotracheally intubated and subjected to injurious mechanical ventilation. following the development of vili, animals were recovered and extubated. thereafter the animals received two intravenous injections of mscs ( . million cells) or vehicle immediately post injury and at h. the extent of the inflammatory response and recovery from vili, as measured by systemic oxygenation, respiratory static compliance, lung wet:dry ratio and lung lavage inflammatory cell infiltration, was assessed at h. mscs reduced inflammation and enhanced repair following vili. msc treatment improved respiratory static compliance, reduced total lung water as assessed by wet:dry ratio, and decreased bronchoalveolar lavage total inflammatory cell and neutrophil counts, from , cells/ml to , cells/ml (ci . - . ) (fig. ). there was a trend towards better oxygenation in the msc group.conclusions. these findings demonstrate the potential of mscs to modulate inflammation and enhance repair following vili. further analysis of our work, including bal cytokine assay and histological assessment of injury, will provide insight into the utility of mscs to enhance repair in the lung. to determine the role of vagus nerve signaling in vili and establish whether stimulation of the vagus reflex can mitigate lung injury from high volume ventilation.methods. first we demonstrate that disruption of the cap reflex by bilateral vagotomy results in worsening lung injury in a mouse model of high-volume-induced lung injury. in a clinically relevant rat model of injurious ventilation following hemorrhagic shock/resuscitation (hs; model of lung ischemia/reperfusion injury), we then tested the hypothesis that electrical and pharmacological stimulation of the vagus nerve can attenuate injurious effects of vili. finally, to determine the molecular mechanisms by which stimulation of the cholinergic response mitigates vili, we exposed human bronchial epithelial cells (beas b) to cyclic stretch ( cycles/min, pka) in the presence of specific agonist or antagonist of the subunit of the acetylcholine nicotine receptor. vagotomy exacerbates lung injury from high volume ventilation in mice as demonstrated by increased wet-to-dry ratio, infiltration of neutrophils in bronchoalveolar lavage fluid and lung tissues, and increased tissue levels of interleukin- . vagotomy exacerbated while vagus stimulation attenuates lung injury in rats after ischemia reperfusion injury ventilated with either high or low volume strategies. treatment of both mice and rats with the vagus mimetic drug, semapimod, resulted in decreased lung injury. vagotomy also increased pulmonary apoptosis whilst vagus stimulation (electrical and pharmacological) attenuated vili-induced apoptosis. in vitro studies suggest that vagus-dependent effects on inflammation and apoptosis are mediated via the a nachrc-dependent effects on cyclic stretch-dependent singling pathways c-jun n-terminal kinase (jnk) and fas (tnf receptor superfamily, member ).conclusions. stimulation of the cholinergic anti-inflammatory reflex may represent a promising alternative for the treatment of vili.introduction. so far, histological data on critical illness myopathy (cim) primarily refers to muscle biopsies taken during protracted critical illness (after weeks), repeatedly describing pronounced type-ii muscle fibre atrophy.objectives. we speculate that type-ii fibre atrophy develops during early critical illness in patients with non-excitable muscle membrane which predicts cim. ( ) methods. due to their elevated risk for cim, critically ill patients with sofa scores c on of consecutive days within the first days after icu admission were eligible for inclusion into this prospective, observational study. preexisting iddm or neuromuscular disorder, pregnancy, bmi c kg/m , age \ years, or pretreatment[ days on other icu constituted exclusion criteria. surgical muscle biopsies were taken from vastus lateralis muscles between day and after first sofa c and postprocessed according to standard procedures (isopentane, liquid nitrogen, atpase/toluidineblue staining). we assessed muscle membrane excitability after direct muscle stimulation, abnormal muscle membrane excitabilty indicating cim ( ). after quantifying fibre-type specific median cross sectional areas (csa) with imagej-software, we compared fibre-type specific csa in patients with and without non-excitable muscle membrane. nonparametric tests (mann-whitney u) were used for statistical analyses, results expressed as median and ( th/ th) percentiles for continuous variables. . patients were enrolled and subsequently biopsied. patients were evaluated for muscle membrane excitability, of whom % (n = ) showed non-excitable muscle membrane. reliable csa quantification was obtainable for patients.type-ii but not type-i muscle fibre csa during early critical illness was significantly decreased in patients with non-excitable muscle membrane ( , lm compared to , lm for type-ii, p = . ; , lm compared to , lm for type-i, p = . ; n = ). furthermore, non-excitable muscle membrane was associated with significantly lower mrc scores after end of sedation ( . ( . / . ) vs. . ( . / . ) , p = . , n = ). in patients showing non-excitable muscle membrane after direct muscle stimulation we could observe selective type-ii fibre atrophy as early as within the first days after icu admission (day - after st sofa c ). our findings demonstrate that nonexcitable muscle membrane indeed is associated with a histomorphological correlate previously linked to cim. these results highlight the need to focus on early critically illness in order to investigate pathophysiological aspects of cim. bacterial sepsis is a major threat in neonates born prematurely, and is associated with elevated morbidity and mortality. little is known on the innate immune response to bacteria among extremely premature infants. objectives. identify innate immune defect in premature infants as risk factor for the development of neonatal sepsis. methods. we compared innate immune functions to bacteria commonly causing sepsis in infants of less than wks of gestational age, infants born between and wks of gestational age, term newborns and healthy adults. levels of surface expression of innate immune receptors (cd , tlr , tlr , and md- ) for gram-positive and gramnegative bacteria were measured in cord blood leukocytes at the time of birth. the cytokine response to bacteria of those leukocytes as well as plasma-dependent opsonophagocytosis of bacteria by target leukocytes were also measured in the presence or absence of interferon-c. results. leukocytes from extremely premature infants expressed very low levels of receptors important for bacterial recognition. leukocyte inflammatory responses to bacteria and opsonophagocytic activity of plasma from premature infants were also severely impaired compared to term newborns or adults. these innate immune defects could be corrected when blood from premature infants was incubated ex vivo h with interferon-c. conclusions. premature infants display markedly impaired innate immune functions, which likely account for their propensity to develop bacterial sepsis during the neonatal period. maturation of the innate immune response to bacteria can be induced by interferon-c ex vivo and represents a promising strategy to prevent neonatal sepsis. the anaphylotoxin c a impairs neutrophil phagocytosis in animals and humans with sepsis. although dependency on the phosphoinositol -kinase delta (pi kd) pathway has been identified , , greater understanding of the mechanism will allow novel therapeutic options. objectives. to test the hypotheses that c a mediates its effect on phagocytosis by impairing rhoa activation, and that similar defects will be found in neutrophils from critically ill patients. methods. the mechanism was dissected using an in vitro model of c a-mediated neutrophil dysfunction, treating healthy human donor neutrophils with c a at concentrations found in sepsis ( nm). phagocytosis was assessed by zymosan particle uptake. neutrophils exposed to zymosan were assayed for rhoa activity, a key mediator of actin polymerisation in phagocytosis . phagocytosis by neutrophils from critically ill patients was investigated, looking for correlations with a marker of c a exposure (cd , the main c a receptor) , an examination of the rhoa and actin polymerisation response to zymosan, and the ability of gm-csf to restore phagocytosis ex-vivo. results. c a inhibited phagocytosis of zymosan by healthy donor neutrophils (reducing from to %, p \ . ) and also impaired rhoa activation (figure) . blocking pi kd, using inhibitor ic , prevented the inhibition of rhoa by c a, and prevented the reduction in phagocytosis. treatment with gm-csf restored phagocytosis and rhoa activation (fig. ). neutrophils from patients with critical illness showed a strong correlation between phagocytosis and surface cd expression (r = . , p \ . ), consistent with our previous findings . patient neutrophils failed to up regulate rhoa or polymerise actin in response to zymosan, in marked contrast to cells from healthy donors (p = . and p = . respectively). ex-vivo gm-csf was able to improve phagocytosis by patient neutrophils from to %, p \ . . conclusions. these data demonstrate that c a inhibits rhoa activity through pi kd, inhibiting phagocytosis. gm-csf is able to reverse this inhibition. similar effects are seen in neutrophils from critically ill patients, providing new avenues for therapeutic intervention in critical illness. host infection triggers an innate immune response leading to a systemic inflammatory response, often followed by an immune dysfunction which impairs the lung defence mechanisms in mice and increases susceptibility to secondary p. aeruginosa pneumonia. activation of the toll-like receptor (tlr)-dependent signalling pathways influences the magnitude of the initial pro-inflammatory phase of sepsis. contribution of tlr signaling to the subsequent development of post-infective immunosuppression has been poorly studied.objectives. to investigate the relative contribution of tlr and tlr in lung defence towards p. aeruginosa in the setting of sepsis-induced immune dysfunction. we used wild-type (wt) c bl /j mice and littermates deficient for tlr (tlr ko), tlr (tlr ko) or both tlr and tlr (tlr ko). these animals were subjected to a sublethal polymicrobial sepsis (cecal ligature and puncture, clp) followed by a secondary p. aeruginosa pneumonia at day post-clp . we evaluated -day survival and the lung response and h after instillation through lung histology, quantification of protein level, cell recruitment and myeloperoxydase (mpo) activity. lung expression of tlr , tlr and tlr was assessed through quantitative rt-pcr. bacterial lung clearance was evaluated through quantitative culture of bronchoalveolar lavage fluid (balf). bacteremic dissemination was assessed through quantitative blood cultures. finally, we measured cytokines in the balf and in the whole lung. post-septic wt and tlr ko mice displayed high susceptibility (mortality rate %) towards secondary pneumonia. in contrast, post-septic tlr -deficient mice (either tlr ko or tlr ko), survived the secondary pulmonary infection (mortality rate \ %). in wt mice, clp increased lung expression of tlr , but neither of tlr nor tlr . tlr ko mice displayed improvement in lung bacterial clearance and reduction in bacteremic dissemination as compared to wt mice. with regard to pulmonary inflammation, tlr ko mice displayed decreased alveolar damage. furthermore wt and tlr ko mice displayed differences in the pulmonary release of cytokines. thus tlr ko mice exhibited increased production of tnf-a and ifn-c and a decreased production of il- .conclusions. in a model of polymicrobial sepsis followed by p. aeruginosa pneumonia, tlr deficiency improves survival by promoting efficient bacterial clearance and decreasing pulmonary inflammation. tlr -dependent mechanisms that specifically contribute to lung defence in the setting of sepsis-induced immune dysfunction are currently investigated. infection is a serious complication in critically ill patients, who can be in a state of secondary immunodeficiency due to a severe illness. apart from common nosocomial pathogens, highly unusual microorganisms may be found in these patients, i.e. pathogens whose cultivation requires specific conditions, and/or agents which are difficult to cultivate. molecular biology-based methods (pathogen-specific probes with real-time pcr detection, or universal system pcr detection with subsequent sequenation) make diagnosis faster and more accurate.objectives. i) to assess an agreement of investigation results using classical microbiology techniques and molecular biology-based methods; ii)to evaluate the clinical effect of the diagnoses based on the frequency of changes in antibiotic therapy as a direct result of molecular detection of ''pathogens'' (mpd) and to assess the effect of this change by evaluating a -day trend of inflammatory parameter concentrations i.e. of procalcitonin (pct) and c-reactive protein (crp). a total of samples (blood, bal, tracheal aspirate, urine, cerebrospinal fluid and secretions from abdomen drains and thoracic punctures) were taken from icu patients (aged - ). these were investigated simultaneously, both by classical microbiology and microbial methods, using the system of pathogen-specific probes with real time pcr for agents. each sample was tested simultaneously with the universal pcr detection system for bacteria and fungi with the subsequent sequenation.results. an agreement between the two compared examination methods was found in % of samples and disagreement in % of the samples. % of the results were classified as ''not possible to interpret''. in % of the samples, mbm detected the presence of other agents, which were not confirmed by cultivation. in % of cases, the mdp results did not contribute to the decision to change the atb. in % of cases, a modification of atb treatment followed; a change, reduction or stopping the administration of the drug. in % of cases, atb was changed without any direct connection to the results. in % of patients who underwent the change in atb treatment, a decrease in inflammatory parameters occurred (pct and crp), however, in % there was an increase. the remaining % are divided equally between those ''without any change'' and ''data not available''.conclusions. the advantage of septic-state diagnostics using molecular biology techniques, as opposed to classical microbiology methods, is the fast availability of the examination results ( - h) , and its high sensitivity and specificity. proving the presence of agents in biological material does not necessarily signify its pathogenicity. however, in combination with a thorough assessment of the clinical progression, including laboratory indicators of inflammation, it is of considerable benefit in decisions about the efficacy of antibiotic therapy. common antibiotics and the number of patients on high or low intensity crrt recruited were: ciprofloxacin ( , ) , meropenem ( , ), piperacillin-tazobactam ( , ) , vancomycin ( , ). the clearance of individual antibiotics varied approximately -and fold within a single crrt regimen for high and low flow rates, clearance, estimated using ccrt extraction ratios for the two flow rates, differed significantly: meropenem ( vs. ml/min; p = . ) and vancomycin ( vs. ml/min; p = . ). using dialysate clearances, significant differences for vancomycin ( vs. ( ) objectives. to perform a meta-analysis on incidence and outcome of intra-abdominal hypertension (iah) in different icu populations, the evolution of iap over time and the correlation with organ failure and fluid balance (fb)methods. pts admitted to icu with iap measurements (gastric or bladder) were included. data from existing databases were collected on , pts from centers ( countries [ ] . recently, it was demonstrated that % hes / . induces increased inflammation and leads to more tubular damage compared to % hes / . in an ex-vivo kidney perfusion model [ ] . we investigated whether different hes solutions lead to disturbed cell proliferation or to increased apoptosis in murine kidney cells. we performed a large cohort study on prospectively collected data over a year period ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . data were extracted from the cub-réa network , a french regional database in which icus from paris and its suburb prospectively record data using standardized coding methods. cancer patients with septic shock were selected through keywords including the malignancy status on one hand (''hematological malignancy'', ''cancer'', ''cancer with metastasis''), and ''septic shock'' or the combination of ''septicemia'' and ''shock'' on the other hand. extracted variables included demographic characteristics, type of malignancy, requirements for organ failure supports (vasopressor therapy, mechanical ventilation, renal replacement therapy) and severity-of-illness score (saps , , , , however, some studies have suggested little effect on morbidity or mortality. , clarification of any differences would improve pre-operative risk assessment, providing more information for the clinician and patient. it would also aid resource planning in the critical care unit. we hypothesized a proportional increase in the extremes of bmi occurring over the -year study period. we analysed data collected prospectively between april and april on patients undergoing cardiac surgery in our unit using the patient analysis and tracking system (pats Ò ) database. the patients were grouped according to bmi. for each group we calculated organ specific complication rates, re-operation and readmission rates, itu and postoperative length of stay and overall mortality. we studied the change in mean bmi of patients over the year period. in comparison with normal bmi range ( . - . ), patients with bmi range \ . had significantly increased rates of peri-operative myocardial infarction (mi) ( conclusions. both the high and low extremes of bmi range show significant increases in complication rates compared to normal bmi patients undergoing cardiac surgery. the bmi group - . shows significant increase in re-operation, readmission and mortality rates.there is a year on rear increase in the bmi group [ . this suggests a greater demand for resources particularly in the intensive care unit as the population with a higher morbidity and mortality increases. we would welcome an opportunity to present a detailed analysis of our findings. with advances in critical care medicine, more patients are surviving intensive care units stays. patients admitted to critical care may experience morbidity that affects their life after discharge . in addition to any physical morbidity, treatment in critical care may also be stressful and psychologically traumatic for patients .objectives. to describe the psychological outcome of patients surviving icu admission at months. a second end-point was to find possible relationships between patients' background and intensive care variables, post-traumatic stress and depression disorders.methods. retrospective analysis of data from icu follow-up clinic. data were collected in questionnaires (ptss- and beck inventory) during an interview at months after discharge of icu in the last years. statistics analysis: pearson's chi-square or fisher's exact test, significance for p \ . . . patients were interviewed, mean age was ± , % were male and . % were trauma victims. mean icu length of stay was ± days and sapsii score ± . . % of patients had less than years of education. concerning previous health status . % were healthy and . % were dependent for daily living activities. . % were retired. more than % had new complaints after discharge. only . % of the previously professionally active patients resumed their work and only % of the retired were able to maintain their normal activity. almost % of patients had new psychiatrics symptoms and only . % were being followed by psychiatry: % were on benzodiazepines and . % on anti-depressants. . % of the patients had symptoms suggestive of diagnosis of post-traumatic stress disorder (ptsd) having a ptss- superior to . regarding beck inventory, % were considered to have a depression, with . % having moderate to severe depression. after the interview % were oriented to a psychiatric consultation. % of depressive patients had new symptoms (p \ . ). of the previously active patients who did not resume normal activities, a significant (p \ . ) part was depressed ( . %). the same is true for the retired patients ( . %), p = . . longer hospital and icu lengths of stay were related with development of depression (p = . and p = . , respectively). patients with higher sapsii were more prone to develop ptsd. women had more ptsd than men (p = . ). patients in risk of ptsd and depression were younger (p = . ; p = . , respectively). as with depression these patients also had more new complains and did not return to work. introduction. mild hypothermia improves outcome after cardiopulmonary resuscitation (cpr). modes of action for it are manifold, though one way might be reduction of basal metabolic rate (bmr). therapeutic hypothermia was able to reduce bmr in patients with traumatic brain injury and critically ill patients with fever.objectives. in the present study we investigated the metabolic effect of therapeutic hypothermia in patients after successful cpr.methods. patients after cpr were treated with therapeutic hypothermia ( °c) for h and subsequently rewarmed with a rate of . °c per hour until °c was reached. all patients received standardized sedoanalgetic medication and neuromuscular blockers. indirect calorimetry was performed at , . and °c, as well as between . and . °c and - h after cpr. for statistical analysis repeated measures anova, linear and logistic regression were used. a linear relation between bmr and temperature was detected ( kj/m / . °c; p \ . ). therapeutic hypothermia ( °c) was associated with a reduction of bmr by ± % compared to °c. in this regard no difference was found between patients with good and bad neurological outcome (good outcome vs. bad outcome: ± vs. ± %; p = . ). concerning substrate oxidation rates only fat oxidation rate showed a temperature dependency ( g/day/ . °c; p \ . ). in contrast to protein oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) patients with good neurological outcome had a significantly higher fat oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) and a significantly lower glucose oxidation rate (good outcome vs. bad outcome: ± vs. ± g/day; p = . ) as compared to patients with bad neurological outcome.conclusions. in patients after cpr mild therapeutic hypothermia ( °c) was associated with a reduction of bmr by %. a linear relation between temperature and bmr was detected. fat oxidation rate was temperature dependent in contrast to protein and glucose oxidation rate. a significant difference in glucose and fat oxidation rates was found between patients with good and bad neurological outcome. objectives. our goal was to determine whether its institution after resumption of spontaneous circulation (rosc) improves survival and neurological recovery in an experimental model of cardiac arrest in rabbits.methods. ventricular fibrillation was induced in anesthetized rabbits. after -min of untreated fibrillation, cardiopulmonary resuscitation was attempted using external massage, electric shocks and intravenous epinephrine. after rosc, rabbits randomly underwent either normothermic life support (control group with conventional ventilation until weaning) or hypothermic support with rapid cooling (tlv group). in this last group, a °c hypothermia was induced by -min of tlv using a perfluorocarbon. subsequently, the perfluorocarbon was removed from the lungs and rabbits were conventionally ventilated with maintenance of hypothermia during h. rabbits were further warmed and weaned from ventilation. in both groups, hemodynamic and biochemical parameters were monitored, as well as survival and neurological recovery. after days, survivors were finally euthanized for post-mortem analyses. neurological dysfunction was assessed by a - % scoring system evaluating reflexes, postural reactions and behaviour ( %: no dysfunction; %: brain death).results. ten rabbits were randomized to the control group and to the tlv one. defibrillation was obtained using . ± . and . ± . electric shocks, respectively. subsequent rosc was observed after . ± . and . ± . min, respectively. oesophageal and tympanic temperatures were rapidly reduced in the tlv group, achieving . ± . and . ± . °c within -min versus . ± . and . ± . °c in control, respectively. in the tlv group, rabbits returned to normothermia within - h after the hypothermic episode. throughout follow-up, no significant difference in blood pressure was observed between both groups (e.g., ± and ± mmhg in control vs. tlv at h after cardiac arrest, respectively) whereas heart rate was decreased throughout hypothermia in tlv vs. control (e.g., ± vs. ± beats/min at h following cardiac arrest, respectively). lactates's concentration and epinephrine dosages were not significantly different between groups. importantly, neurological dysfunction was significantly attenuated in tlv vs. control (e.g., ± vs. ± % after h). in control, / ( %) rabbits survived throughout the follow-up and the others died or should be euthanized earlier following severe disability. in the tlv group, survival was significantly increased as / rabbits survived to the entire follow-up ( %).conclusion. ultra-fast cooling induced by tlv after rosc improves survival and neurological recovery following -min of experimental cardiac arrest in rabbits.grant acknowledgment. (ca) . th involves at least h of induced hypothermia ( - °c), mechanical ventilation and sedation. th may affect sedation through changes in pharmacology. still, no clinical studies have investigated the use of sedation during th. objective. to compare the efficacy of two sedation protocols for patients treated with th. methods. open, randomised, controlled, population based study of patients treated with th ( - c for h) after ca in two norwegian university hospitals. patients were randomised to sedation with remifentanil + propofol (rp) or fentanyl + midazolam (fm). baseline characteristics (age, sex, bmi, saps-ii) and cardiovascular variables during study drug infusion (blood pressure, heart rate, use of fluids, vasopressors and inotropic drugs) were recorded. the primary end point was defined as time from stop of sedation to extubation. results. sixty patients were randomised. one patient was withdrawn by next of kin. baseline characteristics were similar in the two groups. for two patients in the rp group, and one in the fm group, study drugs were stopped shortly after allocation due to cardiovascular instability. the rp group had lower heart rates and more patients needed noradrenaline infusions than the fm group ( . ( . ) (mean(sd)) vs. . ( ) beats/min, p = . , and vs. patients, p = . , respectively). other circulatory variables were similar. reasons to not stop sedation or not extubate after stop of sedation were; cessation of icu treatment (n = ), need for mechanical ventilation (n = ), inadequate awakening (n = ), seizures after stop (n = ), and other (n = ). sedation was stopped according to protocol in of patients. median (range) time from stop of sedation to extubation for the patients who could be extubated according to protocol was . ( - . ) vs. . ( . - . ) h in the rp and fm group, respectively, p = . . ''cerebral performance category'' on day - was similar in the two groups. conclusions. time to extubation after cessation of sedation was significantly shorter in patients sedated with rp compared to fm. however, the benefit from a short time to extubation is limited by that only one-third of the patents can be extubated according to protocol. the rp group had lower heart rates and needed more noradrenaline. no major differences were observed for outcome.grant acknowledgment. ntnu. increased blood glucose variability during therapeutic hypo-thermia and neurological recovery after cardiac arrest key: cord- - lqlx rv authors: nan title: poster sessions date: - - journal: j diabetes doi: . / - . _ sha: doc_id: cord_uid: lqlx rv nan polycystic ovarian syndrome (pcos) is the most common endocrinopathy in women before menopause, the purpose of this study was to determine the effects of a diet and physical activity trial for improving pcos clinical and laboratory findings in obese women. this semi-experimental single-blind controlled trial was conducted among women with pcos ( cases and controls). initially, all the patients′ information was evaluated in terms of: demographic, menstrual status, clinical characteristics of hyperandrogenemia, as well as biochemical, hormonal and abdominal ultra-sonography. the intervention plan consisted of a -week exercise and diet program for the experimental group. all baseline assessments were repeated in both groups within months after beginning of the trial, and the results were analyzed. the comparison between the two groups revealed that in the experimental group, the interventions have been effective for the following variables: follicle stimulating hormone (p = . ), the luteinizing hormone (p = . ), total testosterone (p = . ), free testosterone (p = . ), estradiol (p = . ), selfglobulin band sex hormone (p = . ), triiodotyronine (p = . ), thyroxine (p = . ), tsh (p = . ), hydroxy progesterone (p = . ), triglycerides (p = . ), total cholesterol (p = . ), body mass index (bmi; p = . ), the ultrasound exam (p < . ), oligomenorrhea (p < . ), of hirsutism (p < . ), acne (p < . ) and alopecia (p = . ). it seems that regular exercise and dietary intervention are effective to improve pcos among obese women. a series of studies have recently demonstrated that the oxidative stress, nuclear factor-kappa b (nf-jb) activation and the subsequent coordinated inflammatory responses played an important role in the pathogenesis of urate nephropathy (un). polydatin has been suggested to have the properties of anti-oxidative, anti-inflammatory and nephroprotective effects. however, the possible protective and beneficial effects of polydatin on un are not fully elucidated. therefore, we investigated the potential beneficial effects and possible mechanisms of polydatin on un. in this study, polydatin showed inhibitory activities on xanthine oxidase to repress the level of serum uric acid in vivo and in vitro. further investigations revealed that polydatin displayed little toxic effects and significantly ameliorated the renal function in fructose-induced un mice. the nephroprotective activities of polydatin was not only due to the effects on remarkably attenuating the oxidative stress induced by uric acid, but also on markedly suppressing the oxidative stress-related inflammatory cascade, including decreasing the expressions of nf-jb p , cox- and inos proteins and inhibiting the productions of tnf-a, pge and il- β. these findings elucidated that polydatin exhibited prominent nephroprotective activities and low toxic effects. drug discovery, obetherapy, evry, france many obesity related genes have been proposed as targets for the treatment of obesity. however, these obesity genes did not provide efficient drug therapy for obesity treatment. this is mainly due to the redundancy of the biochemical pathway involved in obesity and the lack of specificity of the gene targets. it is therefore a challenge to identify crucial gene(s) targets involved in energy metabolism associated with "lean or starvation phenotype". congenital enteropeptidase defficiency is an extremly rare pathology which answer to all these criteria. enteropeptidase catalyzes the conversion of inactive trypsinogen into active trypsin via the cleavage of the acidic propeptide from trypsinogen. we have generated knock out transgenic mice for enteropeptidase which shows the same phenotype like in human. these data and in vivo preclinical data using per os small molecule for long term treatment ( weeks) will be presented. f. nasiri amiri , f. ramezani tehrani , m. simbar babol medical sciences university, babol, shahid beheshti university of medical sciences, tehran, iran polycystic ovary syndrome (pcos) is the most common chronic endocrine disorder with a prevalence estimated at - % depending on the diagnostic criteria used. it has significant and diverse clinical consequence including reproductive, metabolic, psychological morbidity and some cancer. it is unclear how pcos symptom influences such women's experiences of their bodies. this study aimed to explain women's experiences of their health concerns when living with pcos. this research is a qualitative study. semi-structured opened interviews were conducted with women aged - years who were diagnosed with pcos. interviewing the participants were continued to reach data saturation. all the interviews were recorded and transcribed. the data were analysed using content analysis. four closely intertwined themes were disclosed: physical consequences of pcos, fear of future, economic burden of desease and coming to terms with a chronic condition. our findings suggest that healthcare professionals working with pcos patients should consider providing peer support groups as a means to alleviate patients concern and to promote self management activities such as lifestyle modification. ideally, groups should be designed to meet patients support needs and expectations, and should be evaluated regularly. m. kidron , e. arbit oramed pharmaceuticals, jerusalem, israel, biomedical engineering, nyu -oramed pharmaceuticals, englewood, nj, usa introduction: the major cause of hyperglycemia in t dm is inappropriate, non-suppressible hepatic glucose production due to hepatic insulin resistance (hir)) and elevated glucagon levels. hir is a result of fat deposition in the liver which in turn begets a local inflammatory process, a common thread observed in t dm, the metabolic syndrome and obesity which are all known risk factors for morbidity. the only antidiabetic drug that addresses specifically hir, up to now is metformin and its effects wanes over time. there is an unmet need for other drugs that target the liver specifically. insulin has a direct effect on hepatocytic receptors and thus has shown to be capable to reduce hepatic steatosis and improve glycemic control, as well as reduce hepatic insulin resistance. insulin administered orally is absorbed into the portal-hepatic vein and reaches the liver at high concentrations. this route of administration may confer physiologic advantages over systemic insulin administration and lower the risk of hypoglycemia. results: bmi, hdl and cu levels were found to be significantly higher in women compared to men (p < . ). _ it was established that blood copper levels, similar to hscrp, predicted ms and ms parameters, but predicted different ms parameters at different sensitivities and specifities. we obereved that there was a more significant correlation between tg level, blood pressure and cu, compared to hscrp (tables , and ). conclusion: based upon these results, it may be stated that cu predicts ms and ms parameters as well as hscrp does and that it is even a better predictor for ms and atherosclerosis since it is less influenced from inflammatory events than crp. short-chain fatty acids which then up regulate proglucagon (precursor to glp ) and pyy gene. these gut hormones are collectively known as "incretin" and they primarily regulate insulin level after eating. very recently, two new classes of drugs based on incretin action have been approved for lowering blood glucose levels in type diabetes milliets. one is exenatide, long-acting agonist of the glp- receptor and other is incretin enhancer known as sitagliptin, a dpp inhibitor. however, glp- agonist reduces body weight (anti-obesity therapy) and leads to hypoglycemia. similarly, liraglutide, dpp-iv-resistant glp- receptor agonists is also synthesized using glp- sequence with prolongs half-life. in conclusion, polysaccharides might be a way to decrease the hurdle in diabetes managements and special attention should be paid to naturally derived polysaccharides. ms is often associated with inflammation caused by latent infections or sibo. we investigated whether treatments of such items may help to control ms. method: we prospectively studied patients presenting with ms and three concomitant causes of inflammation [helicobacter pylori (hp = cases); oral papillomavirus virus (hpv = ) or ebv ( ); sibo (h or ch breath tests: cases)] who were all successfully treated for hp, hpv or ebv, and sibo (decrease of h or ch > % and decrease of circulating th cells > % which are correlated with intestinal chronic inflammation). patients were followed-up months. conclusion: treatment of latent infection and sibo benefits mainly to patients younger than , without methanogenic flora and with few circulating th cells. and increases the gastric emptying time, intestinal transit time, gastric acid secretion in the ms bark juice treated group. there was significant (p < . ) decrease in the t max , t / and increase in the c max of met in ms bark juice treated group as compare to diabetic group. present study suggests that the bark juice of ms shows significant effects in the treatment of gastroparesis and it improves the pharmacokinetic of met compared to diabetic group of rat. type diabetes mellitus (t dm) is a complex metabolic disorder. its prevalence is expected to increase exponentially around the world. insulin resistance, inflammation and dysregulation of adipokines play a major role in the pathogenesis of t dm. among the huge growing adipose secretome, nicotinamide phosphoribosyl transferase (nampt) and vaspin emerged as novel interesting adipokines having insulinmimetic and -sensitizing effects, respectively. however, their role in t dm is still controversial. accordingly, this study was designed to investigate their levels in t dm patients compared to healthy control subjects, and to study the correlation between these two novel adipokines and the correlation between each of them with anthropometric parameters, insulin resistance, hyperglycemia, dyslipidemia, and also the inflammatory marker interleukin- (il- ). the levels of these two novel adipokines and other parameters were measured in non-obese and obese t dm patients together with matched healthy non-diabetic control subjects. the nampt, vaspin and il- levels were measured by elisa while insulin levels by chemiluminescence technique. the nampt and vaspin levels were found to be significantly elevated in non-obese ( . ae . and . ae . ng/ml, respectively) and obese t dm patients ( . ae . and . ae . ng/ml, respectively) compared to control subjects ( . ae . and . ae . ng/ml, respectively) at p < . . furthermore, nampt as well as vaspin were found to be significantly correlated with one another and with various metabolic parameters. in conclusion, nampt and vaspin are potential candidates to play important role in the development and progression of t dm. . to compare insulin resistance in sub-clinical and overt thyroid hypo-function. methods: one hundred eighteen patients with the diagnosis of hypothyroidism based on their clinical and thyroid function test profile were included in this cross sectional hospital based descriptive study with their informed consent. homa-ir as an index of insulin resistance was calculated for each subject from their fasting plasma glucose and serum insulin levels. autoimmunity against thyroid was evaluated by estimating anti tpo antibodies. results: homa-ir as an index of insulin resistance was comparable in overt ( . ae . ) and subclinical hypothyroidism ( . ae . ) but was above the reference range for this population. hypothyroid anti tpo positive cases has high tsh compared to negative cases in both overt hypothyroidism and subclinical hypothyroidism. conclusions: hypothyroidism induces insulin resistance but the degree of insulin resistance is not dependent on severity of thyroid hypofunction however is associated with autoimmunity against thyroid. . ae . in smoker and . ae . in non-smoker, insulin: . ae . and . ae . (p < . ), control: glucose level was . ae . in and . ae . mmole/l, insulin level: . ae . and . ae . mkiu/ ml, respectively. both growth in height and weight gain are accelerated during puberty. they are mainly affected by sex hormone, growth hormone and igf- , and influenced by various factors either directly or indirectly. the aim of this study is to find out the association of various cytokines with obesity and early-or precocious puberty in female children. twenty-eight female children with breast budding before years old, who underwent the lhrh stimulation test as well as cytokine analysis in their blood, were included in this study. the height, weight, and bmi were measured. we defined obesity when the bmi was percentile or more, and puberty when the maximum lh level was iu/l or more during lhrh stimulation test. adiponectin, leptin, ghrelin, il- β, il- , il- , resistin, and tnfa levels in the blood were analyzed by luminex multiple bead technology (milliplex; millipore co., billerica, ma, bio-plex; bio-rad laboratories, hercules, ca). nineteen out of children were categorized as having early-or precocious puberty. their mean il- level was lower in pubertal children than that in prepubertal state ( . ae . vs. . ae . , p = . ). the leptin and resistin levels were significantly higher in obesity group (n = ) than in non-obesity group, while the ghrelin was significantly lower in obesity group (p < . ). in conclusion, the female children younger than years of age in early-or precocious puberty did not show the increment of leptin or resistin comparing with the female prepubertal children, although the obesity group showed significantly higher levels of leptin and resistin. aims: arterial stiffness is independent risk factor of cardiovascular events. suggest that the statins benefit associated with improvement in arterial stiffness parameters beyond lipidslowering effects. to evaluate changes in pulse-wave shape in obese high risk patients with ah and dyslipidemia treated with rosuvastatin compared with atorvastatin. methods: eighty-two obese patients (age . ae years) with ah, dyslipidemia were randomized to atorvastatin group (n = ) or rosuvastatin (n = ). acei and thiazide diuretics added blood pressure control. pulse-wave characteristics measured before and after weeks of treatment using finger photoplethysmographic device. stiffness index (si), reflection index (ri), augmentation index (aix), systolic bp in aorta (spa), digital pulse amplitude augmentation (paa) were accessed. results: before the treatment impared si, elevated ri, aix, spa were shown. lipids and bp goals were achieved in all patients validating further analysis. decrease in si (d si, м/c À . atorva and À . rosuva), ri (dri, % À . atorva and À . rosuva) were revealed in both treatment arms (p > . ), whereas significant trends towards aix decrease were demonstrated only in rosuvastatin-treated patients (dai, % À . atorva and À . rosuva, p < . ) rosuvastatin group demonstrated better increasing in paa than atorvastatin group (paa (atorva): before treatment . ae . and after weeks: . ae . , p = . vs. paa (rosuva): before . ae . and after weeks . ae . , p < . ). conclusions: pulse-wave analysis in obese ah patients demonstrated increasing vascular stiffness. both atorvastatin and rosuvastatin treatment resulted in arterial stiffness parameters, whereas only rosuvastatin treatment was significantly associated with trends in aix and paa improvement in short-term follow-up. z. wang , m. xu methods: four thousand two hundred and twenty-six adults above years of age and adults under years from a cohort investigated in - at the medical examination center of zhongnan hospital were recuited. cases of fld was identified through ultrasound imaging. the risk factors measured were bmi, and plasma concentrations of alt, ast, tc, tg, hdl, ldl and serum uric acid (sua). the probability of steatohepatitis with advanced fibrosis was calculated according to the body mass index, age, alt, and triglyceride (baat) and ast/alt ratio (aar). results: the prevalence of fld was higher in elderly ( . %) than in non-elderly ( . %) and similar in elderly between men and women ( . % vs. . %, p > . ). multiple regression analyses showed that obesity, high tc, tg, sua, low hdl, and elevated alt, aar < were closely related to the elderly fld the prevalence of steatohepatitis estimated as baat index ! was . % in all subjects, and was higher elderly fld patients than in the non-elderly fld patients. conclusion: the prevalence of fld is higher in the elderly, and is broadly related to the same metabolic risk factors as in the nonelderly. however, female-sex is no longer protective with increasing age, and the prevalence of steatohepatitis with advanced fibrosis is estimated to be considerably higher in the elderly fld patients than in the non-elderly fld controls. vanderbilt, nashville, tn, usa bariatric surgery improves glucose tolerance and may be a viable strategy to prevent the progression from obesity-induced insulin resistance to overt diabetes; however, the recurrence of diabetes is significant following the surgery. we sought to determine whether gastric bypass surgery protected pancreatic beta cells and prevented disease progression to overt diabetes. gastric bypass (roux-en-y gastric bypass, rygb) was performed in young ( weeks old) prediabetic blks db/db null (bks-db) mice, young ( weeks old) new zealand obese (nzo) male mice that were fed high-fat diet (hfd) post-surgery, c bl/ db/db null (b -db) mice that developed insulin resistance, and streptozotocin (stz)-induced diabetic mice. rygb resulted in sustained normoglycemia and improved glucose tolerance in pre-diabetic bks-db mice and hfd-fed nzo mice. remarkably, rygb preserved beta-cell mass and increased plasma insulin with reduced beta-cell apoptosis which was independent of weight loss and body fat reduction. rygb neither reversed hyperglycemia when performed in diabetic bks-db and nzo mice nor resulted in resolution of diabetes in stz-induced diabetic mice. the results demonstrate that gastric bypass prevents beta-cell failure if performed prior to onset of severe beta-cell damage in genetic obese mice. l. ruzic , g. sporis , m. prasek sport and exercise medicine, applied kinesiology, faculty of kinesiology, university of zagreb, vuk vrhovac university clinic, zagreb, croatia the aim of the study was to examine the influence of strength training program on pre-and post workout glycemia. twelve able-bodied diabetic patients using insulin pump (mean age . ae . , m/ f) were enrolled into gym programs /week ( min warm-up aerobic workout, intensity at % hrmax plus strength training exercises involving different muscle groups) for months. no other interventions were introduced. we were interested in effects of the programe on pre-and post workout glycemia, so the comparisons between the first weeks and the last weeks of the study were performed. also the subjects were asked about hypoglycemic episodes. there was a great variability observed in pre-and post glucose concentration within and between subjects. the mean pre-workout glucose concentration in the first weeks of the program was . ae . vs. . ae . mmol/l in last weeks of the program and the difference was not significant (p = . ). nevertheless, the mean glucose decrease after workout was higher in the last weeks of the program (deltaglu: . ae . vs. . ae . mmol/l; p < . ). no hypoglycemic episodes were reported. the months strength training program did not influence large variability in glucose levels before the workout as it depends on many other factors. the only observed effect were larger pre-to post workout glucose differences. it seems that over the time, the strength training may stimulate the body to use more glucose during the workout, which might be explainable with the expected increase of lean body mass. aim: the aim of this study was to evaluate the level of c-reactive protein in gestational diabetes mellitus. materials and methods: sixty-five healthy pregnant women aged . ae . years between the th and th weeks of gestation were studied. all women referred for a -g oral glucose tolerance test following an abnormal result on a screening. the demographic data, waist circumference, height, and weight of the participants were recorded. fasting levels of insulin, triglycerides (tg), c-reactive protein (crp), fasting blood glucose (fbg) and hba c were measured. results: based on oral glucose tolerance testing participants were divided into two groups: normal glucose tolerance (ngt; n = ) and gestational diabetes mellitus (gdm; n = ). the mean crp level was highest in gdm group ( . ae . mg/l), followed by ngt ( . ae . mg/l), (p < . ). the mean fbg ( . ae . vs. . ae . mmol/l, p < . ), homa-ir ( . ae . vs. . ae . , p < . ) and tg levels ( . ae . vs. . ae . mmol/l, p < . ) in the women with gdm were significantly higher than those in the ngt group. methods: in , an observational, prospective study started in france on request of the health authorities (has). one thousand seven hundred and two type diabetic patients treated by vildagliptin were recruited through a national representative sample of gps and diabetologists. we report the data of interim analyses after months of follow-up. results: one thousand four hundred and sixty-three patients are included in this interim analysis: % males, aged ae years, with mean bmi of kg/m . hba c was equal to . ae . % at vildagliptin initiation, then . ae . %, . ae . % and . ae . %, while mean weight decreased from to , and kg at , and months respectively. vildagliptin, rarely prescribed when not recommended, was well tolerated: asat and/or alat were > ui in . % at initiation of vildagliptin then . % at months, with a slight decrease for mean asat and alat. mean gfr was ml/mn at initiation of vildagliptin then ml/mn at months, with a stable percentage of gfr < ml/mn ( %) and < ml/mn ( . %). six severe hypoglycemic episodes occurred in six patients (incidence = . / patient-years), all treated by insulin and/or sulfonylurea in addition to vildagliptin. the proportion of patients still treated by vildagliptin at months was . %. conclusions: over months, in real-life conditions of care, vildagliptin showed a sustained effectiveness in terms of hba c reduction, a good tolerance, very few severe hypoglycemic episodes, rare treatment discontinuations and was most often prescribed as recommended. background: hdl lipoproteins are known to play a causative role in atherosclerosis and its clinical manifestation-coronary artery disease (cad). carotid intima media thickness (imt) is considered as a marker of atherosclerosis and in prediction clinical coronary events. aim: to determine the associations between plasma lipids and subclinical atherosclerosis measured by the common carotid intimamedia thickness (imt) in cad patients. methods: hdl subclasses were separated with - % pag electrophoresis, and imt was determined using high-resolution b-mode ultrasound in cad patients, with normal levels of traditional lipid risk factors. results: mean value of left and right carotid artery measurement was selected as value for correlation with hdl subclass size in each patient. the mean hdl size was . ae . nm, and the mean imt in all patients was . ae . mm ( . - . mm). hdl size was not correlated with imt (r = À . ; p > . ). by univariate analyses, carotid imt was the most closely related to systolic pressure (r = . , p < . ), followed by diastolic pressure (r = . , p < . ) and age (r = . , p < . ). stepwise multiple linear regression analysis revealed that diastolic pressure (β = . , p < . ), systolic pressure (β = . , p < . ) and age (β = . , p < . ) were independent predictors of determining carotid imt (adjusted r < . , p < . ). conclusion: these results indicate that diastolic pressure, systolic pressure and age are an important, independent determinants of carotid imt in cad patients. no other traditional risk factors imparted imt. objective: antinuclear antibodies (ana) are present in approximately - % of patients with non-alcoholic steatohepatitis (nash). a recent study implied the relationship between obesity and autoimmunity. the purpose of this study was to investigate the relationship between seropositivity for ana and metabolic abnormalities including insulin resistance, obesity and hepatic steatosis in patients with nash. methods: the severity of hepatic steatosis and fibrosis was scored by the nafld activity score system. seropositivity for ana was defined as titers of : or higher by an indirect immunofluorescence method using hep- cells. insulin resistance and obesity were evaluated by the value of homa-ir and bmi, respectively. the diagnosis of autoimmune hepatitis (aih) was based on the simplified scoring system. results: nine ( %) of patients with nash had ana. overall bmi in nash patients with ana was higher than that in those without ana. laboratory analyses revealed significantly higher mean igg level ( ae vs. ae mg/dl, p = . ) and the mean value of homa-ir ( . ae . vs. . ae . , p = . ) in nash patients with ana than those in those without ana. histological examinations exhibited that nash patients with ana had higher scores in hepatic steatosis ( . ae . , vs. . ae . , p = . ) and fibrosis ( . ae . vs. . ae . , p = . ) than those without ana. however, none of nash patients fulfilled the criteria for "definite" aih. conclusion: nash patients with ana had clinical characteristics of significantly higher serum igg levels and severe insulin resistance, and they tended to have more severe obesity, hepatic steatosis and fibrosis than nash patients without ana. r.f. alponti , , p.f. silveira pharmacology, instituto butantan, physiology, instituto de biociencias/universidade de sao paulo, sao paulo, brazil introduction: although irap (ec . . . ) is well-known, the existence of other aminopeptidases (aps) related to energy homeostasis remains unclear. objectives: to search a diverse array of aps in high (hdm) and low (ldm) density microsomes and in plasma membrane (mf) of retroperitoneal adipocytes from healthy control (c), monosodium glutamate (msg) obese and food deprived (fd) rats with their in vitro responses to insulin (is), vasopressin (avp), angiotensin (ang)-ii and ang-iv. methods: ultracentrifugation and spectrofluorometry. results: dipeptidyl-peptidase-iv (dppiv) and aps basic (apb), neutral puromycin-sensitive (psa) and -insensitive (apm), and methionyl (metap) were found. compared with non-stimulated, these aps were unaffected by is; avp increased apb/apm (ldm) and dppiv/psa (hdm) of msg-fd and metap/psa (hdm) of c; ang-ii increased apm (fm-ldm) of c, dppiv (fm) of msg and psa (fm) of fd; ang-iv increased apb (fm) of fd, apm (hdm) of msg and dppiv (fm) of c and msg. aps were modulated by avp in hdm-ldm, by ang-ii in fm-ldm and by ang-iv in fm-hdm. compared with ldm, metap decreased in fm of c and increased in fm of msg-fd without peptide stimuli; and only diabetes-related enzyme dppiv exhibited peptide-mediated intracellular translocation, which was from ldm to hdm (stimulated by avp) in msg-fd, and from ldm and hdm to fm in msg and msg-fd (stimulated by ang-ii) and in c and msg (stimulated by ang-iv). conclusion: novel peptide-modulated apb, apm, psa, metap and dppiv are found in adipocyte, this last with altered subcellular trafficking under metabolic distress. supported by fapesp, cnpq and capes. nutritional and environmental sciences, university of shizuoka, shizuoka city, japan previous studies have suggested that (-)-epigallocatechin- -gallate (egcg) exerts antioxidative and anti-inflammatory actions in various tissues, which might be beneficial for reducing risks of development of diabetes. however, an optimum intake level of egcg is unknown. in this study, we have examined the effect of a diet containing egcg on the expression of inflammation-related genes in various tissues including visceral adipose tissue and the muscle of non-obese type- diabetes animal model, goto-kakizaki (gk) rats. gk rats at weeks of age were fed a control high-fat diet ( energy% as fat) or the high-fat diet containing . %, . % or . % egcg for weeks. the mrna and protein levels of il- β, il- , mcp- , cd s, il- , tnf-a, resistin and pai- were significantly reduced in the adipose tissue of rats fed a diet containing . % egcg, but not in those fed diets containing . % or more egcg, as compared with control. the mrna levels of tnf-a, ifn-g, il- b, il- and il- in the muscle of rats fed a diet containing . % egcg were also significantly lower than those in the control. these results suggest that there is an optimum range of intake of egcg, which may suppress the expression of genes involved in inflammation in the adipose tissue and the muscle. diabetes and hypertension are the most relevant factors leading to vascular disease and cardiovascular problems. since both pathologies are greatly increasing nowadays, there is a need to detect at early stages the occurrence of target organ damage associated with them. this is the relevance of identifying biomarkers that can detect or predict the onset of cardiovascular and renal damage associated with diabetes and hypertension. given that the role of osteoprotegerin in bone metabolism is well known, and some evidence of its putative relationship with diabetes-associated pathologies has been found, to this date there is no evidence linking this molecule with target organ damage associated with diabetes. in this study, we analyze whether osteoprotegerin may be used to detect and evaluate cardiovascular and renal pathologies associated with diabetes in an in vivo model. we used normotensive and hypertensive rats, a subset of rats of each group receiving a single streptozotocin injection in order to induce diabetes. we performed an -month followup, periodically collecting blood and urine samples and monitoring both blood pressure and blood flow in the lower limbs. our results showed that osteoprotegerin was associated with the presence of diabetes, suggesting that it might be used as a biomarker for the occurrence of cardiovascular damage or to detect cardiovascular risk under these circumstances. blood flow in the lower limbs decreased soon after diabetes onset, as osteoprotegerin levels increased. our data suggest the potential use of serum levels of osteoprotegerin as a biomarker for diabetes and hypertension-associated endothelial dysfunction. purpose: this study examined whether breakfast meal composition alters the incretin response and glycemic control following both the breakfast and lunch meal. methods: seven subjects with t d completed two conditions where they consumed either a kcal high protein (pro: % carbohydrate, % protein, % fat) or high carbohydrate (cho: % cho, % protein, % fat) breakfast for days of acclimatization. on day , they underwent meal testing in which they consumed the respective breakfast followed by a lunch meal ( kcal: % cho, % pro, % fat). blood samples were collected over the -h period and analyzed for glucagon, insulin, glucagon-like peptide- (glp- ) and glucose-dependent insulinotropic polypeptide (gip) concentrations. incremental area under the curve (iauc) for the -h post-breakfast and -h post-lunch period was calculated. results: the iauc for insulin, glucose and glp- were not significantly different between conditions or between meals. the gip response to the pro breakfast ( ae pg/ml*min for -h) was lower (p = . ) compared to the cho breakfast ( ae pg/ ml*min for -h), with the opposite effect occurring in response to the lunch meal (pro: lunch ae ; cho: lunch ae pg/ ml*min for -h, p < . ). conclusion: despite no differences in glucose and insulin levels, a pro breakfast, compared to a cho breakfast, resulted in lower gip levels for the initial meal with a greater second meal effect after a lunch meal. however, a pro breakfast potentiates gip levels after a lunch meal. further research is needed to determine the physiological role of changes in circulating gip. high risk pregnancy, kasralainy university, cairo, egypt background: pregnancy tends to reset the glucose homeostasis in the direction of diabetes. about - % of all pregnant women develop an abnormal glucose tolerance in pregnancy, but most often glucose tolerance returns to normal postpartum. this condition is called gestational diabetes mellitus (gdm). aims: comparative study between gestational and pregestational diabetes in relation to glycemic control as regarding fetal and neonatal outcome. methods: this study was conducted in kasralainy maternity hospital from september to march and it included pregnant women complicated by dm attending outpatient clinic or inpatient. patients were classified into two groups, gestational diabetes: pregnant women complicated by dm which is diagnosed for the first time during pregnancy and pregestational diabetes: pregnant women who have dm that has been diagnosed prior to pregnancy. the two groups were compared according to fetal (macrosomia and intrauterine fetal death) and neonatal (respiratory distress syndrome and birth injuries) complications. all patients were - years old, singltone pregnancy, with time of termination after completed weeks. results: fetal macrosomia occurred more with gdm, on the otherhand birth injuries and rds occurred more with pre-gdm. macrosomia and rds were commoner among poor glycemic control in pregnant diabetic females than birth injuries and iufd. conclusions: glycemic control started as early as possible (the best being preconceptional) is important to decrease the incidence of birth injuries, macrosomia, fetal mortality, the need for nicu admission (rds). adiponectin, an adipocyte-derived hormone, is implicated in type diabetes and atherosclerosis. this study was designed to investigate whether serum adiponectin levels in coronary artery disease (cad) patients with type diabetes (t dm) are lower than in patients with cad alone and healthy controls. we measured serum adiponctin levels in subjects, patients with cad ( subjects of whom had both cad and t dm), and also healthy subjects were selected as controls. all patients were subjected to anthropometric indexes assessment and biochemical measurement of serum adiponectin, interleukin six (il- ), insulin, lipid profile and glucose by standard methods. the results revealed significant differences in serum adiponectin levels between cad patients with t dm and cad patients without t dm ( . ae . vs. . ae . lg/ml, p = . ), between patients with cad and healthy controls ( . ae . vs. . ae . lg/ml, p = . ), and between men and women ( . ae . vs. . ae . , p = . ). serum adiponectin levels were correlated significantly with insulin, total cholesterol, low density lipoprotein, body mass index, glucose, homa-ir, il- (r = À . , p = . , r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . ; r = À . , p = . , respectively). adiponectin was correlated positively only with high density lipoprotein (r = . , p = . ). conclusions: we conclude that low serum adiponectin levels and insulin resistance coexist in cad patients with t dm. it is speculated that subjects who have very low levels of serum adiponectin may be at increased risk of developing both t dm and cad. objective: to simultaneously examine the impact of self-reported and newly-identified hypertension upon subsequent type diabetes (t d). methods: two community-based adult prospective cohort studies, with the same protocols, instruments and questionnaires, were conducted during - and - in urban areas of nanjing, china. data from these two cohorts were pooled and analyzed. t d (outcome variable) was identified using the world health organization diagnosis criteria. based on status of blood pressure (independent variable), participants were categorized into three groups: (i) people with normal blood pressure at baseline survey and during follow-up period (normal blood pressure), (ii) subjects with self-reported hypertension at baseline survey (self-reported hypertension) and (iii) those who did not report hypertension at baseline but were diagnosed having hypertension during follow-up period (newly-identified hypertension). all covariates were assessed at baseline and in the third-year follow-up survey. results: among participants, the -year cumulative incidence of t d was . %, . % and . % for participants with newly-identified hypertension, self-reported hypertension and normal blood pressure, respectively. after adjustment for potential confounders, compared to people with normal blood pressure, participants with newly-identified (or = . ; %ci = . , . ) or self-reported (or = . ; % ci = . , . ) hypertension were more likely to develop t d. furthermore, subjects with newly-identified hypertension (or = . ; % ci = . , . ) were at elevated risk of developing t d relative to their counterparts with self-reported hypertension. the similar associations of hypertension with t d were also found in both men and women, separately. hypertension, either self-reported or newly-identified, is an independent risk factor for developing t d among urban chinese adults. methods: a total of patients with type diabetes receiving standard glucose-lowering therapy were enrolled. efficacy of the lowcalorie diet ( kcal/day) with inclusion of specialized nutrison advanced diason product was assessed in two similar groups in during weeks: main group patients (n = ) received diet with nutrison advanced diason in the amount of ml as the only food for the day twice a week for weeks; control group patients (n = ) received a low-calorie diet with the inclusion of a standard meal at calories twice a week. results: the average weight loss in the main group was ae g, in the control group - ae g per day. according bioimpedance complex therapy with specialized product increased the content of lean mass by an average of . ae . kg and decreased fat mass by an average of . ae . kg. in main droup was a reduction of the basal level of glucose to . ae . - . ae . mmol/l (p = . ), in control groupfrom . ae . to . ae . mmol l (p = . ). total cholesterol level in the main group decreased from . ae . to . ae . mmol/l (p = . ), in the control groupfrom . ae . to . ae . mmol/l. the inclusion of the specialized product nutrison advanced diason in the standard low-calorie diet allows to raise the efficacy of dietary therapy in patients with type diabetes. liver injury and regeneration involve complicated processes and are affected by various physio-pathological factors. this study was designed to investigate the mechanisms of steatosis-associated liver injury and impaired regeneration in a mouse partial hepatectomy model. male c bl/ j and db/db mice were used as mice with normal and steatotic liver, respectively. liver regeneration and injury were evaluated chronologically after hepatectomy. initial regeneration of the steatotic liver was markedly impaired after hepatectomy. although hepatocyte proliferation was not significantly suppressed, intense liver injury with oxidative stress occurred immediately. fasl/fas expression was up-regulated in the steatotic liver, whereas the expression of anti-oxidative and anti-apoptotic molecules (catalase/mn-sod/ref- and bcl- /bcl-xl/flip, respectively) and p /sqstm , a steatosis-associated protein, were down-regulated. interestingly pro-survival akt was not activated/phosphorylated in response to hepatectomy though it was sufficiently expressed/ phosphorylated even before hepatectomy. suppression of p /sqstm increased fasl/fas-expression and reduced nrf- -dependent are activity and anti-oxidative responses in steatotic and non-steatotic hepatocytes. exogenously added fasl induced intense cellular oxidative stress and necrosis/apoptosis in steatotic hepatocytes, only the necrosis being inhibited by pretreatment with anti-oxidants, suggesting that fasl/fas-induced oxidative stress mainly leads to necrosis. furthermore, p /sqstm re-expression in the steatotic liver markedly reduced liver injury and improved tissue regeneration. in the steatotic liver, reduced expression of p /sqstm induced fasl/fas expression and suppressed anti-oxidant genes through nrf- inactivation, which together with hypo-responsiveness of akt, caused post-hepatectomy necrotic and apoptotic liver injury in redoxdependent and -independent manners, respectively. p /sqstm may be a key molecule in post-hepatectomy acute liver injury and impaired regeneration in fatty liver in mice. objective: mastication can accelerate satiety sensation and lipolysis through activation of histamine neurons; however, the data on antiobesity effects of mastication are limited. we therefore examined the effect of chewing on postprandial satiety and energy metabolism in humans. methods: satiety, energy expenditure, and fat oxidation were measured in lean young women on separate occasions, before and h after consumption of a solid meal with chewing per bite or after swallowing the same mashed meal without chewing, in a randomized, crossover design. each test meal consisting of kj ( % of energy as carbohydrate, % of energy as protein, and % of energy as fat) was consumed between and min regardless of texture difference. the thermic effect was greater after the solid meal ( . ae . %) than after the mashed meal ( . ae . %, p < . ). time course of fat oxidation tended to be higher after the solid meal than after the mashed meal (p = . ). in addition, solid meal was more satiating than mashed meal (p = . ). the results suggest that mastication contributes to postprandial satiety and thermic effect of meal. chewing meal thoroughly could be a useful eating behavior for preventing weight gain. introduction: raven noted an association between insulin resistance and cardiovascular consequences and type dm. mathew prescribed the method of insulin resistance designation using mathematic model homa-ir. aim: to estimate insulin resistance homa-ir in adult population according to gender, assess selected parameters in people with homa-ir ! . (i group) and homa-ir < . (ii group) and determine dependence between homa-ir and the above parameters. materials and methods: one hundred and fifty-four people medium age . years, from tarnawa city constituted the material. bp was examined. blood samples were obtained for plasma glycaemia, lipidogram and serum insulinaemia. all people were measured and weighed, bmi and homa ir were calculated, waist circumference was obtained. the cut-off point . for homa-ir was accepted. results: . % of the examined population had insulin resistance without a difference between women and men. significant differences between i and ii group were observed according to tg and waist circumference. in women all examined parameters were significantly different except hdl. in men bmi, waist circumference and hdl were significantly different in i and ii group. in the female group correlations between homa ir concerned all examined parameters, in the male group-hdl and waist circumference. conclusions: there was no significant difference between women and men according to insulin resistance in the whole study group. the difference between selected parameters in the two examinated groups were more strongly in women. body mass was the main factor determining insulin resistance in the whole study group as well as in men and women. background: the immune system is altered in obesity and diabetes, through changes in adipocytes, liver, pancreatic islets, vasculature and circulating leukocytes, with increased cytokine and leukocytes activation, suggesting inflammation participation in diabetes. minocycline presents a potent anti-inflammatory activity, as evaluated in vivo and in vitro. objectives: minocycline anti-diabetic effects were assessed in alloxaninduced diabetes through biochemical parameters measurements, histological and immunohistochemistry analyses. methods: alloxan was injected to rats, blood collected h later and after oral treatments ( , and days) for glycemia, triglycerides, cholesterol and transaminases measurements. diabetic controls and diabetic plus minocycline ( and mg/kg) or glibenclamide ( mg/ kg) were used. furthermore, pancreas, liver and kidney were submitted to histological and immunohistochemistry (cox- and tnf-a) analyses. results: decreases in glycemic and triglyceride levels, at the th and mainly th days after minocycline treatments, were observed. he staining showed that minocycline partly reversed tissue alterations, and decreased expressions of cox- and tnf-a, as compared to untreated animals. conclusions: beneficial minocycline effects in diabetes could be due to its anti-inflammatory and antioxidant properties and, by inhibiting microglial activation, it may be an important therapeutic strategy in diabetes where inflammation plays a significant role. methodology: forty-eight hours after alloxan-induced diabetes, blood from male wistar rats was collected for biochemical measurements. then, diabetic rats untreated or treated ( week, or months) with pentoxifylline ( , , and mg/kg, p.o.) or glibenclamide ( or mg/kg, p.o., alone or associated to pentoxifylline) were divided into eight groups with - animals each. after treatments, biochemical measurements were repeated. glycated hemoglobin determinations, and histological and immunohistochemistry analyses for inos were also performed. results: pentoxifylline brought hyperglycemia and triglycerides towards normality. glycated hemoglobin was improved. the use of diazoxide showed the mechanism of action of pentoxifylline partly related to atp-dependent k + channels. pentoxifylline improved histological alterations in pancreas, liver and kidney, and decreased inos cell expression. conclusions: pentoxifylline effects are probably related to its action on oxidative stress and inflammation, decreasing pro-inflammatory cytokines. thus, pentoxifylline is a potential candidate for diabetes mellitus therapy, since patients with vascular complications present beneficial effects, as shown in clinical practice. recently, a close relationship between the development of adiposity and gut-derived hormonal dysregulation has been clearly established. for instance, studies of gut-derived peptides such as pyy - , glp- , oxyntomodulin, discovered more than years ago and, later on ghrelin have significantly improved our understanding of mechanisms underlying ectopic lipid infiltration in organs and tissues. the etiology of non-alcoholic fatty liver disease (nafld) is intimately related to the capacity of hepatocytes to acquire an "adipocyte-like" phenotype. we previously reported that unacylated ghrelin (uag) is more potent than acylated ghrelin (ag) to stimulate adipogenesis. the present study intends to investigate the relevance of uag and ag as mediators of lipid accumulation in hepatocytes. hepg hepatocytes were treated with a control, uag or ag ( nmol/l and pmol/l) in the presence or absence of oleate ( nmol/l) to measure lipid droplet (ld) number and size. gene expression analyses were performed for key mediators of pre-adipocyte differentiation or liver functions. in response to uag or ag treatment in the presence or absence of oleate, ld number was markedly increased in hepg cells. similarly, increased ld size was noted following the treatment of hepg cells with uag or ag. however this effect could not be detected in the presence of oleate. gene expression of ppar-c and c/ebp-a was increased while that of ppar-a was decreased in response to ag treatment. these results are first to describe mechanisms through which uag and ag could promote the development of lipid infiltration in liver. deakin university, melbourne, vic., australia the world health organization believes that type diabetes mellitus is an important public health problem in the world. however some statistics showed that only . % of all world population had diabetes in , but the health professionals argue, this amount will reach to % in . diabetes australia -nsw estimates that almost million australians have diabetes and also around . million australian populations are at risk of this disease and unfortunately, the number of australian with diabetes will be approximately . millions in . obviously, direct and indirect medical costs due to health care of diabetic's patients are very high and % of the australian government's health budget is spent on health care of type diabetes. therefore, the health professionals have tried to provide the optimal public health programs for control and management of type diabetes. many researchers and health professionals argue that control of weight by change diet habits and exercise are major keys in lifestyle programs for prevention of type diabetes. in this case, the results of several studies like the finnish study, american study, the swedish malmo study and chinese study showed that the focus on diet and exercise programs are significant approaches in type diabetes prevention, while some other studies claim that the change diet habits and exercise may not sufficient and some medicines for control of insulin sensitivity and energy expenditure may also be necessary. therefore, lifestyle intervention programs and pharmacologic intervention programs are the major prevention programs. objectives: metabolic responses to acute endurance exercise may be affected by time of day because the nervous and endocrine systems have circadian rhythms clearly. the purpose of this study was to investigate the influence of acute endurance exercise in the morning and evening on metabolic responses in young men. methods: ten healthy young men completed two trials in a randomized cross-over design: . morning ( : - : ) and . evening ( : - : ) trials. in the morning and evening trials, participants walked for min at % of maximal oxygen uptake on a treadmill. pulmonary gas exchange was determined breath-by-breath by a gas analyzer. blood samples were collected to determine hormones and metabolites at preexercise, immediately and h after exercise. results: plasma interleukin- and adrenaline concentrations were significantly higher immediately after exercise in the evening trial than in the morning trial (p < . and p < . , respectively). serum growth hormone concentrations were significantly higher immediately after exercise in the evening trial than in the morning trial (p < . ). serum free fatty acids concentrations were significantly higher in the evening trial than in the morning trial at h after exercise (p < . ). however, there was no significant difference in fat oxidation between the morning and evening trials. conclusion: these findings suggest that acute endurance exercise in the evening is more effective on lipolysis compared to that in the morning in young men. nutrition, school of public health, university of sao paulo, sao paulo, brazil background: the rs snp of fto (t>a) has been associated with obesity and its comorbidities. in a allele carriers, physical activity (pa) minimizes the deleterious impact on body weight, which could reduce cardiovascular risk. objectives: to investigate whether pa level and television viewing modulate the effects of a allele of fto on adiposity and markers of inflammation in individuals at high cardiometabolic risk. methods: this cross-sectional study included prediabetic individuals ( women, . ae . years, bmi . ae . kg/m²). physical activities were measured by the long-version of ipaq; individuals were genotyped and stratified according to total pa (< or ! min/week) and television watching (< or ! h/week). anthropometric, biochemical and inflammatory data were obtained. subgroups of individuals with or without a allele were compared by student's t test. results: among individuals who watched tv < h/week, those carrying the a allele had significantly higher concentrations of total and ldl-cholesterol, apolipoprotein b ( . ae . vs. . ae . mg/dl) and interleukin- ( . ae . vs. . ae . pg/ ml), but did not differ regarding anthropometric measures. among those who watched tv ! h/week, no difference in any clinical data was detected comparing carriers and non-carriers of a allele. regarding pa, the presence of the variant allele did not influence the metabolic profile. the presence of the variant allele at fto gene seems to favor a deleterious metabolic and inflammatory profiles particularly for individuals less exposed to sedentary activities such as watching tv. for inactive individuals, the allele presence might not affect predisposition to adiposity-induced disturbances. cardiovascular disease is the leading cause of death in brazil and in the world and its development is directly related to lifestyles and habits acquired in childhood. the objective of this study was to evaluate the anthropometric data and blood pressure levels of schoolchildren to verify that the body mass index and waist circumference maintain a relationship with blood pressure. the descriptive study was conducted with schoolchildren of both sexes in schools of cruzeiro do oeste, a small town in southern of brazil. the evaluations consisted of: measurement of weight (w) and height (e) to calculate the body mass index (bmi), waist circumference (wc) and blood pressure (bp). associations between variables were determined using the chi-square test. we observed a high percentage of overweight, wc modified and high pressure measurements. both bmi and wc showed significant association with the high pressure measurements. there is an association between increased blood pressure and increasing age. increases in bmi and central adiposity are associated with higher risks of high pressure measurements, and consequently other chronic diseases in - years old children. this study, descriptive and cross-sectional, had as objective to evaluate the relationships between anthropometric measures and lifestyle habits with the lipid profile of brazilian schoolchildren (n = ). the variables obtained were: weight and height to calculate body mass index (bmi), waist circumference (wc), blood pressure (bp), physical activity and dietary habits, serum lipid profile and glycemia. the results were analyzed by the mann-whitney test, the chi-square test and a relative measure of effects odds ratio. the significance was set at % (p < . ). anthropometric variables showed . % of schoolchildren are overweight, . % showed elevated levels of total cholesterol. there was no significant association between nutritional status and lipid profile. this evidence suggests that an appropriate bmi is not indicative of the absence of changes in lipid profile components. the risk factors associated with the development of cardiovascular disease among the children evaluated were: absence of mean meals, lack of daily physical activity, physical activity < times a week, and the consumption of salty snacks more than four times a week. the physical activity was negatively associated with dyslipidemia, suggesting that physical activity may underlying mechanisms by which zinc and magnesium influence glucose metabolism involved oxidative stress and inflammation. this crosssectional study investigated whether intakes of zinc and magnesium are useful to indicate oxidative stress, inflammation and insulin resistance in individuals at cardiometabolic risk. two hundred and five individuals ( . ae . years) with pre-diabetes were evaluated regarding dietary ( -h food recalls) and clinical variables and compared according to zinc and magnesium intake tertiles by anova. multiple linear regression analysis was employed including adjustments for age, gender and bmi (model ), and saturated fat acid intake, smoking status and physical activity (model ). stratified according to tertiles of magnesium intake, no significant differences in anthropometric, plasma glucose, lipid variables, superoxide dismutase (sod), oxidized ldl, inflammatory markers and homa-ir were found. mean values of fat mass ( . ae . . ae . . ae . %) and homa-ir ( . ae . . ae . . ae . ) were significantly lower in the highest tertile of zinc intake; significant trends to decrease fat mass, homa-ir and c-reactive protein were also observed (p-trend < . ). in linear regression models, intakes of both micronutrients were inversely associated with homa-ir but not with inflammatory markers. direct associations were found between magnesium intake and sod concentrations in adjusted models. our findings suggest that assessment of zinc and magnesium intakes may indicate oxidative stress, inflammatory status and insulin resistance in at risk individuals. our design does not allow establishing cause-effect relationship. longitudinal studies are needed to clarify if increased consumption of these micronutrients would ameliorate these pathophysiological processes. a. cezaretto, b. almeida-pititto, c.r. barros, a. siqueira-catania, s.r.g. ferreira nutrition, school of public health/university of sao paulo, sao paulo, brazil introduction: lifestyle changes remain a major challenge for reducing cardiometabolic risk. psychological disorders coexist with risk factors such as unhealthy life habits, decreasing quality of life (qol) and favoring dropouts during interventions. objectives: to compare clinical and psychological characteristics of individuals who dropped or not from lifestyle interventions, traditional or interdisciplinary. methods: one hundred and eighty-three prediabetic individuals ( . ae . years; bmi . ae . kg/m²) were allocated to month interventions on diet, physical activity and stress management. traditional intervention was based on quarterly medical visits, while participants of interdisciplinary intervention also had psychoeducative group sessions. depressive symptoms were assessed by the beck depression inventory (score ! ) and qol by the sf- . independent t-test was used to compare dropouts and non-dropouts. results: body adiposity, blood pressure, fasting glycemia, lipids, depression and qol improved in both interventions, but, in general, improvements were greater in the interdisciplinary intervention. comparing baseline data of dropouts and non-dropouts at the th month, dropouts of traditional intervention had higher bmi ( . vs. . ; p = . ), depression score ( . vs. . ; p = . ) and lower qol ( . vs. . ; p = . ) than non-dropouts. however, no difference between individuals who dropped or not was found in the interdisciplinary intervention. conclusion: interdisciplinary approach may be more effective to improve clinical features and qol. in addition, this intervention avoids dropout of individuals with worse risk profile concerning adiposity, depression and qol when compared with those having only medical visits. interdisciplinary approach may favor the retention of a subset of individuals at higher risk, which may result in long-term cardiovascular protection. aims: consumption of high fat diet (hfd) leads to accumulation of intramuscular bioactive lipids: long-chain acyl-coa (lcacoa), diacylglycerols (dag) and ceramides (cer) which are implicated in induction of muscle insulin resistance. the aim of this study was to elucidate the role of hfd, myriocin (an inhibitor of ceramide de novo synthesis) and metformin on skeletal muscle lcacoa, dag, cer and acyl-carnitine content and their impact on proteins of insulin pathway. the experiments were performed on male wistar rats: -fed standard rodent chow (control), -fed hfd, -fed hfd treated with myriocin, (hfd/myr) and -fed hfd treated with myriocin and metformin (hfd/myr/met). muscle bioactive lipids were analyzed by lc/ms/ms and plasma glucose and insulin concentration by standard assays. content and phosphorylation of akt and glycogen synthase (gs) was measured by western blot. results: compared to control, all measured lipids were elevated in hfd group. these changes were accompanied by decreased phosphorylation of akt and gs and impaired glucose disposal. myriocin caused a decrease in cer but an increase in the other lipids content as compared to hfd. introducing metformin to hfd/myr group attenuated levels of lipid metabolites known to interfere with insulin signaling (cer, dag, lcacoa) and increased acyl-carnitine content as compared to hfd/myr. in hfd/myr and hfd/myr/met groups insulin-sensitizing effects were accompanied by enhanced akt and gs phosphorylation when compared to hfd. conclusions: simultaneous treatment with myriocin and metformin redistributes fatty acids to β-oxidation which attenuates muscular content of bioactive lipids and improves glucose tolerance by promoting akt phosphorylation. pro-inflammatory state leading to abnormal production of hormones like leptin and adiponectin. the present study was designed to explore endocrine dysfunction of adipose tissue in metabolic syndrome. the study included subjects; metabolic syndrome cases as defined by international diabetes federation and age and sex matched controls. the blood samples were collected for estimation of serum triglycerides, hdl-c, insulin, leptin, adiponectin and fasting plasma glucose. leptin and adiponectin were estimated by elisa and insulin by electrochemiluminescence immunoassay. other biochemical parameters were estimated on clinical chemistry analyzer by standard methods. homa-ir as an index of insulin resistance was calculated from fasting plasma glucose and serum insulin levels. results: serum leptin level was significantly higher in metabolic syndrome patients ( . ae . ng/ml) in comparison to control group ( . ae . ng/ml). serum adiponectin was significantly lower in metabolic syndrome patients ( . ae . lg/ml) in comparison to control group ( . ae . lg/ml) levels. significant difference of homa-ir was between metabolic syndrome cases and controls (p < . ). conclusions: it is concluded that altered endocrine functions of adipocytes are associated with metabolic syndrome and leptin and adiponectin has potential to be incorporated as components of diagnostic criteria of metabolic syndrome. aim: to devise noninvasive method to diagnose nafld. methods: one hundred and eight patients were examined: biochemical blood analysis, endotoxin and nitric oxide in blood, shortchain fat acids (sfa) in faeces, biopsy of liver. patients have been divided into two groups depending on activity of hepatitis: . steatosis; . steatohepatitis, and into three groups according to the therapy: . statin; . probiotic; results: we didn′t revealed direct correlation between biochemical parameters of liver function and heaviness of morphological changes in liver. however patients with steatohepatitis had increased level of endotoxin ( . ae . ) and nitric oxide ( . ae . ) in blood. total quantity of sfa in faeces was also decreased in those patients. there was more effective decrease of lipids, endotoxin and nitric oxide in those patients, who received probiotic in combination with statin. if patient received only probiotic there was not any changes of lipids, but the level of endotoxin and nitric oxide became lower. if nafld progressed in steatohepatitis and there was high level of c-gtp and transaminases we didn′n notice such effective decrease of cholesterol. . the increase level of endotoxin and nitric oxide in blood is the marker of steatohepatitis. . application of statin in combination with probiotic is more effective in achievement of target levels of lipids and decreasing endotoxin and nitric oxide. . if patient has steatohepatitis, effectiveness in the hypolipidemic therapy decreases (in comparison with steatosis), because the metabolism of drugs in liver decrease. methods: one hundred and eight patients with nafld were examined: biochemical blood analysis, endotoxin and no in blood, shortchain fat acids (sfa) in faeces, biopsy of liver (index of steatosis (is) and index of histological activity (iha)). patients have been divided into two groups: . steatosis; . steatohepatitis. results: total quantity of sfa in faeces was decreased in all patients, but there wasn′t difference between i and ii groups. all patients with had increased level of endotoxin ( . ae . ) and nitric oxide ( . ae . ). there was correlation between alt and ggtp with endotoxin and no (ast/endotoxin r = . ; ggtp/endotoxin r = . ; ast/no r = . ; ggtp/no r = . ; p < . ). the biopsy of liver showed all signs of nafld including changes of tiny bilious ductules. we didn′t revealed direct correlation between biochemical parameters of liver function and heaviness of morphological changes in liver (appearance of morphological attributes of steatohepatitis precedes development of cytolytic and cholestatic syndrome). however there was reliable direct correlation between endotoxin and no with histological parameters of nafld (is and iha): is/endotoxin r = . ; iha/endotoxin r = . ; is/no r = . ; iha/no r = . ; p < . . . endotoxin and no may be used in diagnosing of nafld. . increase of level of endotoxin and no in blood in patients with nafld is associated with progression of inflammation in liver. thereby blood analysis for endotoxin and no can be used in diagnosing of nafld progression. . we also can judge about effectiveness of treatment of nafld by the level of endotoxin and no in blood. of this study was to analyze incidence obesity and insulin resistance in patients with fatty liver. the study involved patients with diagnosis non alcoholic fatty liver at the clinical centre pristina. there were analyzed demographic and anthropometric characteristics of the examined patients. of clinical characteristics, there were determined smoking habit, arterial pressure. routine biochemical analyses were carried out by a standard laboratory procedure. homa-ir was used to evaluate insulin resistance. results: in the study group, fatty liver was demonstrated by ultrasound in ( . %) subjects and in the control group there were respondents ( . %) without pathological findings of ultrasound and with the level of p < . . the values of bmi ( . ae . kg/m vs.; p < . ), waist circumference ( . ae . vs. . ae . cm; p < . ) and glucose ( . ae . vs. . ae . mmol/l; p < . ), level of insulin ( . vs. . mu/i; p < . ) and homa-ir ( . vs. . ; p < . ) were significantly higher. conclusions: these results confirm that obesity and insulin resistance are associated with fatty liver infiltration. background and aim: this study was designed to determine the impairment of the skin structure in experimentally-induced diabetes with injection of streptozotocin (stz). material and methods: experimental groups consisted of controls (group , n = ) and diabetes groups (group , n = ). dorsal skin was removed for routine histological tissue procedures. hematoxylene and eosin (he), masson's trichrome and periodic acid schiff (pas) stainings, immunohistochemical connexin (cx ) and type iv collagen stainings were applied. morphometry of epidermal thickness were also determined. results: group revealed decrease in epidermal thickness with disintegration of epithelium and decrease of dermal collagen fibers. stratum spinosum were morphologically abnormal for group . measurements of epidermal thickness revealed statistically significant decrease (p . ). pas staining for group revealed disruption of the basement membrane. epithelial scar formation, deterioration of transformation in the polyhedral cells, degradation of epidermis and decrease in pas staining for vascular structures were observed, whereas the reticular dermis and hair follicles were normal. collagen fiber density in group were found to be prominently decreased in dermis with masson's trichrome staining. evident decrease in immunostaining of cx and type iv collagen were also shown in diabetic group in comparison to the controls. conclusion: diabetes not only induced impairment of the epidermal integrity and deterioration in the epidermis via loss of gap junctions (the most prominent cellular junctional complex), but also caused dramatically negative impact on the dermal collagen content, and integrity of the basement membrane. background and aims: obesity, a major obstacle in the improvement of human health, is associated with an increased risk of development of numerous diseases. on the other hand, plant metabolites showed various bioactivities on affecting food intake, lipase activity, energy expenditure and lipid metabolism that may have potential on preventing body weight gain. therefore, this study aims to discover a new metabolite with anti-obesity efficiency. brief methods: adipocyte differentiation was induced by dexamethasone, -iso-butyl- -methylxanthine and insulin in t -l preadipocyte. in vivo, male c bl/ mice were fed a normal diet (nd), high-fat diet (hfd), a lucidone-supplemented hfd in lower dosage of mg/kg of diet (lsh/l) or in higher dosage of mg/ kg of diet (lsh/h) for weeks. record the changes of body weight and food consumptions. physiological parameters in plasma were determined after sacrificed. epididymal and perirenal adipose tissues were collected for further histological analysis. results: lucidone at mmol/l suppressed adipogenesis in t -l cells by reducing transcription levels of adipogenic genes, including pparg, c/ebpa, lxr-a, lpl, ap , glut and adiponectin. lsh/ h mice showed lowered body and liver weights, decreased food efficiency, and lowered plasma cholesterol, triglyceride, glucose, and insulin levels. dissection of adipose tissue from lucidone-fed mice showed reductions in the average fat-cell size and percentage of large adipocytes. conclusion: these results provided evidence that dietary intake of lucidone alleviates high fat diet-induced obesity in c bl/ mice and reveals the potential of lucidone as a nutraceutical on preventing obesity and consequent metabolic disorders under unhealthy eating habits. introduction and aim: obesity and type diabetes (t d) are accompanied by intramyocellular lipid accumulation which might lead to mitochondrial dysfunction and insulin resistance. our aim was to compare changes in peripheral insulin sensitivity and mitochondrial respiration after a diet-and subsequently a gastric bypass induced weight loss in obese patients with or without t d. materials and methods: sixteen subjects ( m/ f; with (t dm) and (ob) without t d) reported thrice to the lab after an overnight fast: prior to weight loss (a), mo later just prior to operation (b) and mo after operation (c). at each visit tree tests were performed: day : dexa scan for body composition and stationary graded bicycle test for vo max. day : hyperinsulinaemic euglycemic clamp for peripheral insulin sensitivity. prior to the clamp a vastus lateralis muscle biopsy for high resolution respirometry was obtained. respiration protocol is shown in fig. . results: anthropometric, body composition and vo max data are shown in fig. . insulin sensitivity (gir ffm ) and maximally coupled respiration (gmso ) data are shown in fig. . conclusion: in spite of a marked difference in insulin sensitivity, maximally coupled mitochondrial respiration was similar in the two groups. moreover, with marked improvements in t dm insulin sensitivity, due to the massive weight loss, mitochondrial respiration remained unchanged. these results speak against an association of mitochondrial respiratory capacity and insulin resistance in skeletal muscle in obese and t d patients. introduction: increased circulating levels of resistin was proposed as a possible link between obesity and insulin resistance. we investigated if increased resistin expression in adipose tissue affected age-related changes in insulin resistance of peripheral tissues, including brown adipose tissue (bat), and oxidative stress parameters in the spontaneously hypertensive rats (shr). methods: sixteen months old male shrs expressing the mouse resistin gene under control of adipose tissue specific ap promoter (shr-tg) and age matched non-transgenic shrs were used. results: transgenic expression of resistin was associated with impaired glucose tolerance measured during ogtt (auc ae vs. ae mmol/l/ h, p < . ); elevated serum insulin ( . ae . vs. . ae . nmol/l, p < . ) and triacylglycerols ( . ae . vs. . ae . mmol/l, p < . ) levels. shr-tg exhibited lower insulin sensitivity measured as insulin stimulated incorporation of c-glucose into lipids in epididymal adipose tissue ( ae vs. ae nmol gl./g/ h, p < . ) and into skeletal muscle glycogen (p < . ). glucose oxidation in soleus muscle (p < . ), and bat (p < . ) were reduced. shr-tg displayed decreased c-palmitate oxidation to co in bat ( . ae . vs. . ae . nmol/g/ hod, p < . ). in adipose tissue of shr-tg rats was increased concentration of lipid peroxidation products (conjugated dienes and tbars), reduced activity of antioxidant enzymes: superoxide dismutase ( . ae . vs. . ae . u/ mg protein, p < . ) and glutathione peroxidase ( ae vs. ae lmol nadph/min/mg protein, p < . ). conclusion: chronic transgenic expression of resistin gene might contribute to insulin resistance and associated metabolic disorders suggesting possible involvement of reduced bat metabolic activity in age-induced prodibetogenic effect of resistin. examination of patients with type diabetes mellitus (t dm) revealed patients ( . %) with non-alcoholic fatty liver disease (nafld). nafld met more often in the patients with obesity ( . %) and overweight ( . %) and only in . % patients with normal body weight. all the patients had abdominal type of adipose tissue distribution regardless of body weight. in patients with t dm and normal body weight the nafld met more often in women, and in overweight and obesity in men. in the examined patients with t dm and nafld complaints peculiar to dyspepsia and asthenovegetative syndrome prevailed. the average level of hba c corresponded the state of subcompensated carbohydrate exchange ( . %). these patients had marked dyslipidemia with predominance of ii and iib types of hyperlipidemia. cytolytic, cholestatic, mesenchymal-inflammatory syndromes were marked out as well as syndrome of hepatic-cellular insufficiency. increased level of immunoreactive insulin iri ( . ae . ) mu/ml and index of homa ir ( . ae . ) mu/ml testified the presence of expressed insulin resistance in the patients with t dm and nafld. the patients revealed the increase of free fatty acids level ( . ae . ) mmol/l/ml, that meaningfully differed from such indexes in the control group (p < . ) and low level of adiponektin ( . ae . ) mg/ml that confirms their role in development of nafld even for persons with normal body weight after the presence of abdominal type of adipose tissue distribution. study object: diene (dc), triene (tc), oxydien (odc), tetraen (trc) conjugates, malondialdehyde (mda), aspartate aminotransferase (ast), alanine aminotransferase (alt). the study involved patients with type diabetes mellitus and non-alcoholic fatty liver disease (nafld) - men and women among them and diabetes women without nafld. all subjects are representative on age and diabetes duration. correlation analysis has been conducted with the calculation of spierman rank correlation coefficient. study results: the increase of tc and odc levels has been marked in type diabetes men with nafld vs. women -( . ae . ); ( . ae . ) and ( . ae . ); ( . ae . ), respectively, p < . , as well as ast and alt levels -( . ae . ); ( . ae . ) and ( . ae . ); ( . ae . ), respectively, p < . , p < . . the positive correlation of ast, alt with odc and trc has been found among type diabetes women with nafld (r = . , r = . , p < . ) and (r = . , r = . , p < . ) unlike women without nafld -(r = À . ) between ast and trc and (r = . ) between alt and trc. ast, alt are in positive correlation with ct in men (r = . , r = . , p < . ). in type diabetes men with nafld the oxidative stress displays are more clearly seen. it is expressed in increasing of tc and odc combined with ast and alt hyperactivity. trc levels are increased in women group with ast and alt increasing vs. type diabetes women without nafld. the above mentioned can serve as a diagnostic marker of nafld in type diabetes women. i. kara, b. bonardo, f. peiretti umr , inserm, marseille, france gamma secretase and the triggered notch signalling are involved in the regulation of the differentiation/proliferation equilibrium of progenitor cells. gamma secretase consists of four subunits: presenilin or , nicastrin, pen- and aph (stoichiometry : : : ). in humans, there are two aph proteins (aph a and aph b). in rodents there is an additional protein, aph c issued from a duplication of the aph b gene. it has been reported that inhibition of c-secretase improves insulin resistance and stimulates adipogenesis. these data led us to study the impact of obesity in the regulation of the c-secretase composition. expression of c-secretase subunits was measured by quantitative pcr (tissues and cells) and western blot (cells). the expression of aph b is significantly increased in the adipose tissue of obese mice whereas the expression of the other subunits of the c-secretase is not altered. the increased expression of aph b is not observed in muscles and liver of obese mice. the expression of aph b is also increased in visceral adipose tissue of human obese subjects. in addition, the expression of aph b/c increases during adipocyte differentiation of t l cells. in conclusion, the c-secretase composition is specifically altered in hypertrophied adipocytes. this result provides the first evidence of a pathophysiological regulation of aph b/c expression. an approach to knockdown adipocyte expression of aph b/c is in progress. the analysis of the consequences of this manipulation on csecretase activity, notch signalling and the biology of the adipocyte will help assess the importance of the alteration of c-secretase composition during adipocyte differentiation. background and aim: certain legumes and barley kernels may favorably modify metabolic risk parameters in semi-acute studies in healthy subjects. this investigation assessed the medium-term effect of a diet combining specific legume and whole grain barley products on markers associated with the metabolic syndrome (mets) in mature women. design and methods: randomized crossover intervention in women ( - years-old, bmi - , normal fasting glycemia), comparing a diet rich in kernel-based barley products, brown beans and chickpeas (d ) with a control diet (d ) of similar macronutrient composition but lacking legumes and barley. d included g (as eaten)/day legumes, g whole grain barley kernels and g barley kernel bread. both diets followed the nordic nutrition recommendations and provided similar amounts of dietary fiber ( . g/day, d ; . g/ day, d ), with wheat-based products as main fiber supplier in d . each diet was consumed for week under weight-maintenance conditions. blood lipids, glucose, insulin, crp, gamma-glutamyl transferase (ggt) and blood pressure were the measured outcomes. results: both diets decreased serum cholesterol fractions, but d had greater effect (p < . ) on total and ldl-cholesterol (changes from baseline: À % and À %, respectively) than d . d also reduced ggt (À %, p < . ), diastolic blood pressure (À %, p < . ) and the framingham cardiovascular risk estimate (À %, p < . ), while d had no effect. methods: group i (n = )women with ms were examined proinflammatory cytokines polymorphisms, group ii (n = )testing for hereditary and acquired forms of thrombophilia. all subjects had the fetal loss syndrome, fetoplacental insufficiency, severe preeclampsia in previous pregnancies. results: group ipolymorphisms il- β - t/c in . %, il- - g/c-in . %, tumor necrosis factor-a - g/ain . % of cases. in ii group the multigenic defects were verified in % of cases; the feature of multigenic defects is that the g/ g polymorphism of plasminogen activator inhibitor- (pai- ) gene was found in . % of cases, the g/ g phenotype of the gene pai- was verified in . % of cases. the polymorphism in the tissue-type plasminogen activator i/d gene, in the angiotensin-converting enzyme i/d gene, in the fibrinogen g/a gene were found in . %, . %, . % respectively. acquired antiphospholipid antibodies were verified in . % of cases. all women received antithrombotic therapy from the fertile cycle involved low molecular-weight heparin (enoxaparin sodium, daily dose . - . ml), vitamins b, folic acid. pregnancy was achieved in %. there were not recurrent fetal loss, severe pre-eclampsia, placental abruption in the study groups. live births was in all cases. conclusions: we suggest that proinflammatory and thrombophilic status is an important pathogenetic factor of recurrent fetal loss, severe pre-eclampsia and other obstetric complications in women with ms. timely antithrombotic prophylaxis may be a key of successful outcome of pregnancy. the prescription of an individualized rehabilitation program based on the crossover point of substrate utilization (cop) could be particularly relevant in patients with metabolic syndrome (ms). the aim of the study was to examine: . the effects of a week rehabilitation program at an intensity corresponding to cop on the anthropometric characteristics of women with ms, and . these effects after a month follow-up period without supervision. nineteen women with ms ( . ae . years; . ae . kg; bmi = . ae ) performed an indirect calorimetry test to determine their cop and then participated in a supervised rehabilitation program ( min/week at cop on cycle-ergometer over weeks). afterward, they were instructed to continue to practice a physical activity without supervision over months. the target exercise intensity at cop was . ae . % maximal aerobic power. mass, body mass index, waist and hip circumferences, waist-hip ratio, relative fat mass and fat-free mass were significantly decreased whereas energy balance was significantly increased after the rehabilitation program. there were no significant differences at the end vs. months after the rehabilitation program. two months after the rehabilitation program, only both circumferences, waist-hip ratio and energy balance were not significantly different from baseline values. an individualized rehabilitation program over weeks at cop allowed to improve the anthropometric characteristics in women with ms. however, although the energy balance remains unchanged during the month follow-up period, only the effects on circumferences are maintained months after the rehabilitation program. objective: hypoxia contributes to adipose tissue inflammation and fibrotic remodeling in obesity. we have recently shown that longchain n- polyunsaturated fatty acids (pufa) ameliorate adipose tissue inflammation in obese subjects. here we investigated, whether long-chain n- pufa also reduce adipose tissue hypoxia and may prevent adipose tissue remodeling. patients and methods: in a randomized controlled clinical trial we treated severely obese subjects (bmi > kg/m ) with either . g/ day highly purified long-chain n- pufa or control for weeks. at the end of the treatment we sampled visceral and subcutaneous adipose tissue (vat and sat) during elective bariatric surgery. we quantified gene expression of hypoxia and fibrosis markers in tissue specimen by real-time quantitative rt-pcr. statistical analyses were performed by one-way anova. results: adipose tissue gene expression of hif a correlated positively with cd expression, a m macrophage marker and expression of both genes was significantly reduced after n- pufa treatment in sat (p < . ). furthermore, hif a expression correlated negatively with the anti-inflammatory fatty acid index in the treatment group. n- pufa significantly downregulated the pro-fibrotic markers tgfb, mmp and col a in sat. conclusions: mitigation of adipose tissue inflammation by n- pufa is paralleled by the amelioration of hypoxia and prevention of tissue remodeling as estimated by marker gene expression. these data emphasize beneficial effects of high-dose n- pufa in obesity. biochemistry, university of medicine and pharmacy "carol davila", faculty of medicine, university "titu maiorescu", delta hospital, nidnmd "n.c. paulescu," bucharest, romania background and aim: the diabetes "epidemic" nowadays appeared at the same time with the obesity "epidemic", their relationship being a causal one. weight gain cannot be conceived without a good sensitivity to insulin. all three paraoxonases have antioxidant properties. these protect vascular tissues from oxidative damage by modulating the effects of the main actors in the atherosclerotic process, namely the hdl and ldl particles and the macrophage. in this study we aimed to investigate the role of paraoxoanse (pon ) in the relationship between obesity and type diabetes. materials and methods: ten obese patients with type diabetes mellitus were compared with non-diabetic obese subjects. we determined the pon in preadipocytes cells obtained from bariatric interventions and in differentiated adipocytes (day , , , , ) . elisa method was used for leptin and adiponectin measurements. results: the obesity antropometric markers (waist and hip circumference, visceral fat index) were positively correlated with the value for leptin and negatively with the value for adiponectin (p < . ). the intracellular pon tented to be lower with the degree of diferentiation and these was associated with adipokines changes both in serum and cell lysates. conclusion: resuming our data, we presume that pon is present in pre/adipocytes and could be implicated in prevention of type diabetes obesity associated complications. acknowledgements: this work was supported by a grant of the romanian national authority for scientific research, cncs-uefiscdi, project numer pn-ii-id-pce- - - ". dr. lixandru was supported by the postdoctoral program posdru/ / . /s/ , from european social fund. . the effects of a week individualized rehabilitation program (irp) coached at an intensity corresponding to the crossover point of substrate utilization (cop) on hqrol, peak of oxygen uptake (vo peak ) and power out peak (p peak ); . the effects on hqrol after a month follow-up period without coach. nineteen women with metsyn ( . ae . years; . ae . kg) performed a test to exhaustion to estimate the vo peak and p peak , and an indirect calorimetry test to determine their cop used during a irp ( min/week) on cycle-ergometer over weeks. afterward, they were instructed to continue their physical activity without coach over months. vo peak and p peak were increased after the irp (p < . ). hrqol were no different in every domain at the end and months after the irp. only the question about their change of health compared to year ago has improved but it was at the verge of significativity (p = . ). women with metsyn undergoing irp coached at cop improved vo peak and p peak, but showed no improvement in hrqol after a week coached irp nor after the month follow-up period without coach. consequently, physical fitness seems not be associated with self-perceived quality of life in women with metsyn. t.b. domagala , k. kotula-horowitz , r. januszek , m. janczura , j. zagajewski , j. musial micronized fenofibrate ( mg/day) for months. fifty cardiovascular risk male volunteers (mean age years) with no prior myocardial infarction or stroke were enrolled as the controls. brachial fmd and homocysteine levels were measured at baseline and after months. the respective groups also differed in: bmi (p < . ), plasma total (p = . ), hdl cholesterol (p = . ) and triglycerides (p = . ), but not in baseline plasma homocysteine levels ( . ae . vs. . ae . lmol/l; p = ns). at baseline, mean brachial fmd were lower in the subjects with metabolic syndrome ( . ae . % vs. . ae . %; p < . ). in those subjects fenofibrate therapy significantly improved fmd ( . ae . % vs. . ae . %; p < . ) and increased plasma homocysteine levels ( . ae . vs. . ae . lmol/l; p < . ). no such differences were noted in the controls, neither before nor after months. conclusions: fenofibrates improve endothelium-dependent fmd of the brachial artery, irrespective of the simultaneously induced hiperhomocysteinemia. a. picu , l. petcu , d. lixandru , i. stoian , c. cristescu , e. rusu , c. ionescu-tirgoviste nidnmd "n.c. paulescu", biochemistry, university of medicine and pharmacy "carol davila", "titu maiorescu" university, bucharest, romania background and aims: oxidative stress leading to macrophage foam cell formation is the hallmark of the early atherosclerotic lesion. the aim of these study was to assess the relationship between clinical, biochemical and oxidative stress risk factors with obesity in newly diagnosed type diabetes (n-dm). materials and methods: one hundred and forty-five patients with n-dm registered in the nidnmd ambulatory, "n.c.paulescu" and healthy volunteers were included. the n-dm patients were divided into two subgroups according to the bmi (body mass index): group overweight (bmi = . - . kg/m²) and group -obese (bmi ! kg/m²). in circulating monocytes, the ability to produce free radicals vs. their neutralizing capacity was determined by measuring nadph oxidase activity (respiratory burst; rb) and intracellular activity of pon . we also determined the serum leptin and adiponectine by elisa, total antioxidant capacity (teac) and the concentration of non-protein thiols (shneproteic) by spectrophotometric methods. results: in diabetic patients vs. normal subjects, leptin, proinsulin and rb were increased (p < . ), while adiponectin and pon decreased (p < . ). the differences were accentuated in the obese group. the strongest correlation was between proinsulin and leptin (r = . , p < . ) and both contribute for the high cardiovascular risk in type diabetes. our results showed imbalance pro/antioxidant of obese diabetic patients, low pon activity and increased rb being influenced by the degree of obesity. introduction: cardio-protective role of human hdl-associated serum paraoxonase (pon ) is believed to be due, at least partly, to its antioxidative properties. pon activity is genetically determined by major polymorphism q r. brachial flow-mediated dilation (fmd) is a non-invasive physiological measurement used to quantify endothelial dysfunction. fibrates are known to exert hypolipidemic effects, while their effect on pon activity remains unclear. aim: to assess pon activity and fmd in the subjects with metabolic syndrome on fenofibrate treatment. methods: forty male subjects (mean age years) with hipertriglicerydemia, as well as metabolic syndrome, were treated with micronized fenofibrate ( mg/day) for months. pon activity in serum and brachial fmd were measured at baseline and after months. pon q r polymorphism was determined by pcr amplification and restricted digestion; serum pon activity was assayed spectrophotometrically. results there were subjects with qq genotype (group a) and carriers of r allele (group b). at baseline both groups differed in pon activity only ( ae vs. ae u/l; p < . ). fenofibrate treatment reduced pon activity in all subjects, nonetheless significantly in those with qq genotype ( ae vs. ae u/l; p = . ), unlike in the r allele carriers (p = ns). at baseline mean brachial fmd did not differ between groups a and b. fenofibrate therapy significantly improved fmd ( . ae . % vs. . ae . %; p = . ) in group a subjects, unlike group b ( . ae . % vs. . ae . %; p = ns). this study was to investigate the effect of nicotine on insulin sensitivity and explore the underlying mechanisms. treatment of sprague-dawley rats with nicotine ( mg/kg/day) for weeks significantly reduced blood insulin level but had no effect on blood glucose level. both insulin tolerance test and glucose tolerance test demonstrated that nicotine treatment enhanced insulin sensitivity. pretreatment of rats with hexamethonium ( mg/kg/day) to antagonize peripheral nicotinic receptors except for a nicotinic acetylcholine receptor (a -nachr) had no effect on the insulin sensitizing effect of nicotine. however, the insulin sensitizing effect of nicotine was totally abrogated in a -nachr knockout mice, indicating the involvement of a -nachr. further, chronic treatment with pnu- ( . mg/kg/day), a selective a -nachr agonist, significantly enhanced insulin sensitivity not only in normal mice but also in amp-activated kinase-a knockout mice, an animal model of insulin resistance with no sign of inflammation. moreover, pnu- treatment enhanced phosphorylation of signal transducer and activator of transcription (stat ), a molecule involved in regulating insulin signaling, in skeletal muscle, adipose tissue and liver in normal mice. pnu- treatment also improved glucose uptake in c c myotubes and this effect was totally abrogated by stat inhibitor, s i- . all together, these findings indicate that nicotine enhances insulin sensitivity in animals with or without insulin resistance, at least in part via stimulation of a -nachr-stat pathway independent of inflammation. our results not only contribute to the understanding of the pharmacological effects of nicotine, but also identify new therapeutic targets against insulin resistance and type diabetes. calorie restriction (cr) is one of the most reproducible treatments for weight loss and slowing aging. however, how cr induces these alterations is still unclear. this study was designed to understand whether nicotinamide phosphoribosyltransferase (nampt, also known as visfatin) plays a role in the beneficial effects induced by cr using a specific chemical inhibitor of nampt (fk ). sprague-dawley rats were treated for weeks in four groups: ad libitum (al), cr, al + fk and cr + fk groups. al and al + fk animals were allowed unlimited access to standard chow, while the cr and cr + fk animals were restricted to % of the food intake consumed by al and al + fk animals. fk ( mg/kg/ day) was given via drinking water. we found cr upregulated nampt mrna and protein levels in rat skeletal muscle and white adipose tissue. inhibition of nampt did not affect the sirt upregulation by cr but suppressed the cr-induced sirt activity and deacetylation of foxo- . furthermore, inhibition of nampt not only weakened the cr-induced decrease of oxidative stress (ros, superoxide o À˙a nd mda levels), but also greatly abolished the crinduced improvements of anti-oxidative activity (total-sod, gsh and gsh/gssg ratio) and mitochondrial biogenesis. in addition, inhibition of nampt blocked the cr-induced insulin sensitization, akt signaling activation and enos phosphorylation. collectively, our data demonstrate that cr-induced beneficial effects in oxidative stress, mitochondrial biogenesis and insulin sensitivity require functional nampt. background: the anti-diabetic effect of camel milk (cmk) gained increasing recognition in folk medicine and recent clinical and experimental studies. however, the mechanism(s) by which cmk influence the glucose homeostasis is yet unclear. objectives: to investigate the effects of cmk on the blood glucose regulatory mechanisms in control and diabetic animals. materials and methods: experimental diabetes was induced by intrapertional injection of streptozotocin in wistar rats divided into (d & d-cmk) groups. two healthy (c& c-ckm) groups served as control. camel milk ( ml/rat/day) was administered orally to the (d-cmk) and (c-cmk) groups for weeks. the (d) and (c) groups received no treatment. the changes in body weight, blood glucose, glucose tolerance, serum insulin, blood lipids, incretin hormones (glp- and gip), tnf-a, tgf-β , homa-ir and atherogenic index (ai) were investigated. results: the untreated diabetic animals (d-group) exhibited significant hyperglycemia, hyperlipidemia, increased homa-ir and ai, elevated serum icretins, tnf-a and tgf-β levels. this was associated with weight loss and high mortality. camel milk administration to the d-cmk group inhibited the weight loss and mortality and caused significant hypoglycemia, hypolipidemia, insulin secretion, low homa-ir and ai. serum glp- and gip levels show significant elevation but tnf-a and tgf-β were reduced. conclusion: augmented insulin release and decreased insulin resistance together with enhanced incretin hormones release are anticipated to contribute to the anti-diabetic effect of cmk. besides, the peculiar composition of cmk and its anti-inflammatory properties propose it as a valuable adjuvant anti-diabetic therapy. however large-sized clinical studies are still needed. prediabetics reflect dysregulation in glucose homeostasis with obesity is known risk factor in western countries. different degree of obesity contribution toward prediabetics is observed in lean populations. aim: to investigate the role of plasma leptin as a predictor of prediabetics in lean subjects. method: plasma leptin were measured in non-diabetic subjects aged - years old with bmi < . prediabetes (n = ) was defined based on fasting plasma glucose and -h oral glucose tolerance test. plasma leptin were measured in all subjects using commercial elisa kit. binary logistic regressions were used to estimate the age and sex adjusted odds ratio of leptin and other metabolic parameters. results: plasma leptin levels were significantly and positively correlated with bmi, percent total body fat, fasting plasma insulin and blood sugar and homa-ir values. plasma leptin were significantly higher in lean prediabetics ( . ae . ) compared to euglycemic lean subjects ( . ae . ; p < . ). increase in plasma leptin value by one increases the risk of prediabetics with or . ( % ci: . - . ). discussion: in a population of relatively lean and non-diabetic subjects, plasma leptin levels were associated with insulin resistance and prediabetes. furthermore, plasma leptin levels increases risk of prediabetics in non-obese subjects independent of age and sex. our data suggest that leptin as biomarker for screening individuals at high risk for prediabetes in lean population. f. al-zadjali, r. bayoumi latest update from the international diabetes federation shows that the prevalence of type diabetes (t dm) in the arabian gulf countries is among the top worldwide. the rapid increase in t dm prevalence in these countries suggests that psychological and behavioral factors, more than genetic factors, are primarily responsible for this trend. aim: to estimate heritability of plasma levels of adipocytokines in a large isolated arab pedigree. method: blood samples and anthropometric data were obtained from a large arab pedigree of individuals with high level of consanguinity. plasma levels of il- , il- b, leptin, total adiponectin, svcam- were measured using commercial kits. heritability parameters were measured using measured genotype analysis. results: fout hundred and sixty-nine individuals were structured in a large pedigree which consisted of interrelated nuclear families founded by founders. the heritability values were adjusted using age and gender as covariates. percentage of variation of plasma adipocytokines attributed to genetic factors were as following: leptin ( %), total adiponectin ( %), il- b ( %), il- ( %) and svcam- ( %). discussion: adipocytokines play central role in the development of t dm. our data shows high degree of heritability of leptin, il- and svcam- indicating their production is under tight genetic control. furthermore, our heritability values are different from previously reported heritability values of these adipocytkines studied in different ethnic populations. therefore, our results suggests that arab population are distinct and further genetic association and behavioral studies should be conducted for better understanding of the nature of t dm and its increasing trend in middle-east region. results: all treatments were well tolerated and no subjects was withdrawn from the study. compared to the baseline, the group treated with chrome picolinate only experienced a mild but significant decrease in fpg (À . ae . mg/dl). compared to the baseline, the group treated with chrome picolinate-berberine experienced a mild but significant decrease in bmi (À . ae . kg/m ), tc (À . ae . mg/dl), tg (À . ae . mg/dl), non-hdl cholesterol (À . ae . mg/dl), and fpg (À . ae . mg/dl). compared to the baseline, the group treated with chrome picolinate-berberine-banaba experienced a significant reduction in bmi (À . ae . kg/m ), waist circumference (À . ae . cm), sbp (À . ae . mmhg), tc (À . ae . mg/dl), tg (À . ae . mg/dl), ldl-c (À . ae . mg/dl), non-hdl cholesterol (À . ae . mg/dl), fpg (À . ae . mg/dl), insulin (À . ae . mu/l), homa index (À . ae . ) and hba c (À . ae . %), while hdl-c increased (+ . ae . mg/dl). waist circumference, sbp, ldl-c, hdl-c, insulin, homa index and hba c, also significantly improved when compared with other groups. the tested combined nutraceutical appears to significantly improve insulin-sensitivity and a large number of related parameters in subjects with ifg and metabolic syndrome. antioxidative mechanisms prevent human body from the damaging action of free radicals and reactive oxygen species. glutathione and related to it enzyme systems detoxicate h o and hyperoxide and from there, reduced glutathione is a potential marker of oxidative stress level. purpose: to investigete glutathione of erythrocytes in patients with prediabetes (igt and ifg) and type diabetes. matherial and methods: we examined patients with t d and concomitant coronary heart disease (chd) and atherosclerosis (group ), patients with prediabetes (igt and ifg) newly diagnosed and the same co-morbidity (group ) and almost healthy person (group ). examinations included clinical laboratory evaluation, fasting glicose, hba c. total glutathione (gsht) and oxidized glutathione (gssg) were measered by use of glutathione reductase reaction. redox potential (e h ) of glutathione was evaluated by use of nernst equation. results: concentrations of gsht and gsh were greater in group to compare with groups and (by . times, p = . and by . times, p = . respectively). inrease of concentration of gssg in group may change extracellular redox condition. calculation of e h revealed its change to oxidized condition in group to compare with group ( . mv greater) and group ( . mv greater). conclusion: antioxidant defense in red-cells is overactivated during prediabetes (igt and ifg) with concomitant chd and atherosclerosis while in patients with t d was noticed depletion of compensatory mechanisms with increased gssg and e h . reduction in gsh/gssg suggests that intracellular antioxidant is lost; herewith cells become sensitive to oxidative stress. clozapine increases meal size and meal duration, effects similar to the pharmacological blockade or congenital deficiency of cck- (cck- r) receptor. we aimed to investigate the role of cck- r in clozapine-induced weight gain (wg) and insulin sensitivity (is) in cck- r deficient, male otsuka long evans tokushima fatty rats (oletf). long evans tokushima otsuka (leto) rats served as healthy control. animals were orally treated with either clozapine or its vehicle over days. daily food intake was measured by means of metabolic cages. the is was determined by hyperinsulinemic euglycemic glucose clamping (hegc). hypothalamic mrna expression of cck- r and cck- r was measured by real-time pcr, plasma insulin was determined by radioimmunoassay. clozapine failed to induce wg or increment in food intake in either oletf or leto rats. the fasting plasma insulin and blood glucose level was significantly higher in oletf than in leto rats, but clozapine failed to modify these parameters. the glucose infusion rate during the steady state of the hegc was lower in oletf than in leto rats and clozapine did not modify it. the insulin sensitivity index (isi) was lower in oletf rats than in leto and the isi was further decreased by clozapine. the metabolic clearance rate of insulin changed parallel with isi indicating the possible source of the surplus of insulin, which is responsible for the decrement in is. clozapine induced insulin resistance without hyperphagia and wg in male leto and oletf rats. changes in cck- r and cck- r expression were inconsistent with the changes in the isi. clinical biochemistry & immunology, peterborough and stamford nhsft, peterborough, uk the national institute for clinical evidence has published guidelines for the treatment of prediabetes. these stress diet and exercise as shown by the dpp study a decade ago. however, recently published dpp follow-up data show how difficult it is for patients to follow that advice long-term. metformin was also found to be effective and is cheap and generally well-tolerated. this study shows the long-term effectiveness of routine metformin use in patients with igt. all patients attending two rural lipid clinics from who were found to have igt after a standard g ogtt were offered metformin mg bd or given diet and exercise advice if they did not wish medication. metformin was preferred over diet and exercise despite being shown to be inferior in dpp because of the extra cardiovascular benefits shown in ukpds. in , after a mean (range) follow-up of . ( . - . ) years, it was decided to review the data to see if the (off-label) treatment was effective. metformin significantly reduced t dm threefold after years ( % v %). further, it was possible to estimate that metformin could prevent / ever becoming diabetic (p = . ). the effect was due to restoring normoglycymia (fbg < . mmol/l) as the patients' weights and triglyceride levels did not change significantly. patients regularly present to lipidologists with fasting hypertriglyceridaemia. those with igt appear particularly likely to revert to normoglycaemia with metformin. routine use of this inexpensive and well-tolerated drug reduces the lifetime risk of developing t dm by over %. k. salehzadeh, m. shirmohammad zadeh azarbaijan shahid madani university, tabriz, iran as a fermented drink probiotic doogh [ ] can help promote the health of the society. studying crp [ ] changes as an important inflammatory index that predicts coronary-heart diseases such as arteriosclerosis has received attention in medical and nutrition studies. the present study was carried out to study the effects of week drinking different types of dough (probiotic and plain) on the changes of liver crp and other blood factors of male athletes with normal weight. the research sample of this study included healthy male athlete students with equal bmi characteristics that were divided into two testing groups ( each) and were homogenized and randomly divided and went through some exercises. the results of the paired t test showed that drinking plain doogh resulted in significant reduction of blood's urea ( . %) and crp ( . %) and significant increase of hdl ( . %; p < . ). the probiotic doogh also resulted in significant reduction of crp ( . %) and significant increase of hdl ( . %). the comparison of the two groups showed that the only statistically significant difference was in the amount of crp and the reduction effect of probiotic doogh on crp was more compared to the plain doogh (p < . ). also the amount of record changes in the probiotic group (À s) was significantly better than the plain doogh (+ s). background and aims: nutrition has significant effects on human health and diseases. diabetes is a chronic disease that can be affect by nutritional status. therefore, monitoring of nutritional status in these patients is one of the main components of prevention and controlling of complications. therefore, in this study the nutritional status of patients that referred to health center in songhor city was assessed. materials and methods: this descriptiveanalytical study was done on patients with type diabetes ( ae years old) with no insulin therapy. anthropometric mesearments and dietary intake assessment were done. ffq and three recall quessionare were filled with face to face interview. n software were used for analysis. mean ae sd of variables were reported. background: the aetiology of type diabetes and obesity may involve dysregulation of brain appetite control networks. we explored the impact of systemic insulin resistance, common to both conditions, on the effect of meal ingestion on brain responses to food cues. methods: eight insulin resistant (ir, homa -ir . ae . ) and insulin sensitive (is, homa -ir . ae . ) non-obese non-diabetic right-handed men were studied twice, min after consuming ml water (fasted) or kcal mixed meal (fed) in random order. brain responses upon viewing high (hc) and low (lc) calorie food images vs. non-food object (nf) and gaussian blurred (gb) images presented in a block design paradigm were measured using blood oxygenation level dependent functional magnetic resonance imaging. results: the meal reduced hunger (f = . , p = . ) and increased fullness (f = . , p < . ). meal ingestion had no specific impact on responses to lc in either group. in contrast, on viewing hc, there were decreased precuneus responses (vs. gb and nf) and superior temporal gyrus/insula responses to hc (vs. nf) in ir subjects, whilst in is subjects, meal ingestion increased responses to hc (vs. gb) in somatosensory cortex and to all food images vs. gb in putamen/insula, with a trend towards increased dorsolateral prefrontal cortex activity. conclusions: meal ingestion augmented activity in brain regions involved in sensation, interoception and inhibitory control in is subjects during food cue exposure. by diminishing activity in regions involved in imagery and interoception, insulin resistance may influence central appetite control networks to promote further eating after consuming a satiating meal. methods: we examined children with obesity in the endocrinological department of university hospital (minsk) over the year . the number of boys (b) ( . %), mean ae sd age . ae . years; girls (g) ( . %), mean ae sd age . ae years (p = . ). ultrasound (u/s) of the abdominal cavity; the levels of insulin (i); total cholesterol (tc); triglycerides (tg); high-density (hdlc), low-density (ldlc), very low-density (vldlc) lipoprotein cholesterol; atherogenic coefficient (ac); standart oral glucose tolerance test (ogtt) with the calculation of homa-ir and caro indexes; the levels of blood pressure (bp) and body mass index (bmi) were held to all patients. results: sds bmi b was . ae . , g . ae . (p = . ). bp more than th percentile was in ( . %) b and ( %) g (p = . ). the signs of steatohepatosis were determined in ( . %)b, ( %)g. the average levels of tc and tg were in normal limits, gender differenses weren′t noted (p = . ), (p = . ). the concentration of vldlc . ae . mmol/l ( . - . ), . ae . (p = . ). hdlc b and ldlc b didn′t exceed normal limits in boys and girls (p = . ), (p = . ). ac b . ae . ( - ), g . ae . (p = . ). basal and postprandial plasma glucose levels didn′t exceed normal limits regardless of gender (p = . ), (p = . ). the levels of i b . ae . mu/ml ( . - ), g . ae . (p = . ). homa-ir b . ae (< . ), g . ae (p = . ), caro . ae . (> . ), . ae . (p = . ). conclusions: obesity in children was accompanied with arterial hypertension, steatohepatosis and dyslipidemia. the development of insulin resistance with maintaining the basal and postrandial normoglycemia was noted by conducting ogtt in all patients regardless of gender. objective: to evaluate the effect of short-term, moderately high-fat diets on body weight, lipid profile and serum leptin levels. the study was undertaken to create a model with an acute metabolic stress without marked obesity. design: the laboratory mice were fed either a moderately high-fat diet or control diet. body weight, energy intake, body composition, and fasting plasma leptin were compared after and week of dietary treatment. results: after week, abdominal fat mass was % greater in mice fed the high-fat diet than in those fed the control diet (p < . ). however, plasma leptin concentrations did not change much in animals fed the high-fat diet. from to week, animals fed the highfat diet gained weight twice the normal diet group and consumed kj/day more than controls (both p < . ). at week, plasma leptin concentrations per unit abdominal fat mass were % lower in mice fed the high-fat diet (p = . ) and there was a significant negative association between leptin concentrations per unit abdominal fat mass and body weight (r = . , p < . ). conclusions: feeding for weeks moderately high-fat diet is associated with lower than expected circulating leptin concentrations, which correlate with a higher body weight. a high-fat diet may therefore contribute to weight gain by reducing leptin secretion in adipose tissue. the significance of these findings will be discussed. objective: to describe diabetes-related risk factors associated with lower respiratory tract infection (pneumonia) complications among children. methods: we obtained claims data on all hospital admissions to acute care hospitals for children patients with diabetes and pneumonia who were aged - years in bosnia and herzegovina and sarajevo between november , , and november , . these data are checked for accuracy and validity by the pulmologist and diabetologist pediatricians that oversee data collection. in both data sets, we linked diabetic kids patient charts to allow for calculation of previous admission and rehospitalization diabetic kids rates with complications of pneumonia in children. children prescribed more than one antibiotic class contributed to determining the rates of each class. objectives: to examine the extent to which adherence with multiple concomitant healthy lifestyle traits will be associated with the avoidance of the future development of t d. methods: five independent cohorts comprising , men and , women aged - and free of diabetes and cvd at baseline were examined in , , , objective: to investigate the effects of raloxifene on the insulin sensitivity and lipid profile in insulin sensitive and insulin resistant postmenopausal women. study design: this placebo-controlled, double-blind, randomized study involved postmenopausal women aged between and years. all subjects were screened with the insulin resistance homeostasis model assessment (ir-homa) and those patients in the lowest quartile (n = ) were assigned as insulin sensitive and those in the highest quartile as insulin resistant (n = ). patients in both groups received either raloxifene hydrochloride ( mg/day) or a placebo, for a period of weeks. insulin sensitivity, the serum lipid profile, and anthropometric measurements were established before and after therapy. results: women with the highest ir-homa scores were associated with a significantly higher weight, body mass index, waist, and waistto-hip ratio (p < . ). raloxifene significantly reduced the ir-homa scores from . ae . to . ae . (p = . ) and modified the lipid profile in insulin resistant patients when compared to the placebo group and those patients receiving raloxifene in the insulin sensitive group. conclusion: raloxifene reduced insulin resistance and modified the lipid profile in insulin resistant postmenopausal women. diseases, smoking, alcohol consumption, the use of sleeping pills and other potential confounders was also gathered. statistical analyses were done by spss ver. . the average age of the participants was . years old; % was reported current pet ownership. mean hba c was . %, bmi was , and systolic and diastolic blood pressure was and mmhg respectively. pet owners were significantly younger and slightly more overweight; and dog owners were much younger and more overweight than cat owners. in unadjusted analyses, dog owners had a lower rate of taking sleeping tablets than cat owners (p = . %), and dog owners were more likely to be smokers than cat owners (p = . %). however, pet ownership was not associated with hba c, systolic or diastolic blood pressure, bmi, or the prevalence of diabetic complications. conclusions: our results suggest that pet ownership may be associated with insomnia and smoking habits. however, pet ownership is not independently associated with control of diabetes, obesity and prevalence of diabetic complications. objectives: to non-invasively assess the muscular oxygenation response using near-infrared spectroscopy (nirs) and to determine the association between increasing levels of a c and oxygenation response in subjects with type diabetes. materials and methods: forty-five subjects with uncomplicated type diabetes were categorized into two groups: group i (a c < ) and group ii (a c ! ). nirs measurement of vastus lateralis was performed at rest and during a symptom-limited maximal treadmill exercise test to determine muscular oxygenation response. at rest and during peak exercise, deoxygenated hemoglobin (deoxy-hb), oxygenated hemoglobin (oxy-hb) and total hemoglobin (total-hb) were measured with characteristics of light absorptance from nirs. muscle saturation (%) was expressed as the ratio of oxy-hb to total hb volume, an index of tissue de-oxygenation. results: group i subjects (n = with females, . ae . years) were older than subjects in group ii (n = with females, aged . ae . years). the peak vo was comparable between groups. significant lower muscle saturation ( . ae . % vs. . ae . %, p < . ) and more decline (À . ae . % vs. À . ae . %, p < . ) at peak exercise, was noted in group ii. a significant correlation between a c and decline of saturation (r = À . , p < . ) was noted in this study, whereas no other significance were demonstrated in deoxy-hb or oxy-hb. conclusions: this study provided evidence of imbalance of oxygen supply to exercising muscle in asymptomatic and uncomplicated diabetic subjects with elevated a c levels. the insufficient perfusion occurred before vasculopathy and might develop metabolic impairments even myopathy in diabetic subjects with poor glycemic control. study design and method: the lifestyle intervention was conducted as a cluster randomized trial (n = ) in semi-urban setting in sri lanka. the intervention group ( ) received a family centered lifestyle intervention package from family health workers while the control group ( ) received a brief advice from a doctor. duration of the study was -months. results: this study has shown effectiveness in reduction in fasting blood glucose (p < . ), systolic blood pressure (p = . ), diastolic blood pressure (p = . ), weight (p = . ), added sugar (p = . ) and fat consumption (p < . ) while improving physical activity (p < . ) and insulin sensitivity (p < . ) in the intervention group when compared with the control group at follow up assessment. this lifestyle intervention sessions ( ) were carried out by family health workers during their routine house visits. aim: we aimed to compare an experimental type diabetic animal model generated by applying high fat diet combined with single shot of streptozotocin (stz) at mg/kg bw sprague-dawley (sd) rats. methods: we generated and selected rats based on fasting glucose, oral glucose tolerance, and %hba c. once sever type diabetic rats were identified, serum proteins were subjected to d-dige proteomics or comparative d-proteomics after phosphorylation or glycation. results: seven protein targets differentially expressed in severe type diabetic rats (st d) were identified as albumin, vitamin d-binding protein precursor, and transthyretin, respectively. in terms of serum proteins extracted by affinity columns for phosphorylation and glycation, the affinity of phosphorylated protein targets and glycated protein targets were modified under st d condition. results of the ingenuity pathway analysis (ipa) for those targets indicated that antigen presentation, humoral immune response, and inflammatory response are associated networks highly modified in st d group. kidney and liver damages under those st d rats were proposed by ipa and validated by histopathology. polymorphism of patatin-like phospholipase- (pnpla ) has been associated with susceptibility to non-alcoholic fatty liver disease (nafld); whereas genetic studies of nafld in asian indians are not investigated. we investigated the association of polymorphism rs of pnpla with clinical, anthropometric and biochemical profiles in asian indians with nafld. methods: in this case-control study, cases and controls were recruited. abdominal ultrasound, clinical, anthropometry and biochemical profiles were determined. fasting insulin levels and value of homeostasis model assessment of insulin resistance (homa-ir) was determined. polymerase chain reaction and restriction fragment length polymorphism of pnpla gene was performed. the associations of this polymorphism with clinical, anthropometric and biochemical profiles were investigated. results: higher frequency of c/g and g/g genotypes of rs polymorphism was obtained in cases as compared to controls (p = . ), as a consequence frequency of the minor allele g was significantly higher in cases (p = . ). the c/g+g/g genotypes was associated with significantly higher fasting insulin (p = . ), homa-ir (p = . ), alanine transaminase (p = . ) and aspartate transaminase (p = . ). using a multivariate logistic regression model after adjusting for age, sex, body mass index and fasting insulin, subjects with g/g genotype showed higher risk of nafld (or, . , % ci: . - . , p = . ). results: group ; before diet: bg- . ae . mmol/l; months on diet: ae . mmol/l ( . - . mmol/l) months: . ae . mmol/l ( . - . mmol/l); histology: marked necrosis and destruction of bcells on - % islet's surface in islets from ( %); in % not marked necrobiosis or without changes; decreasing of insulin content in b-cells: ig- . ae . (intact- . ae . ); histology: without changes; group : before diet: bg- . ae . mmol/l; months on diet + vitamin b : -bg- . ae . ( . - . mmol/l); months diet + vitamin b : bg- . ae . mmol/l ( . - . mmol/l); histology: partial necro-biosis on - % islet surface in islets from ( %); in other % -without changes; ig- . ae . (intact- . ae . ). conclusions: . months prolonged administration of vitamin b result not marked decreasing of insulin content in b-cells of animals contained on diabetogenic diet and treated by pyridoxin but not protect b-cells of part islets of necrobiosis. aim of this study: to determine the behavior of oxidative stress markers and mitocondrial dysfuncton in non-proliferative diabetic retinopathy. patients and methods: a cross-sectional study was designed with four groups: group : healthy-volunteer subjects. group : patients with mild-non-proliferative diabetic retinopathy (npdr). group : patients with moderate-npdr. group : patients with severe-npdr. serum oxidative stress markers: lipid-peroxidation (lpo measured by malondialdehyde and -hidroxyalkenals), nitric oxide (no metabolites measured by nitrites/nitrates), total antioxidant capacity (tac), activities of antioxidant-scavenger-enzymes in erythrocytes (gpx glutathione-peroxidase and catalase), and mitochondrial dysfunction (expressed in erythrocyte/platelet membrane fluidity and platelet hydrolytic activity of adenosine-thriphosphatase enzyme; atpase). the markers were quantified by colorimetric method. results: patients with npdr had a significant increased serum lpo and no metabolites levels compared to the group . the tac in patients with npdr had a significant decreased compared to the control group. a significant increased in the activities of gpx, catalase and atpase was shown in the experimental groups compared to healthy-volunteer subjects. a significant reduction was shown in membrane fluidity in patients with npdr. the results show that oxidative stress and mitochondrial dysfunction are associated to npdr and its severity. background: weight loss after rous-y gastric bypass (rygb) surgery is associated with alteration of body composition and visceral fat mobilization. we analyzed the amount of fat and fat-free mass reduction in order to identify factors that induce more favorable adiposity change. methods: morbidly obese patients (age = ae years) underwent rygb between september and july . anthropometry, dual-energy x-ray absorptiometry (dexa), computed tomography (ct), life style report, and laboratory test results were registered prior to and year after rygb. results: follow-up rate was . %. dexa demonstrated . ae . of %ffml (percentage of weight lost as fat-free mass) with reduction of % of total fat amount. ct demonstrated higher rate of visceral adipose tissue (vat) reduction rather than subcutaneous adipose tissue with . of %dv/%ds (percentage change in vat vs. sat). patients with diabetes mellitus preoperatively showed more favorable visceral fat reduction (%dv/%ds were . in dm and . in non-dm) even though they lost more fat-free mass. objective: prader-willi syndrome (pws), a genetic disorder characterized by childhood-onset obesity, is reported to have elevated levels of adiponectin. the actions of adiponectin are mediated by adiponectin receptors (adipors) which include adipor and adipor . several cytokines such as adiponectin, tnf-a, and il- , have been known to be involved in insulin sensitivity. methods: thirty pws children (median age . year, boys, girls) who were being receiving growth hormone (gh) therapy and obese children not receiving gh therapy (median age . year, boys, girls) were compared. the relative expression of adiponectin, adipors, several proinflammatory cytokines including tnf-a, and il- measured in peripheral blood mononuclear cells (pbmcs) using real-time pcr. their correlation was analyzed by homeostasis model assessment insulin resistance index (homa-ir). the pws children showed increased expression of adipor (p = . ) and decreased expression of il- (p = . ) compared to the obese children. there was a significant positive correlation between the adipors and tnf-a (adipor vs. tnf-a: r = . , p < . in pws, r = . , p < . in control group; adipor vs. tnf-a: r = . , p < . in obese group). the adipors in the obese group showed significant negative correlation with homa-ir (adipor vs. homa-ir; q = . , p = . , adipor vs. homa-ir; q = . , p < . ). conclusion: in result, inflammatory cytokine expression was closely associated with the expression of the adipors in the pbmcs of both the children with pws and the obese group. adipor expression was highly expressed in the pbmcs of the children with pws. august to november , homeostasis model assessment of insulin resistance (homa-r) were calculated. as a control, subjects were selected, who received oral glucose tolerance test (ogtt) between the same period showing normal glucose tolerance pattern. we used mann-whitney u-test and p-values < . were considered statistically significant. results: there was no significant difference in sex, age ( . ae . vs. . ae . ), bmi ( . ae . vs. . ae . ), hba c ( . ae . vs. . ae . ) and fasting plasma glucose level ( . ae . vs. . ae . ) between the gd group (n = : two males and four females) and control group (n = : one male and five females). the gd group showed significantly higher homa-r than control group ( . ae . vs. . ae . , p < . ). discussion: this study showed that gd patients with normal thyroid function had insulin resistance independent of bmi and hba c. conclusion: gd, even in euthyroid state, is associated with insulin resistance. introduction: it is still remain uninvestigated the correlation of prebiotics and leptin and ghrelin level in frame of inflammatory process in liver. aims and methods: the aim of our study was investigation of nifuroxazide and prebiotic therapy influence on leptin and ghrelin levels in nonalcoholic fatty liver disease patients. determination of leptin and ghrelin (elisa), insulin, il -β, tnf-a were performed in all patients. results: n = patients, female, age ae years, bmi ae kg/m . nafld in %, nash in % and ir in %. leptin was higher in women ( . ae . vs. . ae . ng/dl, p = . ), but ghrelin was similar ( . ae . vs. . ae . pg/ml). leptin positively correlated with bmi (r = . , p = . ) and ghrelin correlated (r = . , p = . ). ghrelin correlated with glycaemia (r = . , p = . ) and correlated to homa (r = . , p = . ). both hormones positively correlated to il -β and tnf-a (ghrelin: r = . , p = . ; r = . , p = . , respectively; leptin: r = . , p = . ; r = , p = . , respectively). prebiotic (npc bic) consumption significantly decreased ghrelin, insulin, il -β, tnf-a level and had no influence on leptin level. the results of liver biopsy (histological examination) and fibromax test showed, that in patients additionally treated by prebiotics, the progress of hepatic fibrosis was significantly slowly, then in cg (fibromax test result: f vs. f ; p < . ). conclusion: our data showed that nifuroxazide and prebiotic therapy decreased inflammation activity and ghrelin level in nafld. cardiology, physiology, medical university of białystok, bialystok, poland aim: ceramide (c) is considered to be an important factor reducing insulin sensitivity. the aim of the present study was to investigate the effect of reduction of the sphingolipid synthesis in the solid tissues on the level of c, and other bioactive sphingolipids, namely sphingosine- -pohosphate (s p) sphingosine (sp), sphinganine (sa) and sphinganine- -phosphate (sa p) in different blood compartments. the experiments were carried out on three groups of male wistar rats, - g of body weight fed ad libitum on a commercially available diet: (i) control, (ii)treated with myriocin (an inhibitor of sphingolipid de novo synthesis) and (iii) treated with nicotinic acid (it reduces the level of plasma free fatty acids). the level of the above mentioned bioactive sphingolipis was determined with the use of mass spectrometry. results: both treatments reduced profoundly the level of each of the examined compounds in the plasma. treatment with nicotinic acid did not affect the level of either compound in erythrocytes but reduced it to a great extend in the platelets. treatment with myriocin reduced the level of each compound, with the exception of sh, in erythrocytes. the compound reduced the level of each compound in the platelets to the level comparable to nicotinic acid. . the level of the examined sphingolipids in the plasma, erythrocytes and platelets depends thoroughly on their supply from solid tissues. . short-term reduction in the plasma free fatty acids level very efficiently reduces the level of bioactive sphingolipids in different blood compartments. background: maternal nutrition plays major role in fetal growth and development. low birth weight and impaired early postnatal growth predispose the offspring to an increased risk for future chronic diseases such as metabolic syndrome. stunting in south african children has previously been documented. the study aimed to investigate effects of maternal nutrition on fetal and early postnatal growth in the population of black urban pregnant south african women, employing ffq, ultrasound and anthropometry measurements. results: based on the z-scores (at birth, weeks and month), babies in the current study were born lighter (À . ) and shorter (À . ) with larger head circumference (+ . ) in comparison with the who child growth standards. the z-scores for both the weight and the lengthfor-age decreased after birth with subsequent increase at months, being significant for length (À . , p = . ) after birth and for weight (+ . , p < . ) at months. maternal intake of polyunsaturated fat in early pregnancy and of total protein in late pregnancy were found associated with the fetal head-to-abdomen circumference (β = À . , p = . and β = À . , p < . respectively) and with the lengthfor-age z-score at weeks (β = . , p = . and β = . , p = . respectively). early plant protein intake significantly correlated with fetal growth rate (β = . , p = . ). conclusion: low maternal pregnancy intake of protein, namely of plant protein, and of polyunsaturated fat affected fetal linear growth, and resulted in a possible "brain sparing effect" in fetus. maternal dietary manipulation during pregnancy may therefore affect fetal and postnatal growth and thus modulate the risk of chronic disease later in life. aims and methods: to assess the efficacy of hb in cp patients in a two centre randomised, double-blind, placebo-controlled, crossover trial. one hundred and twenty-six patients with chronic pancreatitis were exposed to screening blood tests and test of elastase in stool before randomization to placebo or hb (buscopan, boehringer ingelheim) for weeks. all patients followed the basic treatment scheme include dietary and physical regimen. drug effect was optimized by dose titration during weeks - starting at mg daily, increasing (max mg t.d.s) or decreasing as required. methods: brown beans, or white wheat bread (wwb, reference product) were provided as evening meals to healthy young adults in a randomized crossover design. markers of glucose-and appetite regulation, glp- , and markers of inflammation were measured at a following standardized breakfast, i.e. - h after the evening meals. colonic fermentation activity was estimated from measurement of plasma short chain fatty acids (scfa) and breath hydrogen (h ) excretion. results: an evening meal of brown beans, in comparison with wwb, lowered blood glucose (À %, p < . )-and insulin (À %, p < . ) responses, increased satiety hormones (pyy %, p < . ), suppressed hunger hormones (ghrelin: À %, p < . ), and hunger sensations (À %, p = . ), increased glp- ( . %, p < . ) and suppressed inflammatory markers (il- À %, and il- À . %, p < . ) at a subsequent standardized breakfast. breath h ( %, p < . ) and plasma scfa (propionate % and isobutyrate %, p < . ) were significantly increased after brown beans. results: the present study revealed significantly lower levels of adiponectin in diabetic children compared to the controls ( . ae . vs. . ae . lg/ml). it also showed significantly increased carotid intima media thickness (cimt) in diabetic children compared to the control group ( . ae . vs. . ae . mm). there was also positive correlation between the mean cimt and age of the patient, age of onset of diabetes mellitus, hba c, and bmi measurements in diabetic children. there was negative correlation between mean cimt and adiponectin level. conclusions: subclinical microvascular disease in type diabetes mellitus begins early in diabetic children, which emphasize the importance of early detection and control of vascular risks in diabetic children. the study also suggests that adiponectin may prove to be useful marker of cardiovascular risks, and potential therapeutic target for risk prevention in diabetics. in overweight and obese individuals ( f/ m; age ae years, bmi = ae kg/m ). an intra-venous glucose tolerance test, hyperinsulinaemic-euglycaemic clamp and circulating markers relevant to age signalling were performed before and after each diet. results: the high age diet was fivefold higher in age content than the low age diet. the high age diet reduced insulin sensitivity by À . mg/kg/min ( % ci, À . to À . ; p = . ) while the low age diet improved insulin sensitivity by + . mg/kg/min (+ . to + . ; p = . ). the overall change in insulin sensitivity was . mg/ kg/min ( . - . , p = . ). the change insulin secretion was correlated inversely with the change in plasma age (cml) concentration (r = À . , p = . ). to investigate the level of transforming growth factor (tgfbl) and basic fibroblast growth factor (bfgf), non-specific markers of inflammation: interleukin- (il- ), tumor necrosis factor-a (tnf-a) in patients with coronary heart disease (chd) depending on the presence of dm . the study involved people: one group À patients with chd without carbohydrate metabolism disorders, two group - patients with dm and chd. blood samples were taken from the cubital vein and the aorta during coronary angiography. . )], as in arterial and venous blood in the presence of chd and dm (p < . ). . availability dm in patients with chd was associated with significant increase in the level of tgfb , il- . these observation reflect the effect of chronic hyperglycemia on the restructuring of the connective tissue and the vascular wall. . tgfb direct correlation with lipid markers confirms the relationship of connective tissue disorders and lipid metabolism in the pathogenesis of atherosclerosis. obesity can be induced with high fat diets (hfd) and is associated with inflammation in white adipose tissue (wat) and liver. the factors that control the early metabolic responses to hfd and that trigger inflammatory gene expression are only poorly understood. a time-resolved analysis of differentially expressed genes in expanding adipose tissue of mice ( weeks hfd feeding) identified specific clusters of lipid metabolism-related genes and inflammation-related genes with similar time expression profiles. subsequent promoter analysis of the clustered genes revealed that specific master regulators (among which fos, esr , hnf a, jun, ppara, pparg, nr h /lxrb, nfkb, srebf and , sfpi , smad , sp ) orchestrate metabolic adaptations and early inflammatory responses in wat. some of these transcription factors (esr , jun, fos, pparg, sp ) have a dual role and regulate the adjustment of lipid metabolism as well as expression of inflammatory genes such as cxcl /kc, ccl /rantes, complement factors, asc, granzyme a ccl /rantes, ccl , ccl /mcp . subsequent analysis of corresponding livers revealed comparable molecular responses on the level of transcription factors. more specifically, many master regulators identified in wat were also involved in the liver response to hfd as demonstrated by analysis of hepatic target gene expression in conjunction with transcription factor binding activity analysis. our findings support the view that metabolic and inflammatory processes are interlinked in wat and liver, and that responses to hfd are controlled in a similar way on the transcription factor level. distortions of the mechanisms which control metabolic homeostasis in these organs may thus also affect their inflammatory tone. aim: to investigate the effects of iptakalim, a novel sur b/kir . type atp-sensitive potassium channel opener, on endothelial dysfunction induced by insulin resistance (ir) and to determine whether iptakalim improved ir associated with hypertension in fructose-fed rats (ffrs) and spontaneously hypertensive rats (shrs). methods: the levels of endothelial vasoactive mediators and enos protein expression were determined usingelisas or western blot. in both ffrs and shrs, hyperinsulinemic-euglycemic clamp was used to evaluate ir states. . cultured human umbilical vein endothelial cells (huvecs) incubated with the pi -kinase inhibitor wortmannin ( nmol/l) and insulin ( nmol/l) induced endothelial dysfunction characterized by reduced release of no and expression of enos protein, and increased production of et- . pretreatment with iptakalim ( . - lmol/l) could potently prevent the endothelial dysfunction by increasing no production and inhibiting et- release. . in ffrs, the levels of sbp, fasting plasma glucose and insulin were elevated, whereas the glucose infusion rate (gir) and insulin sensitive index (isi) were significantly decreased, and the endothelium-dependent vascular relaxation response to ach was also impaired. these changes could be prevented by administration of iptakalim for weeks. the imbalance between serum no and et- was also ameliorated by iptakalim. . in - month-old shrs (ir was established at the age of months), oral administration of iptakalim for weeks significantly ameliorated hypertension and increased the gir to the normal level. conclusion: iptakalim could protect against ir-induced endothelial dysfunction, and ameliorate ir associated with hypertension, via restoring the balance between no and et- signaling. m. ste z pie n , a. ste z pie n , r.n. wlazeł , m. paradowski , m. banach , j. rysz material and methods: patients (f , m ) were divided according to bmi into three groups: a-obesity i (n = ); b-obesity ii (n = ) and c-obesity iii (n = ) and into other four groups: females and males and patients treated with statins or fibrates (n = ) or untreated (n = ). results: leptin was significantly higher in group c compared to group a and b [ . ( . - . ) vs. . ( . - . ) ng/ml, p < . and vs. . ( . - . ) ng/ml, p < . respectively]; hs-crp were higher in group c than in group a [ . ( . - . ) vs. . ( . - . ) mg/ l, p < . ]. adiponectin and leptin were higher in females [ . ( . - . ) vs. . ( . - . ), p < . and . ( . - . ) vs. . ( . - . ), p < . , respectively]. resistin, hs-crp and il- were higher in untreated patients' group [ . ( . - . ) vs. . ( . - . ) ng/ ml, p < . ; . ( . - . ) vs. . ( . - . ) mg/l, p < . and . ( . - . ) vs. . ( . - . ) pg/ml, p < . respectively]. leptin positively correlated with hs-crp in the whole population (r = . , p < . ), in treated patients' group (r = . , p < . ) and with tnf-a in group c (r = . , p = . ). conclusions: leptin may be associated with chronic inflammation in obese hypertensive patients. serum leptin and adiponectin levels are sex dependent. hypolipemic treatment has impact on chronic inflammation and resistin. lean body mass in genetically obese (ob/ob) or anorectic/cachectic subjects is severely reduced. similar outcomes of two different pathological states prompted us to wonder if leptin, adipokine well known from its control of appetite interacts with myogenesis. apparently, recombinant leptin ( ng/ml) stimulated dna synthesis in mononuclear myoblasts together with the increase of t /y p-erk / protein expression levels. additionally, leptin reduced cell viability and muscle fiber formation from c c mouse myoblasts. detailed short-and long-term examination with the use of metabolic inhibitors revealed that both jak/stat and mek/mapk but not pi -k/akt/gsk- beta signaling pathways were stimulated by leptin, and that stat (y p-stat ) and mek (t /y p-erk / ) control these effects. in turn, insulin promoted pi -k-dependent phosphorylation of akt (s ) and gsk- beta (s ) and insulin overruled leptin-dependent inhibition of myogenic differentiation in pi -k-dependent manner. gsk- beta might play dual role in muscle development. insulin-induced effect on gsk- beta (s p-gsk- beta) facilitated myotube formation. in contrast, leptin through mekdependent manner led to gsk- beta phosphorylation (y p-gsk- beta) with resultant retardation of myoblast fusion. in summary, to some extent opposite effects of insulin and leptin on skeletal muscle development emphasize the importance of intercellular signaling between adipose tissue and skeletal muscle. insulin and leptin determine how muscle mass is gained or lost, respectively. objective: obesity is linked to both increased metabolic disturbances and increased adipose tissue macrophage infiltration. however, whether macrophage infiltration directly influences human metabolism is unclear. the aim of this study was to investigate if there are obesity-independent links between adipose tissue macrophages and metabolic disturbances. methods: expression of macrophage markers in adipose tissue was analyzed by dna microarrays in the sos sib pair study and in patients with type diabetes and a bmi-matched healthy control group. results: the expression of macrophage markers in adipose tissue was increased in obesity and associated with several metabolic and anthropometric measurements. after adjustment for bmi, the expression remained associated with insulin sensitivity, serum levels of insulin, c-peptide, high density lipoprotein cholesterol (hdl-cholesterol) and triglycerides. in addition, the expression of most macrophage markers was significantly increased in patients with type diabetes compared to the control group. conclusion: our study shows that infiltration of macrophages in human adipose tissue, estimated by the expression of macrophage markers, is increased in subjects with obesity and diabetes and associated with insulin sensitivity and serum lipid levels independent of bmi. this indicate that adipose tissue macrophages may contribute to the development of insulin resistance and dyslipidemia. hp gene has been demonstrated to be a major determinant of susceptibility to cvd and in the development and progression of dn. hp allele is defective in its ability to protect against oxidative stress cvd and dn. we decide to assess the intracellular localization of iron in the pctcells and its potential toxicity in the development and progression of dn. methods: wild type c b / mice have only an hp allele. we genetically engineered a murine hp allele and inderted it in the murine hp locus by homologous recombinatiobn. we induced dm, by stz for days, at weeks of age we assessed lysosomal membrane integrity, redox-active iron in kidney lysosomes. . increased iron-rich deposits in lysosomes of pct cells in hp - dm vs. hp - dm ( ae % of all lysosomes) compared with hp - dm mice ( ae % of all lysosomes, p < . ). . intralysosomal redox-active iron concentrations are markedly increased in hp - dm mouse kidneys lysosomes of hp - dm mice ( . ae . lmol/l) as compared with those from hp - dm mice ( . ae . lmol/l, p = . ). lysosomal membrane lipid peroxides are increased in hp - dm proximal tubule cell (p < . ). vitamin e supplementation resulted in a % reduction in lysosomal redox-active iron in hp - dm mice (p < . ). conclusion: a novel mechanism whereby the hp genotype may predispose to renal injury in the setting of dm via increased iron deposition in the lysosomes of pct. purpose: we aimed to use other less hazardous route of insulin injection to prevent pharmacokinetic problems of sc insulin and find out response categories in diabetics and prediabetic patients. besides, fbs and hba c are markers for treatment evaluation; we wondered whether aitt could be a marker of residual pancreatic activity regeneration or decelerating progression of type ii diabetes. methods: five hundred diabetic and patients with impaired glucose tolerance were enrolled to this trial. three hours after breakfast they receive - unit equivalents of insulin into the external auditory cannel. blood glucose level was measured every min for h. this was repeated months later in both groups; while prediabetic patients received some sorts of therapy while the other patients remained on their previous lifestyle. auc and best fit curve were evaluated by partial mathematical integration. results: six different prototypic curves were extrapolated from diabetic patients with the possibility of excellent theoretic explanations about etiology and multifactoriality, lifestyle change, drug(s) of choice and prognosis. parallel to this prediabetic patients showed comparable curves. the area under curve in treated prediabetics showed a small but significant reduction compared to untreated ( vs. , p = . ). conclusions: as shown elsewhere the area under curve after an auditory insulin tolerance test is a nice marker in diabetes response evaluation and prognosis and an excellent marker for progression to diabetes and effectiveness of treatment in prediabetics (< compared to > ). introduction: type ii dm is generally regarded as a progressive disease with control of bs becoming more difficult with time. we wondered whether optimal therapy with "mega-treatments" that can let the pancreas rest could reverse the disease. materials and methods: thirty five patients received optimal doses of insulin through the auditory channel for months. contributing factors such as obesity, anxiety, h. pylori infection and reduced physical activity were treated appropriately. at beginning and every month they were evaluated by way of auditory insulin tolerance test after h of drug vacation. the general appearance of the curve, the partial integration of it and the overall area under curve were compared monthly. results: auc declined from a mean of - from first to sixth month meaning reduced insulin resistance (p < . ). this decline was steady during the whole months and minor variations in different patients were not significant. with mathematical calculation it seems very unlikely that this decline becomes asymptotic so that on extension of the curve for - years at least % of the patients eventually fall into the nondiabetic range with auc under . (p < . ) although different definitions exist for dm, auditory insulin tolerance test might be functionally more illuminating. these results are in concordance with available literature that denotes early aggressive treatment might be better. we add to this notion that early aggressive treatment can possibly reverse type ii diabetes. physiology, universidad de guadalajara, guadalajara, mexico background: c-reactive protein (crp) is an acute stage protein whose serum levels become raise by infection or because an undergoing metabolism disruption. our group has found crp variable serum levels in hypertensive patients that course with obesity and dyslipidaemia. the crp polymorphism rs g>a has been associated to lowered crp serum levels in autoimmune diseases. the role of c-reactive protein (crp), a marker and mediator of inflammation, in the pathogenesis of metabolic syndrome and its complications such as non-alcoholic fatty liver disease (nafld) remains to be elucidate. in this study we investigated whether increased levels of human crp itself can promote increase of glucose and lipid metabolism disorders associated with metabolic syndrome. materials and methods: spontaneously hypertensive rats (shr) with transgenic expression of human crp gene under apolipoprotein e promoter (shr-tg) in age -year and age matched non-transgenic shr controls were used. both groups were fed a high fructose diet ( % cal fructose) for weeks. parameters of insulin resistance and oxidative stress were measured by commercially available kits. results: transgenic expression of crp was associated with significant increase of serum triacylglycerols ( . ae . vs. . ae . mmol/l, p < . ) and insulin levels (p < . ), markedly decrease in insulin stimulated c-glucose incorporation into muscle glycogen ( ae vs. ae nmol/g/ h, p < . ), reduced serum adiponectin ( . ae . vs. . ae . mmol/l, p < . ), and microalbuminuria (p < . ). transgenic expression of crp was associated with increased liver triglyceride concentrations ( . ae . vs. . ae . lmol/g, p < . ), decreased liver glutathione peroxidase activity (p < . ) and reduced glutathione concentration (p < . ). liver lipidperoxidation were elevated in shr-tg rats: tbars (p < . ). conclusion: overexpression of human crp induced insulin resistance, oxidative stress and liver steatosis in shr rats. these finding indicate that chronically inflammation might directly contribute to the pathogenesis of metabolic syndrome and nafld. one of the most topical issues of modern pediatrics is obesity in children and adolescents, which has a tendency to doubling every three decades in almost all countries. the aim of our research was to investigate the fatty acid composition of the blood in children with obesity. patients and method: we investigated children aged from to years, divided into two groups: group i - children ( % boys and % girls) who are overweight or obese (bmi . ae . kg/ m ), group ii - persons ( % boys and % girls) with normal body weight (bmi . ae . kg/m ). research methods: quantitation of omega- and omega- polyunsaturated fatty acids, determination of the total amount of fatty acids, the total content of eicosapentaenoic and docosahexaenoic acids by gas chromatography with mass selective detection and determination of the omega- index (the ratio of the sum of eicosapentaenoic and docosahexaenoic acids to total content of fatty acids in %). results: there was a direct correlation between the value of bmi and the increasing of omega- index and the omega- pufas in children with obesity, while for the children with normal body weight the connection of bmi with the change of the fatty acid composition of blood was not obtained. thus changes of the quantitative and qualitative fatty acid composition of blood in obesity children and adolescents had multidirectional nature and require further dynamic study. a. kopp, a. schmid, m. mü ller, a. schä ffler internal medicine i, university hospital regensburg, regensburg, germany introduction: proteins secreted by adipocytes (adipokines) play an important role in the pathophysiology of type diabetes mellitus and the associated chronic and low-grade state of inflammation. it was the aim to characterize the anti-inflammatory potential of the new adipokine, c q/tnf-related protein- (ctrp- ), which shows structural homologies to the pleiotropic adipokine adiponectin. in earlier studies, recombinant ctrp- has been shown to inhibit lps and lauric acid induced release of pro-inflammatory cytokines and chemokines dose-dependently in monocytes and adipocytes. methods: for in vivo analysis, male c bl/ mice were treated by intraperitoneal lps administration for h. anti-inflammatory effects were tested by pre-treatment ( min) with ctrp- . after killing, epididymal adipose tissue was collected for cytokine mrna expression analysis (real-time rt-pcr) and blood for measurements of circulating cytokine levels (elisa). the anti-inflammatory potential previously found in vitro is also seen in lps-treated c bl/ mice. animals pre-treated with ctrp- have lower levels of inflammatory cytokines such as interleukin- (il- ) and macrophage inflammatory protein- (mip- ). furthermore, mrna expression of il- and mip- in the epididymal adipose tissue is significantly reduced by ctrp- . conclusion: ctrp- acts anti-inflammatory in cells and tissues that are involved in obesity and type diabetes mellitus. therefore, it might be an interesting drug target in treating obesity-related chronic inflammation. objective: the aim of the study was to assess the burden of some metabolic syndrome (ms) risk factors in polish adolescents from two less-urbanized regions as well as the relationship between abdominal obesity, dyslipidemia and hypertension incidence. the study involved adolescents aged - . all subjects lived in two less-urbanized regions of poland (small towns and villages in the central and north-eastern regions). the concentration in blood of triglycerides (tg) and hdl-cholesterol (hdl-c), as well as systolic blood pressure (sbp) and waist-to-height ratio (whtr) were determined. using logistics regression, an odds ratio (or) of the incidence of high whtr ( ! percentiles), high tg ( ! mg/dl), high spb (> percentiles) and low hdl-c (boys: < mg/dl; girls: < mg/dl) was calculated. results: high whtr was found in % of adolescents, high tg in %, high spb in % and low hdl-c in %. adolescents with abdominal obesity (whtr ! percentiles) had an or rated as high spb at . ( % ci = . - . ; p < . ), an or rated as high tg at . ( % ci = . - . ; p > . ) and an or rated as low hdl-c at . ( % ci = . - . ; p > . ) in comparison to adolescents with normal whtr (between and percentiles). adolescents from north-eastern poland had an or rated as high spb at . ( % ci = . - . ; p < . ) and an or rated as high tg at . ( % ci = . - . ; p < . ) in comparison with the central region (or = . ). conclusions: dyslipidemia and hypertension were the main metabolic syndrome risk factors in polish adolescents from less-urbanized regions, especially in central poland. the risk of hypertension rose over times in adolescents with abdominal obesity. objective and aims: as employment has become more sedentary in nature, there is a potential for more working individuals to be at risk of developing the metabolic syndrome (mets). physical activity (pa) is recommended for prevention of such chronic conditions. this study investigates self-reported pa and presence of mets in the workplace as part of the established "prosiect sir gâr" initiative in south wales, uk. methods: two hundred and twenty-one male steel workers (sw) and male local health board (lhb) employees were screened and their data analysed. anthropometric data, blood pressure and self-reported physical activity (gppaq) were all recorded alongside obtained blood samples which were subsequently analysed for high-density-lipoprotein cholesterol (hdl-c). presence of the mets was determined based on the following idf criteria: central obesity (waist circumference: ! cm), reduced hdl-c levels (< . mmol/l) and either systolic ( ! mmhg) or diastolic ( ! mmhg) hypertension. results: the proportion of males diagnosed with mets was comparable between worksites (sw: . % vs. lhb: . %; p = . ) despite the sw reporting being more physically "active" or "moderately active" than their lhb counterparts ( . % vs. . %; p < . ). central obesity, reduced hdl-c levels and diastolic hypertension were comparable between worksites (p > . ), although systolic hypertension was higher amongst lhb employees ( . % vs. . %; p < . ). however, more sw were found to be clinically obese ( . % vs. . %; p = . ). introduction: diabetes mellitus is often a silent disease and its prevalence is increasing rapidly worldwide. nonalcoholic steatohepatitis is certainly the less estimated complication of diabetes in frequency and severity. the aim of our study was to evaluate the prevalence of steatohepatitis and to identify its clinical and biological risk factors. materials and methods: the prospective transversal study was comparative between type diabetics (group ) and healthy people (group ) with no chronic hepatopatic diseases, no alcoholism and no intake of hepatotoxic drugs. all have benefit from a clinical exam, biological assay and abdominal echography seeking for steatohepatitis. results: group has statistically a higher frequency of android obesity, insulin resistance, steatohepatitis, high blood pressure, hypertriglyceridemia, chronic inflammation and silent myocardial ischemia in comparison with group . the steatohepatitis was present in % of patients vs. . % of healthy people; p < . . also, patients from group with steatohepatitis (group a) had a body mass index (bmi), waist circumference, a percentage of fat mass, a level of triglycerides, of alanine aminotransferase (alat) higher than diabetics without steatohepatitis (group b), with a risk of metabolic syndrome multiplied by three. with multivariate analysis, we found that in group , alat and bmi were directly associated to steaohepatitis. our study notifies the frequency of steatohepatitis in diabetics. it could be prevented and treated by loss of weight and regular physical activity in order to reduce insulin resistance. objectives: vascular dysfunction and complications are the major cause of mortality in diabetic patients. arterial stiffness has been known as a useful predictor of atherosclerosis and lipoprotein level is one of major risk factors of atherosclerosis. to investigate the association of lipoprotein level with arterial stiffness, we studied the vascular characteristics of patients with diabetes. methods: fifty patients (male:female = : , mean age . ae . years), with diabetes and without coronary artery disease, were enrolled and evaluated. all patients have been taking angiotensin receptor blocker or angiotensin converting enzyme inhibitor. arterial stiffness was assessed by measuring the carotid-radial pulse wave velocity (pwv). the cardiovascular risk factors, including body mass index, lipid profile, pulse pressure, c-reactive protein, flow-mediated vasodilatation (fmd) were also measured. the pwv was significantly higher in patients with metabolic syndrome than those without metabolic syndrome ( ae vs. ae cm/s, p = . ) in diabetic patients. multivariate analysis revealed that hdl cholesterol level, body mass index and metabolic syndrome were highly associated with pwv (p = . ). pulse pressure, crp, hdl cholesterol level and metabolic syndrome were significantly associated with fmd. conclusion: in diabetic patients, metabolic syndrome and hdl cholesterol level were highly associated with arterial stiffness and fmd as in non-diabetic patients. objective: our goal was to compare a weight loss diet with high caloric intake during breakfast to an isocaloric diet with high caloric intake at dinner. research design and methods: obese women (bmi . ae . kg/m ) with metabolic syndrome were randomized into two isocaloric (~ kcal) weight loss groups, a breakfast (bf; kcal breakfast, kcal lunch, kcal dinner) or a dinner (d) group ( kcal breakfast, kcal lunch, kcal dinner) for weeks. anthropometric measurements, oral glucose tolerance test (ogtt) and meal tests were performed. the bf group showed greater weight loss (À . ae . vs. À . ae . kg) and waist circumference reduction (À . ae . vs. À . ae . cm) compared with the d group. although fasting glucose, insulin and ghrelin were reduced in both groups, fasting glucose, insulin and homa-ir decreased significantly to a greater extent in the bf group. mean triglyceride levels decreased by . % in the bf group, but increased by . % in the d group. after ogtt, the extent of reduction of aucglucose and aucinsulin was greater in the bf (À % and À %, respectively) compared with the d group (À % and À %, respectively). in response to meal challenges, the overall daily aucglucose aucinsulin, aucghrelin and mean hunger scores were significantly lower, whereas mean satiety scores were significantly higher in the bf group. conclusions: an isocaloric diet with switched caloric intake during breakfast or dinner differentially influences weight loss and metabolism. high-calorie breakfast with reduced intake at dinner might be a useful alternative for the management of obesity and metabolic syndrome. centre for biomedical sciences, cardiff metropolitan university, cardiff, uk introduction: we have reported that exercise alters markers of monocyte/macrophage polarisation in peripheral polymorphonuclear cells, decreasing the m :m marker ratio. since the m phenotype is considered "anti-atherosclerotic", this may be beneficial in reducing cardiovascular disease risk. this study aimed to determine whether exercise specifically promotes m marker expression in purified monocytes, and to elucidate the molecular mechanisms involved in this process. methods: twenty-six healthy, sedentary individuals ( ae years) participated in a low-intensity exercise programme (walking, min, thrice weekly for weeks). peripheral monocytes were isolated using magnetic immuno-separation, and gene expression was determined by rt-pcr. serum lipids, insulin and glucose levels were measured by standard biochemical methods. the presence of serum pparc ligands was determined by gene reporter assay. results: during the -week exercise programme, pparc ligand generation and cox- gene expression were increased [ . ae . -and . ae . -fold, respectively (p < . )]. similarly, pparc-dependent genes (e.g. cd ) and m marker (e.g. dectin- ) expression increased ( . ae . -(p < . ) and . ae . -fold (p < . ), respectively), while exercise-associated increases in pro-inflammatory m markers were blunted [e.g. mcp- . ae . -fold (p < . conclusion: low-intensity exercise may prime monocytes for differentiation into m -polarised macrophages (possibly via pparcdependent events) and contributes to improved insulin sensitivity. this data supports exercise prescription for the prevention and management of inflammatory-linked diseases such as atherosclerosis and diabetes. quantify and determine possible differences and their correlation with plasma leptin and ghrelin levels. for this study, male rats were underwent a case control study. the fecal bacteria composition was investigated by pcr-denaturing gradient gel electrophoresis and realtime qpcr. in restricted eaters, we have found a significant increase in the number of proteobacteria, bacteroides, clostridium, enteroccoco and prevotella and a significant decrease in the quantities of actinobacteria, firmicutes, bacteroidetes, b. coccoides-e. rectale group, lactobacillus and bifidobacterium with respect to unrestricted eaters. we also found a significant positive correlation between the quantity of bifidobacterium and lactobacillus and plasma leptin levels, and a significant and negative correlation among the number of clostridium, bacteroides and prevotella and plasma leptin levels in all the experimental groups. furthermore, plasma ghrelin levels were negatively correlated with the quantity of bifidobacterium, lactobacillus and b. coccoides-eubacterium rectale group and positively correlated with the number of bacteroides and prevotella. in conclusion, nutritional status and physical activity may have an impact on the gut microbiota composition affecting the diversity and similarity. the significant increase in the quantity of lactic acidproducing bacteria and butyrate-producing bacteria that would also implied an increase in their bacterial metabolites in the exercise rats without dietary restriction could be responsible of the plasma ghrelin levels decrease found in these rats which affect the food intake and the body weight. the aim of this study was to evaluate the relation between weight gain classified according to iom recommendations and macronutrient intake. methods: a cross-sectional study was conducted on women hospitalized in the maternity during august-september . prepregnancy weight was self-reported. gestational weight gain and weight rate gain was determined by means of the weight registered in the maternity before delivery. nutrient intake during pregnancy was evaluated with a -item food frequency questionnaire. results: on average, protein provided . % ( %ci: . - . ), carbohydrate . % ( %ci: . - . ) and fat . % ( % ci: . - . ) of the total energy intake. there was a positive and consistent association between energy intake and maternal weight gain among the pregnant women (p = . ). the percent of energy from protein was associated with maternal weight gain rate (p = . ). women with a weight gain higher then media + sd had a higher intake of protein compared with those with medium (p = . ) and lower (p = . ) weight rate gain. no significant differences regarding fats and carbohydrates intake was noted. similarily, women with weight gain above the iom recommendations had a significant higher protein intake compared with those with a lower weight gain (p = . ). conclusion: a strong association was found only between protein intake and weight gain in the studied sample. a dietary pattern analyses would clarify the relation with weight gain during pregnancy. excessive weight gain and obesity before pregnancy was associated with large for geastational age newborns and prematurity. the aim of the study was to analyse the relation between maternal anthropometric indicators and apgar score. a cross-sectional study was conducted on women hospitalized in the maternity during august-september . multiple pregnancy and obstetrical pathology represented exclusion criteria. self-reported weight was used to estimate prepregnancy bmi. gestational weight gain was determined by means of the weight registered in the maternity before delivery. apgar score was determined by the neonatologist immediately after birth. results: in the sample studied, . % newborn had an apgar score lower than , thus indicating neonatal distress. there weren't noticed significant differences according to weight gain during pregnancy. among the mothers with newborns which had an apgar score lower than , . % had a weight gain lower, . % higher and . % within the iom′ s recommendations. however, excessive prepregnancy weight was associated with neonatal distress (p = . ): . % of women with prepregnacy bmi ! kg/m ; . % of the normal weight and % of the underweight gave birth children with low apgar score. conclusion: prepregnancy excesive weight was associated with neonatal distress, strenghtening the importance of achieving an ideal weight before conception. patients and methods used: six obese women (age . ae . years, bmi . ae . kg/m ) had fasting metabolic measurements taken via indirect calorimetry before and after weeks of a low starch diet. respiratory gases were collected for min using standard procedures in order to determine resting metabolic rate (rmr), respiratory exchange ratio (rer), and macronutrient oxidation (carbohydrate and fat). a paired sample t-test was used to evaluate significant mean differences from pre-to post-diet. results: after weeks on a low starch diet, subjects lost an average of . ae . kg despite the fact that this was not designed as a weight loss diet. rer decreased from . ae . to . ae . (p = . ) from pre-to post-diet measurements. further, carbohydrate oxidation decreased from . ae . to . ae . g/min (p = . ), and fat oxidation increased from . ae . to . ae . g/min (p = . ). changes in rmr were not significantly different. background: weight loss improves insulin resistance and hyperandrogenism in obese women with pcos but is unnecessary in lean women with pcos; however, meal timing and composition may influence glucose metabolism and hyperandrogenism. objective: to investigate the effects of two isocaloric diets with different meal timing on insulin resistance and hyperandrogenism in lean women with pcos. methods: sixty lean women with pcos were randomized to one of two kcal isocaloric diets with different meal timing: the number of young adults with ms is steadily increasing, but ms in children mainly incomplete according to the pediatricians' reports. so it was suggested that there are some flaws in the diagnostic criteria that lead to ms hypodiagnosis. hypothesis: using the clarified criteria may improve quality of ms detection in children. methods: in obese adolescents the ms components were analyzed by idf and clarified criteria. additionally abdominal obesity was analyzed by bmi sd and waist to height ratio; glucose intolerance by ogtt and homa-ir; dyslipidemia by fasting tg, ldl, hdl, tc (according to percentiles by ncep for children); blood pressure by the fourth report on the diagnosis, evaluation and treatment of high blood pressure in children and adolescents. results: the total number of detected ms components by idf vs. clarified ones: " " in . ae . % by idf; " " in . ae . % vs. . ae . % (p < . ); " " in . ae . % vs. . ae . % (p < . ); " " - . ae . % vs. . ae . % (p = . ); " " in . ae . % vs. . ae . % (p < . ); " " in . ae . % vs. . ae . % (p < . ). conclusion: using clarified criteria improves the quality of ms detection in children, which corresponds to a ms global concept of identifying high cardiovascular risk group. aim: polycystic ovary syndrome (pcos) is the most common endocrinopathy among women of reproductive age. pcos is connected with ovulatory disorders, oligomenorrhea, hyperandrogenism, infertility, and an increased miscarriage rate, and is frequently associated with insulin resistance (ir). multiple factors in the follicular fluid affect the fertilization and early embryonic development, including in women with pcos. the aim of this study is to evaluate the predictive value of follicular adiponectine regarding pregnancy outcomes in pcos vs. non pcos patients who underwent in vitro fertilization. material/methods: we designed a prospective study. group : (n: ) non pcos and group : (n: ) pcos patients according to roterdam criteria were included the study. basal ovarian reserve parameters, endometrial thickness, follicular luid adiponectine levels, clinical and laboratory ivf outcomes, pregnancy rates were studied. results: there were statistically significant differences in used gonadotropine dose, total oocyte number, mii oocyte number in non pcos vs. pcos groups (p: . ). but there were no statisticaly significant differences between the groups according to follicular fluid adiponectine levels (p > . ). we evaluated the correlation with adiponectine and ivf outcomes as endometrial thickness, mii oocytes number, fertilization rates and pregnancy rates, but there were no statisticaly significant correlation (p > . ). we could not find differences of follicular fluid adiponectine levels in the pcos vs. non pcos groups. although we could not find correlation with adiponectine and pregnancy rates, further investigations with larger numbers of cases are needed to clarify this subject. hypothesis: using the clarified criteria may improve quality of cardiovascular risk (cvr) evaluation in pediatric group. methods: comparative ms components detection in obese children by idf and clarified criteria as well as prognostic value relative to the myocardial remodeling and diurnal blood pressure patterns. results: it was established that the idf criteria (> ) are highly specific (sp = . ), but low sensitive (se = . ) with deterioration negative predictive value (npv = . ). clarified criteria (sum score > ) correspond to higher sensitivity (se = . ) without loss of specificity (sp = . ). conclusion: using the clarified criteria improves screening sensitivity and helps determine exact cvr. obesity is a global problem associated with numerous health issues includes type diabetes. bariatric surgery provides sustained weight loss and partial or complete diabetes resolution. micrornas (approximately nucleotides long) are post transcription regulators, which play important roles in conditions such as obesity and diabetes. the aim of this study is to investigate whether microrna profile is changed by bariatric surgery in postprandial state and if the altered microrna expression could contribute to long term post bariatric surgery benefits. both bariatric and sham-operated rats were given g of food min before sacrifice. total plasma and tissue rna from post-operative bariatric and sham operated rats were isolated and the microrna component was examined. principle component analysis clearly showed that bariatric surgery dramatically changed circulating microrna expression. correlation between microrna expression and metabonomics data indicated that certain plasma metabolites (for example, ketone bodies) are highly correlated. we also investigated liver microrna expression, microrna targeted mrna and metabonomics profile. mirna regulated key metabolic enzymes and receptors involved in the tca cycle, pentose phosphate pathway, gluconeogenesis and amp-activated protein kinase pathway. liver alanine, pyruvate and glucose levels were altered in bariatric compared to sham-operated rats. in summary, our data show that bariatric surgery changed both circulating and tissue microrna expression. we suggest that these alterations contribute to post bariatric surgery benefits by regulating key metabolic enzymes and receptors. the purpose of the study was to investigate serum concentrations of the asymmetric (adma) and symmetric dimethylarginine (sdma) and high sensitivity c-reactive protein (hs-crp) in hyperuricemic adolescents. patients and methods: the study group consisted of hyperuricemic patients aged median . years. the control group (c) contained healthy individuals with normal serum uric acid (sua) level. serum adma and sdma were measured by immunoenzymatic elisa commercial kits and were expressed in lmol/l. serum hs-crp was determined using nephelometric method (behring) and expressed in mg/l, sua was measured on the hitachi apparatus. results: hyperuricemic patients showed increased sdma (median: . q -q ( . - . ) lmol/l vs. controls . q -q ( . - . ) lmol/l, p < . ). serum adma values did not differ between two estimated groups (p > . ). the positive correlation was observed between adma and sua (r = . , p < . ) and sdma with sua and hs-crp concentrations (r = . , p < . ; r = . , p < . , respectively). we demonstrated that in adolescents with hyperuricemia increased serum sdma, but not adma levels were observed. no significant differences for adma and sdma between hypertensive and normotensive patients with hyperuricemia were found. the large, multicentre, prospective studies are needed to confirm if sdma might play a role in chronic inflammation in patients with hyperuricemia. objective and aim: supplementation of n- polyunsaturated fatty acids expresses anti-diabetic effect by enhancing insulin sensitivity and improving lipid metabolism. in this study we wanted to assess whether supplementation of n- can improve antioxidant status, preferably pon level, in the serum of type diabetic (t dm) patients. subjects and methods: twenty t dm patients ( females, eight males, age . ae . years, bmi . ae . kg/m ) were randomized to intake g marine oil ( . g epa and dha) during weeks, after weeks washout period. anthropometry, blood pressure measurements and fasting blood samples for metabolic parameters (glucose, hba c, insulin, cholesterol, hdl-cholesterol, triglycerides), hscrp, as well as oxidative stress enzymes [pon- , catalase (cat), superoxide dismutase (sod), glutathione peroxidase (gsh-px)] were obtained before and after treatment period. results: serum pon- activity response was increased by % from . to . (p < . ) as well as sod from . to . (p < . ) by epa and dha supplementation. it was associated with serum n- pufa increase by % (p < . ). there were no changes in anthropometry, glycemic control, insulin resistance index, the levels of total cholesterol, triglycerides and parameter of chronic inflammation (hscrp). only hdl-cholesterol increased after supplementation, from . to . mmol/l, with borderline significance (p = . ). conclusion: supplementation with . g n- pufa improves antioxidative status, pon activity and sod level, and repairs dyslipidemia in t dm patients. aim of this study: to determine the behavior of endogenous antioxidants markers and metabolic profile in non-proliferative diabetic retinopathy patients and methods: a cross-sectional study was designed with four groups: group : five healthy-volunteer subjects. group : patients with mild non-proliferative diabetic retinopathy (npdr). group : patients with moderate npdr. group : patients with severe npdr. serum endogenous antioxidants markers (determined by ua and b), glycemic profile (measured by fasting plasma glucose and hemoglobin a c), lipid profile (measured by total colesterol, triglycerides, high and low density lipoproteins-cholesterol), arterial pressure, renal profile (urea and creatinine analysis). serum-markers were quantified using enzymatic-colorimetric methods. results: patients with npdr had a significant increased serum lipid profile, glycemic profile and renal profile levels compared to the control group. ua and b levels showed increased trend in retinopathy groups compared with group . introduction: bone tissue has been recognized as an endocrine organ. recently it′s been found that levels of osteocalcin, a protein produced by osteoblast, is associated with glucose metabolism and lipids in human being. experimental studies showed associations between adiposity and levels of osteocalcin, however in the adolescent population is not quiet elucidated. objective: to establish the association between adiposity indexes and serum levels of osteocalcin in children and adolescents. materials and methods: in this study we included children and adolescents participants of the project "health worker cohort study" adiposity index were establish through bmi, waist circumference and dexa. the total concentration of osteocalcin was determined by chemiluminescence. through multiple lineal regression we evaluated the association between osteocalcin levels and the adiposity index. results: prevalence of overweight and obesity was . % abdominal obesity . %. it was observed a negative correlation between bmi, percentage of fat mass, waist circumference (p < . ). independently of the adiposity index included in the model, have obesity increases the risk of presenting low levels of osteocalcin (or: . ; % ci: . - . , p < . ) and adolescents with higher percentage of fat mass have five times more risk than adolescents with less fat mass of present low levels of osteocalcin (or: . ; % ic: . - . , p < . ). conclusions: adolescents with higher adiposity have more probability of have low levels of osteocalcin. objective: to evaluate the association between physical activity (pa) with presence of burnout syndrome (bs) and its three dimensions: emotional exhaustion, despersonalization and low personal accomplishment in health workers and educational sector. methods: a sample of imss workers, insp and uaem was obtained. after signing informed consent subjects answer a lifestyle questionnaire that included a pa questions and the burnout scale designed by maslach. anthropometric measurements were performed by previously standardized personnel (concordance coefficient of . - . ), with conventional stadiometer and calibrated scales previously tanita brand. we determined body mass index (bmi) based on the criteria of the center for disease control (cdc). pa was considered sufficient to perform or more minutes of daily pa. the data analysis was performed in the stata statistical package version . results: from the analysis of health workers and educational study participants′ cohort health workers. "female sex predominated by %. the mean age was ae years. seven out of ten participants performed < min of pa per day. a trend of higher prevalence of bs in those performing < min of pa per day was showed, to perform ! min of pa reduces the likelihood of developing bs in a % according to grunfeld criteria and % according to the ramı´rez's criteria. conclusions: to perform at least min a day is a protective factor to avoid the presence of bs, but only three out of ten participants to perform af. aims: with research showing that more than one third of this current generation of australian teenagers likely to become obese in adulthood, the need to arm our children with the skills to maintain a healthy weight has never been so urgent. the need for feed cooking program has been developed for teenagers to improve their ability to prepare and cook healthy food, and boost their knowledge about nutrition and support them to develop healthy habits for the future. methods: need for feed is delivered using school facilities and home economics teachers, but is delivered outside of school hours in an informal and engaging format. the program, which delivers h of tuition, focuses on improving participants' food preparation and cooking skills, budgeting and meal planning, basic nutrition knowledge, and attitudes and behaviours associated with healthy eating. results: evaluation demonstrates that participants improve in both skills and confidence in preparing and cooking healthy food, improve their knowledge of healthy eating guidelines and make tangible changes to their eating habits through increased consumption of fruit and vegetables, and reduced consumption of sugary soft drinks, cakes, chocolate and potato chips. conclusion: while the factors contributing to the obesity epidemic and growing rates of type diabetes are complex, the importance of arming the community with skills and confidence in cooking at home is being increasingly recognised. this program has shown that teenagers can develop the necccessary skills to support healthy eating through a targeted and engaging cooking education program. postprandial hyperglycemia is an early defect of type diabetes and the one of primary antidiabetic targets. the therapeutic approach for the treatment of postprandial hyperglycemia can be achieved by inhibiting a-amylase and a-glucosidase, key enzymes for starch digestion and further glucose absorption. in this study, the inhibitory activities of microalgal fucoxanthin against a-amylase and aglucosidase were determined as well as antidiabetic effect to induce differentiation in t -l preadipocytes using oil red-o staining. fucoxanthin exhibited weak inhibitory activity against rat-intestinal aglucosidase, while strong inhibitory activity against pancreatic aamylase in a concentration-dependent manner with ic values of . mmol/l and lmol/l, respectively. microalgal fucoxanthin significantly increased glucose uptake in t -l cell by . % at lmol/l. fucoxanthin inhibited lipid accumulation during adipocyte differentiation of t -l cell and no cytotoxicity was recorded for preadipocytes up to lmol/l. these results suggested that fucoxanthin may be useful approach for the prevention of type diabetes by inhibiting carbohydrate-hydrolyzing enzymes. university of vermont, burlington, vt, usa aims: we compared the effects of ad libitum low-fat, high-fiber and low-carbohydrate diets on caloric intake, anthropometry, and cardiometabolic risk markers in adults with the metabolic syndrome. methods: twenty-three women and men ( - years) with the metabolic syndrome completed a randomized crossover comparison of two -week diets. all meals (low-fat, high-fiber: - % carbohydrate, - % fat, - % protein, - g fiber/day; low-carb: - % carbohydrate, - % fat, - % protein, - g fiber/day) were prepared by a research dietician and consumed ad libitum. results: caloric intake was lower on low-carb ( ae vs. ae kcal/day; p = . ). only low-carb reduced body fat (À . ae . %; p = . ) and tended to produce greater weight loss (À . ae . kg vs. À . ae . kg; p = . ). both diets reduced fasting insulin (À . % to À . %; p < . ) and non-hdl cholesterol (À . % to À . %; p < . ). low-fat, high-fiber reduced serum cholesterol (À . %), while triglycerides (À . %) and vldl cholesterol (À . %) were reduced on low-carb (all p < . ). plasma ffa were elevated on low-carb (+ . %; p = . ). although flow-mediated dilation (fmd) was unchanged after low-fat, high-fiber ( . ae . % vs. . ae . %; p = . ), a trend for reduced fmd was observed after low-carb ( . ae . % vs. . ae . %; p = . ), producing a significant diet interaction (p = . ). introduction: better insulin schedules are needed to prevent hypoglycemic attacks. materials and methods: bs/time curve was plotted in a series of diabetic patients with and without treatment. the best fit curve was used by partial integration and mathematical extrapolation. the first and second derivatives of these curves were plotted by the use of special software and modified matlab. points of major mathematical and lifestyle interest were marked within the curve for correlation. daily variations were also registered. based on mathematical results, patients received auditory insulin and were compared with themselves and other patients under the same dose of insulin. results: although the bs/time curve and its first derivative are completely chaotic due to daily activity and unplanned meal intake the second derivative has some regularities and in regard to cutting the x axis every lambda minutes ( min ( min under % confidence interval. this shows that the innate glucose reducing potential of the body is exhausted after this time giving us the opportunity to treat with lower doses at these points. with this schedule patients needed less insulin and showed extremely better bs control. conclusion: preventing superimposition of innate bs reducing potency and external drugs can give rise to smoother bs control and less hypoglycemic attacks. besides, this can also be exploited in the management of prediabetic patients. introduction: type ii dm is generally regarded as a progressive disease with control of bs becoming more difficult with time. we wondered whether optimal therapy of the disease with "megatreatments" that can let the pancreas rest could reverse the disease. materials and methods: ten patients received optimal doses of insulin through the auditory channel for months. they were previously on oral hypoglycemic agents and relatively in good control. their bs were measured daily for months during the oral regimens before and after the auditory instillation. these two sets of measurements in addition to other subjective and objective parameters such as weight, sense of well being and hba c were compared. results: insertion of a strict insulin regimen in the form of auditory insulin instillation between two intervals of the same oral hypoglycemic agents (sandwich effect) causes a significant improvement in glycemic control and possibly needed dose. conclusion: as fairly good controlled patients were selected there is probably no doubt that more strict control of bs can reverse type ii diabetes progression. we have postulated that rest of the pancreas in the form of auditory insulin or strict diet can restore normal pancreatic response in a later occasion. based on a mathematical model of extrapolation we suggested that strict bs control for - years with a mean bs of mg/dl and possibly no attacks above mg/dl can reverse type ii diabetes in at least % of the patients. the diabetes epidemic could be controlled with effective prevention programs. these programs require accurate identification of subjects at risk. unfortunately, current prediction models have several deficiencies and are not being used. we present results comparing a novel model using association rule mining (arm) against three traditional models applied to data from the electronic medical record (emr). we used a cohort of , adults olmsted county, mn, residents without diagnosis of diabetes who visited mayo clinic between and . we collected pertinent baseline characteristics available as structured data in the emr. we assessed -year incidence of diabetes; a total of subjects developed diabetes during the follow up period. we used c-statistic (mean ae sd) to compare risk of diabetes estimated by framingham score, san antonio index, finrisk index and our arm model. results: some variables used by traditional risk models were not available as structured data in the emr. they were imputed as the mean of the variable as measured on the population in which the index was developed. with the exception of finrisk, all indices preformed similarly. the c-statistic for framingham score, san antonio index, finrisk index and arm model was . ae . , . ae . . , . ae . and . ae . , respectively. conclusions: our novel risk model using arm compares favorably to traditional models and has the advantage that it does not depend on a limited number of risk factors. this model is implementable at the point-of-care or population-based care where emr is in use, assuring universal utilization and improving implementation of preventive management. this study aimed to compare the effects of two types of interventions: diet vs. diet plus sea buckthorn pulp oil intake, in childhood obesity. the results were focused on fmd and imt values and risk factors for endothelial dysfunction. two groups of matched age, sex and bmi obese children (n = , - years old) and controls were enrolled. the measurements in the obese children were done before and after interventions: diet (low caloric, lipid, sugar intake for months) or diet plus sea buckthorn pulp oil intake ( mg/day for months). ultrasounds were used for fmd and imt measurements and colorimetric and elisa methods for biochemical parameters. obese children vs. lean ones had significantly increased values for imt, leptin, apob/apoa ratio, fasting c peptide, c reactive protein (crp), and reduced values for fmd and adiponectin. in the obese group treated only with diet, a light reduction in weight was observed, but no modification of atherosclerotic markers or metabolic improvement. in the obese group treated with diet and sea buckthorn pulp oil, fmd and adiponectin were unchanged, while imt was significantly reduced (p < . ), together with the other atheroscleroric risk factors: fasting c peptide (p < . ), leptin (p < . ). in conclusion, this study shows that sea buckthorn pulp oil intake has beneficial effects by preventing atherosclerosis in obese children. aims: as the rates of type diabetes continue to skyrocket across the globe, public health measures to reduce obesity appear to have limited success. while social marketing campaigns for obesity prevention have their place amongst a suite of strategies, their impact can be limited due to the gap between the campaign messages and individual's ability to identify opportunities for change in their own life. in queensland, a group of peak health agencies are working together to bridge that gap. methods: swap it, don′t stop it is an australian social marketing campaign promoting simple, everyday food and activity changes people can make to improve overall health. a multi channel health promotion and public relations strategy has been implemented to integrate the key messages of the swap it don't stop it campaign with grassroots healthy lifestyle opportunities to support individuals to make changes. this has been achieved by harnessing the collective actions of the non-government health sector to promote clear and consistent obesity prevention messages and by implementing a communications strategy that has connected community and stakeholders with tangible opportunities for healthy lifestyle changes at the local level. outcomes: through collaborative action amongst a broad network of service providers, the national campaign messages have been amplified through community events, radio, print and television stories that have highlighted examples of personal success and provided information that has inspired queenslanders to make small steps towards better health and reduce the risk of type diabetes and other chronic diseases. background and aims: proposed changes to gdm diagnostic criteria are anticipated to increase diagnosis rates leading to rising demand for support during pregnancy. lack of awareness of risks associated with gdm acts as a barrier to healthy lifestyle adaptation and postpregnancy screening ( , ) . the you program delivers a range of strategies to support women at diagnosis, facilitate behaviour modification ( ) and re-enforce importance of post pregnancy screening. methods: newly diagnosed women and their support networks are educated about gdm, risk reducing behaviours and the health care system through a purpose built website and a suite of print resources. specific resources were developed for at risk groups including indigenous australians and women from non-english speaking backgrounds. women are encouraged to join a national register to receive post pregnancy screening reminder letters and text messages in conjunction with regular newsletters containing family-friendly information on healthy lifestyle behaviours and screening. nominated gp's are also sent screening reminders to prompt women to attend screening. results: engagement with the website and newsletters is high, screening reminders evaluated positively with focus groups and participants indicated that they intended to attend their post natal screening. conclusion: you delivers a multi-strategy approach that engages and supports women at diagnosis and re-enforces the importance of screening and behaviour modification during and post pregnancy. family members and peers were recognised as important sources of support and educated to encourage screening and behavioural changes. these low-cost interventions can help reduce prevalence or morbidity in women affected by gdm associated type diabetes. however smoking cessation has many benefits for smokers, but the most important challenge for smoking cessation is withdrawal symptoms during the first days and months of cessation which can be an important reason for unsuccessful in the smoking cessation process. however, many methods are available to help quit smoking, but acupuncture is used for the treatment of nicotine dependency with the aim of reducing of withdrawal symptoms experience. therefore, the aim of this study is to determine the role of acupuncture in success at quit smoking in the iranian samples. methods: one hundred and thirty-two men smokers who were ready to quit smoking were participated in the study. the participants were divided to two groups by randomized sample method. one group was for acupuncture and another group was for acupuncture in shame points. the mean age of smokers was ae years. all participants followed for year and the quit rate evaluated in , , months of the study. the results show, while . % in case-control and . % in control group could quit smoking in the first month of study; but in the month of the study . % in case-control and . % in control group were at quit rate. the quit rate short and long term in case group was higher than control group. therefore, physicians should play an active rate in control of smoking by ensuring and counseling and use of various pharmacology and non pharmacology methods for increase quit rate. panjab university, pgimer, chandigarh, india introduction: , -dimethylhydrazine (dmh)-induced colon carcinogenesis in rats is a reliable model to explore molecular mechanism involved in progression of colorectal cancer from adenoma to carcinoma sequence. objective: to study the transcriptional and translational levels of various genes involved in tumorigenesis pathway of dmh induced rat model. methods: two groups of chow-diet-fed, male sprague-dawley rats, aged weeks (n = /group) were fed a normal diet and injected subcutaneously for two time durations of and weeks dmh at a dose of mg/kg body weight/week or with ethylene diamine tetraacetic acid (edta)-saline. macroscopic and microscopic analyses were performed for confirmation of adenoma and carcinoma. mrna expression of nfkb and caspase- genes were determined by real-time pcr. immunohistochemistry was also performed for expression of above genes. results: gross examination of weeks dmh treated colon showed polypoid lesions and multiple tumors were formed after weeks dmh treatment. histopathological studies confirmed the colon carcinogenesis from adenoma-carcinoma sequence by type of tumor, degree of differentiation and invasion of tumors. in adenomatous and carcinomatous colonic tissues, mrna expression of nfkb was increased by . and . fold respectively, whereas expression of caspase- was reduced by . and . fold respectively. immunohistochemistry studies showed the increase expression of nfkb and reduced expression of caspase- in colonic tissues of dmh induced rat model as compared to controls. the observed data strongly implicates that dmh induced colon carcinogenesis altered the apoptotic machinery by modulating the expression of various genes involved in this pathway. objective: identify anthropometric indicators that present the greatest correlation in the diagnosis of some metabolic syndrome components in adolescents and its association with gender, age, and family history. methods: cross-sectional study with adolescents between and years of age of a public high school in the mexico city. bmi was used to diagnose overweight and obesity according to cut-offs proposed by the international obesity task force. waist circumference (wc) and waist-to-height ratio (whr) were used as fat distribution indexes. results: . % of the students were male. the prevalence of overweight and obesity were . % and . %. there were association between overweight-obesity and the average values of wc, whr, and blood pressure (p < . ). the correlation between waist circumference and bmi and waist-height were the strongest (r = . and r = . , respectively). we recommend using wc and whr in clinical practice as simplified indicators to predict risk of metabolic syndrome in mexican adolescents. c. saely, a. muendlein, a. vonbank, k. geiger, p. rein, h. drexel background: the novel adipocytokine chemerin has been suggested to be linked to insulin resistance and to the metabolic syndrome (mets). its association with coronary artery disease (cad) is unclear. we hypothesized that chemerin is associated with both angiographically determined cad and with the mets. we measured serum chemerin in patients undergoing coronary angiography for the evaluation of established or suspected stable cad; the mets was defined according to ncep-atpiii criteria; significant cad was diagnosed when coronary stenoses ! % were present. results: chemerin was higher in mets patients (n = ) than in subjects without the mets ( ae vs. ae ng/ml; p < . ). it did not differ significantly between patients with significant cad (n = ) and those without significant cad (p = . ). when both, mets and cad status were considered, chemerin was higher in mets patients both among those who had significant cad ( ae vs. ae ng/ml; p = . ) and among those who did not have significant cad ( ae vs. ae ng/ml; p < . ); it did not differ significantly between patients with significant cad and subjects without significant cad among mets patients (p = . ) nor among subjects without mets (p = . ). analysis of covariance (ancova) showed that a large waist circumference as well as elevated trigylcerides were independent predictors of elevated serum chemerin (f = . ; p < . and f = . ; p = . ). we conclude that chemerin is significantly associated mets but not with angiographically determined cad. the overall association of chemerin with the mets is carried by its association with visceral obesity and elevated triglycerides. objective: resistin is a novel adipocyte-secreted hormone proposed to link obesity with diabetes. the role of resistin gene polymorphism in insulin resistance and metabolic syndrome is controversial till date. the present study was attempts to investigate the relationship between resistin gene polymorphism with circulating resistin level, metabolic risk factor and insulin resistance in north indian population. methods: this is a case-control study; total healthy subjects were selected for the study. out of which (age . ae . years) were with metabolic risk factor and age matched control (age . ae . years) were without metabolic risk factors. we estimated homeostatic model assessment (homa) index, circulatory resistin, and lipid profiles. the genotyping of resistin-c g were carried out using pcr-rflp method digested with bbsi restriction enzyme. results: homozygous mutant genotype (cc) (cc v/s cg + gg) (p = . : or = . : % ci = . - . ) and mutant allele (g) (p = . : or = . : % ci = . - . ) of the c/g polymorphism was significantly less frequently observed in the control population as compared to study group. furthermore, on dividing the subjects into two groups according to the absence (resistin - ) or presence (resistin- ) of the mutant g allele, significantly high levels of resistin (p = . , or = . , %ci = . - . ) and insulin resistance (p = . , or = . , %ci = . - . ) were observed in resistin- group as compared to resistin- group. conclusion: our results suggest that the c/g mutation of the resistin gene is likely to play an important role in the development of metabolic syndrome and metabolic abnormalities. king george's medical university, lucknow, rims, saifai, etawah, india objective: adiponectin has been shown to be an insulin-sensitizing hormone and negatively associated with components of metabolic syndrome. present study was attempted to investigate the adiponectin polymorphism in metabolic syndrome and insulin resistance. methods: the adiponectin t g and g t polymorphism has been studied in females with metabolic syndrome and control without metabolic syndrome according to ncep atp iii criteria, . circulating adiponectin and leptin levels were determined by sandwich elisa method and insulin resistance by the homeostasis model assessment (homa) index. the polymorphism of adiponectin t/g and g/t gene were determined by pcr-rflp method. results: significant difference were found for circulating leptin level except adiponectin level ( . ae . vs. . ae . ), and in metabolic risk factors among metabolic syndrome and without metabolic syndrome females. homozygous mutant genotype (gg) (tt vs. tg + gg) (p = . : or = . : % ci = . - . ) and mutant allele (g) (p = . : or = . : % ci = . - . ) of the -t g gene and mutant allele (t) (p = . : or = . : % ci = . - . ) of the g t polymorphism were significantly less frequently observed in the control population as compared to study group. the results of the present study concluded that the mutation of the adiponectin t/g and g/t gene might play a important role in obesity associated metabolic syndrome and metabolic abnormalities except insulin resistance, glucose level and insulin levels in the north indian women due to mutation of the adiponectin gene is associated with decreased adiposity which is protective one for metabolic syndrome design: cross-sectional study of patients with good (excess body mass index lost (ebl) > %) and poor weight loss (ebl %) > months after rygb. material and methods: sixteen patients with good weight loss and patients with poor weight loss were included in the study. the patients underwent dual energy x-ray absorptiometry scan, indirect calorimetry and a -h multiple-meal test with measurements of glucose, insulin, total bile acids (tba), glucagon-like peptide (glp)- , peptide yy - (pyy), cholecystokinin (cck), ghrelin, neurotensin, and pancreatic polypeptide (pp) as well as assessment of early dumping and appetite. results: suppression of hunger was more pronounced in the good than the poor weight loss group in response to the multiple-meal test (p = . ). in addition, the good weight loss group had a larger release of glp- (p = . ) and a greater suppression of ghrelin (p = . ) during the test, whereas the postprandial secretion of cck was highest in the poor weight loss group (p = . ). pyy, neurotensin, pp and tba release did not differ. early dumping was also comparable. differences in resting energy expenditure between the groups were entirely explained by differences in body composition. conclusion: favorable meal-induced changes in hunger and gut hormone release in patients with good compared to poor weight loss support the role of gut hormones in the weight loss after rygb. background: the objective of this study is to explore changes in the vascular tone over the endothelial, neurogenic and myogenic frequency ranges during a contralateral cold pressor test by performing the wavelet analysis of skin temperature fluctuations and to compare the results obtained in healthy subjects and in patients with metabolic syndrome (ms) and type diabetes. methods: thirteen adults with type diabetes aged - years (average diabetes duration of . ae . years) and adults with ms aged - years participated in this pilot study. the control group included practically healthy men and women aged - . the lowfrequency fluctuations of skin temperature in the appropriate frequency ranges, registered during contralateral cold test, were used as a characteristic reflecting the mechanisms of vascular tone regulation. results: the response to cold pressor test in patients with type diabetes and with ms differs essentially from that of healthy subjects. patients with ms show changes in the amplitude of skin temperature fluctuations similar for patients with type diabetes in the endothelial range. the endothelial dysfunction occurs in the pre-clinical stage of diabetes and manifests, in particular, as a disturbance of the endothelial part of vascular tone regulation. with progression of the glucose metabolic disorders the pathological process is worsened due to violation of the neurogenic vasodilatation mechanisms. fetal metabolic programming states that early life nutrition is implicated with the risk of later disease development and both underand overnutrition during gestation might predispose individuals to develop obesity or diabetes later in life. obesity operations called "gastric bypass" operations have shown unexpected involvement of the small intestine in diabetes pathophysiology as it in most cases result in a complete resolution of the diabetes before weight loss. therefore we hypothesize that the small intestine is a subject of metabolic programming and that this programming can predispose for diabetes development. twin-pregnant ewes where fed a normal, a low or a high diet during the last weeks of gestation and the twin lambs where fed either a conventional or a high fat, high carbohydrate (hchf) diet during the first months of life. feeding challenge tests were performed on all lambs and some were slaughtered with collection of intestinal tissue for qpcr. the hchf diet increased the blood level of glucose, insulin and tg and increased the intestinal expression of a range of genes involved in growth, vascularization as well as digestion and absorption. the maternal low and high diet had effects on gene-expression, however the results vary between genes. these observations suggest that small intestine function has been programmed by the late-gestation low or high diet at gene expression level, whereas the physiological metabolic functions has mainly been affected by the hchf diet at such a young age. further investigations on the long-term effects of early nutrition are required. background: liposuction is considered as the treatment for the metabolic complications of obesity. the aim of this study was to evaluate the effect of abdominal liposuction on leptin and interleukin- (il- ) expression in adipose tissue and serum concentration. material and methods: the study included consecutive patients ( females, seven males) aged ae years with bmi ae kg/m , non-diabetic, apparently healthy, who underwent liposuction in mandala beauty clinic in pozna n, poland. the patients were examined clinically and the blood was withdrawn for routine laboratory tests (hematology, glucose, lipids, coagulation). leptin (r&d) and high sensitivity il- (hsil- ) (abcam) were analyzed in the supernatant of adipose tissue homogenate and in serum, by means of elisa. results: the expression of leptin in adipose tissue positively correlated with white blood cells count before liposuction (rs = . , p = . ). it was also higher (p = . ) in patients with bmi ! . ( . ; . - . ng/mg protein; median, interquartile range) than in subjects with bmi < . ( . ; . - . ng/mg protein). following liposuction, after month, serum leptin levels were lowered in smokers ( . ; . - . ng/ml), when comparing with baseline ( . ; . - . ng/ml). serum level of the adipokine, both before (rs = . , p = . ), and after (tau kendall = . , p = . ) liposuction correlated with tissue expression of leptin. no differences in adipose tissue expressions and serum levels of hsil- were observed month after liposuction. conclusion: a count of circulating leukocytes, even presented within references, affects the increasing adipose tissue expression of leptin. smoking status favorably affected the influence of liposuction on serum leptin levels. liposuction has no short-term effect on serum il- concentrations. r.a.l. sertié , s.a. sertié , a.r.g. proenc ßa, t. lima-salgado, a.c. oliveira, f.b. lima introduction: all adaptations acquired through physical training are reversible during inactivity. significant reductions in maximal oxygen uptake (vo max ) are observed within two-four weeks of detraining. conversely, the consequences of detraining on adipose tissue are poorly known. aim: to investigate the physical detraining effects on metabolism and cellularity of rat periepididymal adipose tissue. methods and results: male wistar rats, ageing weeks, were divided in three groups: trained (t) for weeks; detrained (d), (trained for weeks and detrained for weeks), and age-matched sedentary (s). training consisted in treadmill running sessions ( h/day, day/week, - % of the maximal capacity). the morphometric analysis of pe tissue disclosed significant differences between the groups. the adipocyte sectional area of group d was significantly bigger than t and s ( ae . lm vs. . ae . lm vs. . ae . lm , respectively). compared to t the cells of d animals showed % increased ability to perform: lipogenesis, either spontaneously or insulin stimulated and isoproterenol-stimulated lipolysis. basal lipolysis did not change. a % reduction in apoptosis was observed in groups t and d in relation to s. some gene expressions were changed in d vs. s: adiponectin (three-fold up) and ppar-gamma (two-fold up). pref- gene was three-fold higher in t vs. s. conclusions: these results suggest that adipogenesis was stimulated in this group. detraining causes significant increase in adipocyte size and lipogenic capacity. as pe fat cell apoptosis was reduced in d and t. background: chronic red wine (rw) consumption has been associated with a decreased cardiovascular disease risk, mainly attributed to an improvement in lipid profile. rw intake is also able to change gut microbiota composition. high-fat intake has recently been reported to increase metabolic endotoxemia. the gut microbiota has been proposed as the main resource of plasma lipopolysaccharides (lps) in metabolic endotoxemia. objective: to analyze the effect on lps concentrations of chronic rw consumption and acute rw intake in relation to high-fat intake in middle-aged men. design: for the chronic study middle-aged male volunteers were randomized in a crossover trial and after a washout period all received rw, dealcoholized red wine (drw), or gin for days. the serum lps concentration and changes in fecal microbiota were quantified before and after the treatments. for the acute study, five adult men underwent a fat overload or a fat overload together with rw, drw or gin. baseline and postprandial serum lps concentrations and postprandial chylomicron lps concentrations were measured. results: chronic rw consumption led to a significant decrease in lps concentrations compared to baseline. in addition, lps concentrations correlated negatively with bifidobacterium and prevotella levels. there were no differences in postprandial serum or chylomicron lps concentrations between acute rw, drw or gin intake together with a fatty meal. postprandial chylomicron lps concentrations correlated positively with the increase in triglyceride concentrations. conclusions: chronic rw consumption decreases lps concentrations, but it is not able to attenuate the postprandial lps increase induced by a fat overload. physical inactivity increases the risk of metabolic disease, associated with perturbations of muscle energy metabolism. the aim of this study was to assess the effect of exercise training on adiposity, physical fitness and muscle energy metabolism in obese individuals with attributes of ms. methods: sedentary individuals (m/f / ; age . ae . years, bmi . ae . kg/m ) completed -months endurance or strength (n = / ) training program ( h, -times/week). subcutaneous and visceral adiposity was measured by mri. phosphorus mr spectroscopy ( p-mrs) was used to assess the energetic status of muscle in vivo by measuring phosphocreatine (pcr), atp, inorganic phosphate (pi) and maximal oxidative flux (q max ), after exercise-or magnetic-induced equilibrium perturbation (n = ). the samples of skeletal muscle were taken by needle biopsy (vastus lateralis). cytochrome c oxidase (cox) activity of permeabilized muscle fibers was measured by oxymetry and maximal aerobic capacity (vo max) by bicycle ergometry. free-living ambulatory activity was monitored by accelerometers. results: subcutaneous adiposity did not change with training. however, strength training decreased visceral adiposity (p < . ). training increased physical fitness (vo max, n = , p = . ) and in vivo muscle energy metabolism ( p-mrs: q max , pcr, atp, n = , p < . ), without a significant effect on cox activity (n = . ). depletion of muscle pcr was negatively associated with cox activity (p = . ). vo max was not associated with muscle metabolism (p > . ). free-living activity increased during training (p < . ). conclusions: three months training of obese individuals was sufficient to increase both cardiorespiratory fitness and muscle metabolism, assessed by p-mrs. strength training was more efficient in decreasing visceral adiposity. background: the amelioration of metabolic complications of excessive body mass by liposuction is intensively discussed, as the metabolic surgery is proposed for future diabetes therapy. we have undertaken the study on the short-term effect of liposuction on insulin resistance parameters. material and methods: we included in the study consecutive patients ( females, seven males) aged ae years with bmi ae kg/m , who underwent liposuction in mandala beauty clinic in pozna n, poland. the non-diabetic, apparently healthy patients were examined clinically, blood was withdrawn for baseline routine laboratory tests (hematology, glucose, lipids, coagulation). insulin levels in serum and its content in adipose tissue were evaluated by means of elisa (diasource, sunrise tekan). insulin resistance/ sensitivity indexes: homa-ir, quicki and mcauley were calculated. one month observation included re-evaluation of glucose, lipids and insulin along with the indexes. data are presented as mean ae sd or median; interquartile range. we have observed the decrease in glucose concentrations ( ae vs. ae mg/dl, p = . ) and insulin levels ( ; - vs. ; - mu/l, p = . ) month after liposuction, comparing to baseline. homa-ir ( . ae . vs. . ae . , p = . ) and mcauley index ( . ae . vs. . ae . , p = . ) were improved month after liposuction, however no effect on quicki has been found. triglycerides concentrations month after liposuction were lowered comparing to baseline ( ; - mg/dl vs. ; - mg/dl; p = . ). in multiple regression analysis age was independent factor that affected insulin content in adipose tissue in males (b = . , p = . ). conclusion: liposuction causes beneficial effect on insulin resistance parameters in short-term observation of non-diabetic patients. background: a large number of studies showed that community-based health promotion is an effective way of preventing and treating chronic diseases. however, participation rate is very low for health education programs in community health centers (chcs); that of the program is not attractive, in part, because it is not individualized. using diabetes risk assessment tool based on electronic health records (ehr) data for diabetes risk prediction could help to early identify high-risk groups and reduce the incidence of diabetes through health education and lifestyle changes to control risk factors. objectives: to conduct community research to understand the situation of community diabetes prevention and control; to initially established prediction model of diabetes risk factors based on ehr data in chcs. the project randomly selects four districts in shanghai, using a combination of quantitative research and qualitative research method. get ehr data from each chc, attempts to establish the predicted model for diabetes, and test the sensitivity and specificity of the model. outcome measures: the prediction model include age, gender, blood pressure, smoking, drinking, body mass index, family history of diabetes based on ehr data. as pr(d) ! . , the sensitivity is . %, specificity is . % and area under roc curve (auc) is . . the empirical results will contribute to a better understanding of how the diabetes management in chc is important and provider the targeted self-management materials to improve health outcomes as well as evidences directly applicable in improving china's health policy reforms. a. schmid, a. kopp, m. bala, s. leszczak, i. ober, m. mü ller, a. schä ffler internal medicine i, university hospital regensburg, regensburg, germany introduction: the adipokine chemerin has an important role in insulin sensitivity and insulin secretion. elevated systemic chemerin concentrations correlate with obesity and insulin resistance. this study investigated chemerin serum levels of healthy volunteers undergoing an oral fat tolerance test (oftt) and their correlations with gender and markers of insulin sensitivity and inflammation. we further tested effects of the sex hormones estradiol and testosterone on chemerin secretion from adipocytes in vitro. methods: hundred overnight fasted healthy volunteers participating in the study underwent an oftt. after oral uptake of lipid suspension, venous blood was drawn at , , and h. subjects were characterized by anthropometric and standard laboratory parameters. chemerin levels were measured by elisa. mature murine t -l adipocytes were stimulated with estradiol and testosterone. concentrations of secreted chemerin were measured by elisa. results: while there were no significant changes in individual chemerin concentrations resulting from the lipid load, mean chemerin levels in sera of female probands were found to be significantly higher when compared to males ( . ae . vs. . ae . ng/ml, p = . ). the correlation of chemerin with insulin and c-peptide concentrations also was gender-specific. along with these findings, chemerin secretion from mature t -l adipocytes was shown to be affected by estradiol and testosterone treatment. conclusion: human chemerin concentrations are higher in females and there is a gender specific regulation upon stimulation with sex steroids. chemerin is not responsive to an oral lipid load. objective: to study the predictors of change in bmi with respect to time among physically active subjects. methodology: the present study was conducted among physically active individuals in delhi. data was collected longitudinally with a monthly follow up of months. various anthropometric and physiological measurements were taken using standard protocol. the analysis has been performed with mixed effect modeling to assess subject's variation for parameters with respect to time. r . . software with nlme package was used. an akaike information criterion (aic) was applied to find the consistency and measure the relative goodness of fit of a statistical model. : bmi as an important factor was taken as dependent variable and using aic, gender, blood pressure and weight were independent variables or fixed and random variables for months of longitudinal study. using generalized linear model (glm), bmi was dependent variable and other parameters i.e. gender, systolic blood pressure (sbp), diastolic blood pressure (dbp) and weight were independent variables. the regression coefficient obtained for gender with respect to bmi (as response variable) was À . . the estimated values for sbp, dbp and weight were À . , . and . respectively. the reduction of bmi among females was more in comparison to males. the reduction rate of sbp, dbp and weight with bmi was very low with respect to time. a.e. andreazzi , s. grassiolli , j.c. de oliveira , r. torrezan , s.t. paes , m.s. silva , r.m.g. garcia , p.c.d.f. mathias department of physiology, federal university of juiz de fora, juiz de fora, biology, state university of maring a, maring a, biology, federal university of juiz de fora, juiz de fora, brazil obesity is a worldwide epidemic and the most important factor in metabolic syndrome onset. the involvement of sympathoadrenal axis activity in obesity onset was investigated using the experimental model of treating neonatal rats with monosodium l-glutamate (msg). to access general sympathetic nervous system activity, we recorded the firing rates of sympathetic superior cervical ganglion nerves in animals. catecholamine content and secretion from isolated adrenal medulla were measured using the trihydroxyindole fluorescence method. high-performance liquid chromatography (hplc) was used to measure plasmatic adrenaline. intravenous glucose tolerance test was performed, and isolated pancreatic islets were stimulated with glucose and adrenergic agonists. msg treatment increased the epididymal and retroperitoneal fat pad mass by . % and . %, respectively, compared with control animals (p < . ). the nerve firing rate of obese rats was decreased . % compared to the rate for lean rats (p < . ). pre-diabetic rats showed a % reduction in basal catecholamine secretion from the adrenal medulla and % lower plasma adrenaline concentration compared with the control animals (p < . ); whereas catecholamine secretion induced by carbachol, elevated extracellular potassium and caffeine in the isolated adrenal medulla were all increased in obese rats compared to control. both glucose intolerance and hyperinsulinaemia were observed in obese rats. adrenaline strongly inhibited glucose-induced insulin secretion in obese animals ( %, p < . ). these findings suggest that low sympathoadrenal activity contributes to impaired glycaemic control in pre-diabetic obese rats. objective: the aim of the present study was to evaluate the influence of physical activity patterns on cardiovascular health. the study was conducted in delhi, among adult punjabi males and females. total sample of subjects was taken for the study. data was collected crosssectionally using multistage stratified sampling. according to pattern of physical activity using self administered proforma, two groups were formed, one regular physical activity group (rpa; at least days/week brisk walk for min, doing yoga for min), and the other irregular physical activity group (ipa; < days a week with no consistency). various anthropometric and physiological measurements were taken using standard protocol. results: higher percentage of subjects with irregular pattern of pa was at risk of developing high bp, obesity and triglycerides. higher values of whr, whtr among them showed that group was more disposed to cardiovascular health problem. males with ipapattern had . times, . times and . times more risk of increasing regional adiposity using whtr, whr and wc respectively. among females, whtr, whr and wc respectively showed . times, . times and . times higher risk of developing regional adiposity with irregular pattern of pa. the increased risk of being obese was . times more among males with irregular pattern of physical activity while among females fat percentage and obesity level using bmi category were found to be at a risk of . times and . times respectively. conclusion: subjects with regular pattern of pa showed higher percentage of normal values of various cardiovascular and obesity markers. irregular pattern of pa increased the risk of regional and general adiposity markers besides that of high bp. materials and methods: serum glycemia, insulin and c-peptide level were measured at ogl hours - st- nd in: seven healthy controls, patients with ms and with cushing; mean age was . - . - . , bmi - - , ogl glycemia: . - . - . ; . - . - . ; . - . - . respectively. all patients had bp > / mmhg and triglyceride level > . mmol/l. homa assessment: (fasting insulin, pmol/l fasting glucose, mmol/l): . . c-peptide and insulin increase above fasting level (in pmol) per g of ingested glucose was calculated. results: (*p < . vs. control). homa was . - . *- . * and fasting c-peptide and insulin level were / , / *, / * pmol/l in control, ms and cushing respectively. to the st hour of ogl the corresponding data were: / , / * and / * and increase of c-peptide and insulin concentration per g of ingested glucose was almost equal: / . - / . - / . pmol/l. the degree of c-peptide increase to the st hour was twice less than in control and increased fasting hepatic insulin clearance lowered almost to control level (judging by c-peptide/insulin ratio). to the nd hour of ogl c-peptide and insulin level became similar to fasting data. conclusion: ir characteristics were similar in ms and cushing disease. insulin requirement increase on the top of ogl was equal to control. judging by c-peptide/insulin changes ir stops manifesting on the top of glycemia during ogl (probably due to normalizing hepatic insulin clearance). introduction: ir is atfr of high potential, but also one of the first signs of a ateroscl. process. condition when the body has too much insulin at in the same time too much glucose is the resistance of peripheral tissues to the action of insulin. objectives: to investigate the relationship of concentrations of insulin and glucose in the peripheral blood, but also the conc. of gh, becose normalisation of gh secretion could corrects hiperinsulinemia and insulin resistance. on the other hand reduced gh secretion often points to the high expression of somatostatin and the presence of stress, which leads to secretion of somatostatin. further increase in visceral adipose tissue and ffa relise under stress can worsen the condition of and insulin resistance. aims of study: conducted therapeutic program (combination of dietary and physical activity), in which only the group edu implemented and behavioral therapy. monitoring parameters of glycemic control: fasting glucose, fasting insulin and gh and insulin sensitivity of peripheral tissues to insulin, always from in one blood sample, parallely in two different phases of therapy. we used anova-manova statistics to determine the significance of an differencies. material and methods: determining of glucose, insulin, and growth hormone. as and qucki index for determining od insulin sensitivy conclusion: ours finding indicate that the synergistic effects of dieting and increased physical activity improves glucoregulation, reduce excessive insulin secretion and restoration of gh secretion. but only behavioral therapy may lead to permanent changes in nutritional habits and lifestyle. the metabolic and endocrine dysfunctions that may occur with polycystic ovary syndrome (pcos) can be associated with future comorbidities such as diabetes, cardiovascular disease, and endometrial cancer. although a definitive link between pcos and these chronic illnesses has not been demonstrated, there is significant overlap in the clinical characteristics of these disorders. consequently, the issue of identifying and measuring potential conditions that may be associated with pcos is a priority and should be the standard of practice in its management. hiperhomocysteinemia has been shown as independent predictor of cardiovascular events in patients with atherosclerosis. the aim of our study was to determinate levels of homocysteine in woman with polycystic ovary syndrome compared with healthy woman. thirty patients (age, , ae . ) with pcos and (age, . ae . ) healthy woman were involved in the study. blood samples were collected in early follicular phase. total homocysteine was measured using fluorescent immunoassay. statistically significant differences in serum concentration of homocysteine were observed between groups. mean homocysteine level we found as ( . ae . vs. . ae . ) in pcos and normal group respectively (p < . ). for macedonian population we found statistically significant increased homocysteine levels in woman with pcos. although the mean homocysteine levels are within normal limits, there are significant higher mean homocysteine concentrations between these two groups. because an increased concentration of thcy has been shown as and independent risk factor for cardiovascular alterations, it is essential in this group of woman to be taken measures for early prevention. a. alkandari, n.j. gooderham, h. ashrafian surgery and cancer, imperial college london, london, uk globally million people are obese and prevalence is increasing. obesity and its many co-morbidities are leading causes of mortality and morbidity and pose substantial socioeconomic burdens on health services. bariatric surgery is a form of gastrointestinal surgery that leads to sustained weight loss, a decrease in cancer risk and resolution of type diabetes. micrornas are a family of small, endogenous, non-coding rnas that regulate gene expression at the posttranscriptional level. micrornas control expression of over half the human transcriptome and are involved in processes fundamental to both normal physiology and disease, including obesity, diabetes and cancer. we hypothesise that urinary micrornas are biomarkers for bariatric surgery reduction of type diabetes. here, we looked at expression of micrornas involved in diabetes in urine samples prior to bariatric surgery and at months and year postoperatively. urinary rna was obtained using the mirvana paris kit and microrna expression was determined through quantitative pcr. we found significant increases of two to three fold postoperatively in the expression of three micrornas involved in diabetic nephropathy. these findings are consistent among patients undergoing laparoscopic roux-en-y gastric bypass and sleeve gastrectomy. our results indicate that bariatric operations can modulate post-translational effects in end-organs postoperatively and may contribute to the beneficial effects noted after these procedures. hepatic insulin resistance and the ensuing impairment of hepatic glucose metabolism is a major contributor to hyperglycemia in metabolic syndrome. various factors appear to act in parallel to elicit hepatic insulin resistance. while impaired fatty acid handling with a resulting activation of pkc isoforms is one established route, a subacute inflammation also appears to contribute and the impact of cytokines on the insulin signaling cascade is well established. by contrast, the role of small lipid mediators e.g. prostaglandins and sphingolipids, which are also affluent in inflamed tissue, is not well characterized. the current study addressed this question. in a wide array of genetic and diet-induced mouse models of the metabolic syndrome, hepatic expression of key enzymes of prostaglandin formation was induced. prostalgandin e , which is released predominantly from kupffer cells, directly attenuated insulindependent hepatic glucose utilization by an erk / -dependent serinephosphorylation of irs and hence attenuation of insulin-dependent akt-phosphorylation. in addition, pge enhanced lipid accumulation in hepatocytes by inhibiting mitochondrial fatty acid oxidation and vldl formation. furthermore, pge in an autokrine feed forward loop increased the formation of oncostatin m in kupffer cells, which in turn inhibited insulin signaling in hepatocytes by inducing socs . similar to pge , sphingosine- -phosphate, whose production was strongly enhanced by exposing hepatocytes to palmitate, attenuated insulin-stimulated glucose use and the induction of glycolytic enzymes in hepatocytes. in summary, the study provides first evidence that in addition to the established mechanism, small lipid mediators like prostaglandins and sphingolipids may impact on hepatic insulin resistance. background: the progression of childhood cardio-metabolic risk factor to adulthood suggests early origin of pathogenic pathways leading to chronic non-communicable disease as diabetes. objective: we sought to examine the distribution of insulin resistance (homa-ir) among children inhabiting delhi and clustering of cardio-metabolic risk variables among them. research design and methods: a cross sectional study was conducted among children aged - years. estimates of insulin resistance were derived on the basis of homeostatic model assessment. the th percentile of homa-ir for normal weight subjects with normal fasting glucose was considered as cutoff for insulin resistance. total body fat was assayed using body composition analyser (tbf- h a) employing bioelectric impedance technique. bmi was converted to age-and sex-standardized percentiles and subjects were classified as underweight if bmi < th and overweight if bmi was > th percentile. children with blood pressure > th percentile, adjusted for age and sex were categorised as hypertensive. information on socio-demographic features and family history of diabetes was obtained through standardized questionnaire. result: independent student t-tests showed significantly higher percentage of body fat among girls ( . %) as compared to boys ( . %). mann-whitney u-test analysis depicts significantly higher level of fasting sugar among girls ( . mmol/ml) than boys ( . mmol/ml). out of children ( . %) were insulin resistant. among them five were underweight while seven were overweight, / (sbp/dbp) were hypertensive and had family history of diabetes. conclusion: high prevalence of insulin resistance, a precursor of diabetes among these children foreshadows a worrisome trend for the burden of type diabetes in near future. both aims, losing weight as well as improving metabolic conditions, should be reached within the first weeks of an intervention program already. therefore, results of a short-time intervention concept should be presented. in answer to a regional tv-report dealing with "successful weight loss", overweight adults contacted the freiburg institute of preventive medicine (ipm) to participate in a -week intervention program. after looking for exclusion criteria, patients ( . ae . years, . ae . m/kg bmi) could be included. the ipm concept consists of an initial consultation in energy balance and life style changes, the use of a soy-yoghurt-honey product (almased â , per day as meal replacement), and the facility for guidance by phone. forty patients completed the program attending the exit examination. starting from a comparable bmi, the females were younger (n = ; . ae . years) than the males (n = ; . ae . years) and showed less associated risk factors. of significantly older age was the subgroup of patients with metabolic syndrome (ms) or type diabetes mellitus (t dm) (n = ; . ae . years). all completers were successful in losing weight (pre-post diff. . ae . kg) and showed a comparable weight reduction after intervention: females À . %, males À . %, ms/t dm patients À . %. the weight reduction was impressively accompanied by improvements of the metabolic milieu (tg, ldl-c, fbg, hba c) particularly in the ms/ t dm patients. the results confirm that the ipm concept is a successful way to lose weight initially and to improve the metabolic milieu within a shorttime period using a product with a high impact of bioactive compounds. objective: menopause-related changes in female body are associated with the greater risk of metabolic syndrome (ms), which includes obesity, dyslipidemia, impaired glucose tolerance, hypertension. the purpose of our study: was to reveal peculiarities of fat and lean mass distribution between postmenopausal women with abdominal obesity and with ms. design and method: the sample consisted of postmenopausal - years old women (age: mean = . ; sd = . ); duration of menopause: mean = . ; sd = . ). the diagnosis of ms was considered according to idf ( year) criteria. lean and fat mass distrubution were measured by dual-energy x-ray absortiometry, and were compared for the cohorts with and without ms. data were analyzed using statistical package . (statsoft). background and aims: attempts to curb the ongoing epidemic of obesity and diabetes in the us and other developed countries will benefit from better understanding of the broad and upstream determinants of the population prevalence of these conditions. this study explores how individual psychosocial characteristics in addition to the social and physical community environment correlate with prevalent obesity and markers of pre-diabetes in a statewide representative sample of the population of wisconsin, usa. methods: we used cross-sectional data from the to cycles of the ongoing survey of the health of wisconsin (show) a geographically diverse population-based research study of adults, age - years (n = ). obesity (bmi ! kg/m ) and hemoglobin a c levels were the main outcomes. independent variables included individual socioeconomic status (ses), food insecurity, psychosocial status (depression, anxiety and stress), perceived discrimination and neighborhood resources, and access to health are. contextual predictors included county and census-block group socioeconomic nutrition, and built environment indicators. results: the prevalence of obesity and prediabetes was positively associated with lower ses, food insecurity, markers of depression and anxiety, perceptions about lower access to healthy food and physical activity resources in the neighborhood, and poor health care access. lower community-level ses and a poor nutritional and built environment were also associated with higher frequency of obesity and prediabetes. conclusion: our findings on the psychosocial and contextual correlates of obesity and prediabetes offer insights regarding the profile of individuals and subgroups and where tailored individual and community level interventions are most needed. objective: gastric bypass (gbp) is currently the most effective way of treating obesity. interestingly, the majority of type diabetes (t d) patients display remission of the disease after gbp. the underlying mechanisms behind this remission are not known. we used a porcine model to study how hormonal and metobolite profiles are affected by gbp. in addition we studied the impact of gbp on endocrine cell populations in the gut and pancreatic islets. methods: gbp-pigs were subjected to oral (ogtt) and intravenous (ivgtt) glucose tolerance tests before and after surgery. shamoperated, pair-fed pigs served as controls. results: during ivgtt gbp-pigs displayed lower glucose and higher insulin levels compared to controls. during ogtt, gbp-pigs displayed higher glucose and a more rapid and robust insulin response than controls. in line with this, gbp-pigs had higher beta cell mass and more extra-islet beta cells. further, during ogtt gbp-pigs displayed robustly elevated gip levels, whereas glp- levels were unchanged. furthermore, gbp-pigs displayed elevated density of gipproducing k-cells, but reduced density of glp- -producing l-cells in the gut. metabolomic analyses revealed a difference in the metabolite pattern between the two groups, mainly explained by the fact that gbp provoked lower levels of free fatty acids (ffa) and higher levels of branch-chain amino acids (bcaa). conclusions: gbp in pigs provokes, . enhanced insulin secretion and increased beta cell mass. background: several authors have recently reported that both hiv replication and antiretroviral therapy (art) may influence adiponectin expresion which is correlated with insulin sensitivity via glucose transporter type recruitment to plasma membrane. we assessed serum adiponectin patterns in a cohort of hiv- positive caucasian patients undergoing cart in relation to insulin resistance (ir) and hiv replication. a cross-sectional study was performed in a cohort of hiv- infected patients attending the national institute of infectious diseases, bucharest. blood samples were tested for hiv viral load and adiponectin. insulin resistance was estimated by homoeostasis model assessment. in order to evaluate differences between groups we used mann-whitney-wilcoxon and t-tests. results: eighty patients ( . % males) with a median age of years (iqr years) were included in the study. the median time from hiv diagnosis was . months and the median time on cart was . months. most patients ( . %) had undetectable serum hiv loads. median adiponectin serum value was . lg/ml (iqr ). most patients ( . %) had insulin resistance. insulin resistant patients had significantly lower median levels of adiponectin ( . vs. . lg/ ml, p = . ). there were no significant differences between median adiponectin serum levels in groups with persistent and undetectable hiv replication (p = . ). no significant correlation was noted between insulin resistance and hiv replication. conclusions: in our cohort of young hiv- patients with a high prevalence of ir decreased adiponectin serum levels were associated with decreased insulin sensitivity. hiv replication may not influence in vivo adiponectin expression. objective: to examine obesity and metabolic disorders associated with vitd deficiency/insufficiency in children older people. methods: cross sectional study in community-dwelling subjects - year ( women) residing in santiago chile. plasma levels of (oh)d were determined by radioimmunoassay. glucose, insulin and crpus, were measured in a fasting blood sample. blood pressure and complete anthropometry were measured. results: mean serum (oh)d was . ae . nmol/l (men . ae . ; women . ae . , p < . ). (oh)d levels were under nmol/l in . % of men and . % of women (p = . ). insulin resistance was present in . % of all subjects and obesity in . % of women and . % of men (p < . ). significant negative crude association between (oh)d across bmi categories was found in the total sample (p < . ). crude association of vitd < nmol/l with obesity (p = . ), waist circumference (p = . ), insulin resistance (p < . ), metabolic syndrome (p = . ), hta (p < . ) and age ! year (p < . ) was observed. after age, sex, waist circumference and season adjustment, vitd < nmol/l was associated with increased risk of insulin resistance, or . (ic % . - . ) p = . . conclusion: high prevalence of vitd deficiency/insufficiency was observed in the chilean older people. vitd deficiency is associated with insulin resistance. in the future, randomized controlled trials are needed to establish a cause-effect relationship between vitd deficiency, obesity and its metabolic consequences. surrogate markers are used to estimate degree of steatosis and liver fibrosis in nafld. oxidative stress is important in the pathophysiology of nafld. the aim of this study is to find correlations between blood antioxidants and laboratory variables that are routinely determined in patients with nafld in clinical practice and used in fibrosis test. thirty-five obese children ( - years old) with increased liver echogenicity on ultrasounds and healthy lean children were enrolled. other causes of chronic hepatitis, such as chronic viral hepatitis, were excluded. erythrocyte superoxid dismutase (sod), glutathione peroxidase (gpx) activities and plasma levels for albumin, uric acid and bilirubin were measured as antioxidants. the nafld fibrosis score was calculated by an altgoritm including: age, bmi, glycaemia, platelet number, albumin, ast/alt. pearson correlations were calculated. none of the obese children had fibrosis according to the test score. obese children with nafld had lower levels for albumin (p < . ), but higher levels for uric acid (p < . ), sod and gpx activities (p < . ) vs. lean children. all the measured antioxidants were related with variables included in the fibrosis test. for p < . , the calculated correlations were: sod activity with alt activity (r = À . ) and albumin (r = . ), gpx activity with ast/alt ratio (r = . ), uric acid with alt activity, age and bmi (r = . ). this study demonstrates strong relations between blood antioxidant defence systems with fibrosis test variables in nafld in obese children. women; diabetes prevention programs (dpp) are only available for adults at high risk of developing t d. . to develop a dpp for post-gd women. . to assess the feasibility/acceptability of this dpp through a pilot rollout. methods: a working group was formed to develop a dpp that incorporated the needs of a mother with a young family around established lifestyle modification goals. this program was piloted with a group of nine post-gd women. the pilot had high attendance levels ( - % for group sessions), but only % of participants attended all sessions (illness and travel commitments causing non-attendance). the original magda dpp was restructured to: an individual session, five group sessions and two follow-up telephone conversations. childcare arrangements were investigated, but participants elected to have their children attend sessions. participants reported the program to be acceptable and suited to their needs. the pilot determined that the program was feasible and met the needs of the target population. currently, recruitment is underway for post-gd women from three hospital sites for the magda study, which uses a dpp designed for post-gd women and has a whole-of-family focus and tackles common barriers to success. objectives: assess the risk factors associated to physical inactivity (pi). a cross-sectional study was performed in in subjects aged ! years, in the urban area of montes claros, brazil. the physical inactivity level was determined by the international physical activity questionnaire short version. the subjects were classified in active ( ! min per week) and sedentary (< min per week). the univariate analysis was first performed and were included in the model when associated with p < . . the poisson regression with robust variance was realized and the prevalence ratio (pr)-crude and adjusted-and % confidence intervals (ci) were estimated to determine the relationship between pi and risk factors like sex, age group, skin color, marital status, income, education, hypertension, dyslipidemia and overweight. the variables that remained significant when adjusted. the statistic was performed in stata. results: a sample of individuals were studied ( . % women). the prevalence of pi was of . %. the variables were associated with pi were sex, the age group, marital status, education, hypertension, dyslipidemia and overweight with p < . . the following variables were significantly associated with pi after adjustment for confounding variables were: sex, female (rp = . ; ic: . - . ) and marital status, separated/divorced/widowed (rp = . ; ic: . - . ). the gender and marital status were associated with pi with pr higher for these variables in this population, which shows the need for development of effective public policies, integrated to investigate the biological causes, but also the social risk factors. objective: to determine whether an interactive mhealth exercise intervention is more effective than standard of care exercise in patients with metabolic syndrome. methods: participants [n = , mean age . (sd . ) year, % female] reported to the laboratory at baseline (v ) and follow-up [ (v ) and (v ) weeks]. anthropometrics, heart rate (hr) and blood pressure (bp) were measured and blood drawn to examine fasting glucose (fg) and glycated hemoglobin (hba c ). fitness (vo max ) was assessed and individualized exercise programs were prescribed. the intervention group received a smartphone data portal and bluetooth tm enabled biometric tracking. differences between groups in outcomes (v -v ) were examined using analyses of covariance, which adjusted for baseline levels of the outcome of interest. group differences from v to v were examined with two-way repeated measures anovas. results: at v , systolic bp was reduced in both groups but significantly more in the control group (difference in mean change: À . ; % ci: À . , À . , p = . ). there were no differences between groups at v for other outcomes. across the follow-up period, systolic bp, diastolic bp, resting hr, weight, body mass index, waist circumference and hba c were decreased, and vo max and target hr were increased for the entire study population (p < . ) with no difference in rate of change between groups. fg was significantly higher in the intervention group across the entire follow-up period (p = . ) and both groups had increasing levels over time (p = . ). conclusion: over weeks, cardio-metabolic risk factors improved with both standard and mhealth supported exercise interventions. background and aims: breastfeeding improves glucose tolerance in the early postpartum period of women with prior gestational diabetes (gdm), but it is unclear whether future risk of metabolic alterations, like type diabetes, is reduced. the aim of this study was to investigate the effect of lactation, years after pregnancy, on glucose metabolism and beta cell function in women with prior gdm. material and methods: women with prior gdm (carpenter and coustan criteria) were evaluated with comparison of results for "lactating" [bf] vs. "non lactating women" [non bf]. breastfeeding was defined exclusive if lasting more than weeks. each woman performed a -g ogtt to analyze glucose tolerance, insulin sensitivity/resistance and b-cell function. lipid and inflammatory profile was also studied. statistics: paired and un-paired t-test, mann-whitney and v tests. methods: subjects completed three randomly ordered conditions: mie ( % vo peak), hie ( % vo peak), and seated rest (control). exercise energy expenditure was equated to -kcal. one-hour postexercise (or control), subjects received a -g oral glucose tolerance test (ogtt). plasma glucose and insulin concentrations were measured before and at frequent intervals after glucose ingestion. si was derived using the following models (i) oral minimal model (omm), (ii) matsuda composite index, (iii) cederholm index, and (iv) stumvoll index. exercise induced changes in insulin action were expressed relative to the control condition (exercise-control). spearman correlation coefficients and rm-anova were used to compare relative changes in insulin sensitivity. results: si calculated during the control condition was moderately correlated among the various indices (r-value range: . - . , pvalues: . - . ). relative to control, si after mie ranged from % higher (cederholm) to % higher (omm), and after hie ranged from % lower (matsuda index) to % higher (omm excess caloric intake leads to metabolic overload and is associated with development of type diabetes (t dm). current disease management concentrates on risk factors of the disease such as blood glucose, however with limited success. we hypothesize that normalizing blood glucose levels by itself is insufficient to treat the disease and the development of complications, and that dietary interventions which diminish metabolic overload may be more efficacious in retarding the disease. we explored the efficacy and systems effects of pharmaceutical interventions vs. dietary lifestyle interventions (dli) in developing t dm and complications. high fat diet (hfd)-fed ldlr À/À mice with already established disease phenotype, to mimic the human situation, were treated with different drugs mixed into hfd or subjected to dli (switch to lowfat chow), for weeks. interventions were compared to untreated reference mice kept on hfd or chow only. although most of the drugs improved hfd-induced hyperglycemia, drugs only partially affected other risk factors and also had limited effect on disease progression towards microalbuminuria, hepatosteatosis and atherosclerosis. by contrast, dli normalized t dm risk factors, fully reversed hepatosteatosis and microalbuminuria, and attenuated atherosclerosis. the comprehensive beneficial effect of dli was reflected by normalized metabolite profiles in plasma and liver. analysis of disease pathways in liver confirmed reversion of the metabolic distortions with dli. this study demonstrates that the pathogenesis of t dm towards complications is reversible with dli and highlights the differential effects of current pharmacotherapies and their limitation to resolve the disease. introduction: obesity may induce an oxidative stress in adipose tissue, leading to deregulated expression of inflammatory cytokines which could be an early instigator of obesity-associated diabetes and cardiovascular diseases. thus, the biological effect of natural micronutrients such as plant polyphenols that may increase the antioxidant capacity of the body is of high interest. aim: our objective was to explore the antioxidant polyphenol content of three medicinal plants (gouania mauritiana, antirhea borbonica, doratoxylon apetalum) and their impact on the viability, production of reactive oxygen species (ros) and inflammatory response of preadipocytes exposed to oxidative stress. methods: polyphenol-rich extracts from plants were analyzed for their radical-scavenging capacity by dpph method. then, their ability to modulate t -l preadipocyte viability and protection against h o induced oxidative stress was assessed by both mtt viability and ldh death assays, as well as by dcfh-da test evaluating intracellular ros production. finally, il- secretion was measured by elisa. results: all plant extracts exhibited high levels of antioxidant polyphenols which protected preadipocytes against oxidative stress by decreasing ros generation and modulating the inflammatory response. such an antioxidant activity of plant extracts could be partly mediated through their radical-scavenging capacity. we identified three medicinal plants naturally rich in antioxidant polyphenols which exerted antioxidant and antiinflammatory properties on preadipocytes exposed to oxidative stress. further studies are in progress to clarify the molecular mechanism as well as in vivo potential effects of such medicinal plants to protect against metabolic and inflammatory disorders known to play a key role in obesity-related insulin resistance. background: increased fasting plasma glucose is known to lead to diabetes, and diabetes associated complications often manifesting prior to the identification of type diabetes. we aimed to determine the association of fasting plasma glucose levels with cholesterol levels and oxidative stress markers. methods: one hundred and sixty two participants attended the diabetes screening clinic, at charles sturt university, australia between february and june . participants were investigated based on the american diabetes association′s diagnostic criteria of diabetes mellitus and prediabetes, i.e. fasting bgl. results: atherogenic index of plasma (aip) was elevated in the prediabetes group ( . ae . ) and continued to increase in the diabetes group ( . ae . ) compared to controls (À . ae . ; p < . ). serum -hydroxy- -deoxy-guanosine ( -ohdg) level was greater in the prediabetes ( . ae . pg/ml) compared to controls ( . ae . pg/ml; p < . ). the diabetes group ( . ae . pg/ml) had the highest level of -ohdg. these changes paralleled by a reduction in erythrocyte reduced glutathione (gsh) from controls ( . ae mg/ ml, p < . ) to prediabetes ( . ae mg/ ml; p < . ) and the diabetes group ( . ae . mg/ ml, p < . ). conclusion: this increase in -ohdg may be related to the decrease in erythrocyte gsh antioxidant capacity. a statistical significant positive correlation (pearson's r = . ; p < . ) between aip and -ohdg suggests that -ohdg may be a useful additional biomarker to determine the degree atherogenic risk in the presence of elevated lipids. rowett institute of nutrition and health, university of aberdeen, aberdeen, uk, ilsi europe, brussels, belgium, lund university, lund, sweden, mechanistic evidence suggests that elevated blood glucose levels contribute to the development of t dm. adoption of a nutritional approach to manage postprandial glycaemia could deliver a cost-effective t dm prevention and management strategy, applicable across the population. to implement a successful strategy it is essential to understand the impact of dietary modulation on the postprandial rise in blood glucose concentrations. for this reason, a systematic and comprehensive literature review was undertaken, using the highest quality data. included were the major macronutrients (carbohydrate, protein, fat), micronutrient vitamins and minerals, non-nutrient phytochemicals and additional foods including low-calorie sweeteners, vinegar and alcohol. the strongest corroboration of efficacy for improving glucose homeostasis was for insoluble and moderately fermentable cereal-based fibre and monounsaturated fatty acids as replacement of saturated fat. postprandial glucose levels were decreased by intake of viscous soluble fibre and this was considered to be predominantly by delaying absorption of coingested carbohydrates. weaker but substantial evidence demonstrated that certain phytochemical-rich foods were likely to be effective and this may be associated with the suggestion that the gut microbiota plays an important role in metabolic regulation, including provision of phytochemical and other metabolites. it is clear that dietary components have significant and clinically relevant effects on blood glucose modulation. this suggests that employing a dietary regimen to attenuate the postprandial rise in blood glucose levels along with previously identified targets (reducing excess body weight and an increase in physical activity) will benefit the health of the population and limit the increasing worldwide incidence of t dm. knowing their metabolic control, and lipid profile, through an early intervention, we can reduce their risk factors for cardiovascular disease, and diabetes complications. the aim of our study was to determine the lipid profile of patients newly diagnosed with type diabetes. patients and methods: hundred patients, selected at the outpatient policlinic nr. in tirana, the capital of albania. all the patients had completed anthropometric measures, hba c and lipid profile after a -h fast. the persons younger than years, diabetes diagnosed prior to months, or uncompleted data were excluded from the study. results: we obtained all the data for patients. males ( %), mean age . ae . years, mean bmi . ae . kg/m², mean hba c . ae . %. . % of the patients had a total cholesterol > mg/dl, % of the patients had triglycerides > mg/dl, and . % of them had tg < mg/dl, and % had the ldl > mg/ dl . % of males had hdl < mg/dl and % of women had hdl < mg/dl respectively. conclusions: in our study the lipid profile of albanian patients was somehow different from the common profile of patients newly diagnosed with t diabetes. even in the previous studies we have found a lipid profile with high total cholesterol levels, and especially very low hdl levels, probably due to the sedentary lifestyle, which needs further evaluation, because the metabolic control of our patients was not very bad. background and aims: physical activity (pa) in people with type diabetes helps to improve metabolic control, lipid profile, and to reduce weight. the aim of our study was to demonstrate the effect of a single session of pa to the glycaemic profile, and the effect of increasing daily physical activity on the weight and lipid profile. patients and method: fifty patients were recruited for a weeks training session. every pa session lasted min of fast walking. the number of daily steps was measured through a pedometer, and all the participants were encouraged to complete at least , steps/day. all the patients had completed anthropometric measures, fat body composition and lipid profile at the beginning and the end of study period. background: homocysteine is a cardiovascular risk factor for the development of vascular pathology. large population studies have been conducted demonstrating a positive association between homocysteine levels and risk of developing cardiovascular disease. paradoxically in type diabetes, if renal function is within a normal range, homocysteine levels are either similar or reduced when compared to levels in the normal non-diabetic population. whether the same is true for pre-diabetes has not been previously explored. our study examines the plasma levels of homocysteine in controls, and participants with prediabetes and diabetes from a screening program in regional new south wales. methods: seven hundred and forty-four participants attended the diabetes screening clinic, at charles sturt university, australia. participants were investigated based on the american diabetes association′s diagnostic criteria of diabetes mellitus and prediabetes, i.e. fasting blood sugar levels. venous plasma homocysteine samples were measured using the fluorescence polarization immunoassay on the imx â analyzer (abbott laboratories, abbott park, il). results: median age across the three groups ranged from to years. the median levels for plasma homocysteine between groups were not significantly different. there was a trend for plasma homocysteine (μmol/l) levels to be higher in the prediabetic group . ae . (sd) compared to the control group with . ae . (sd) and in the diabetic group of . ae . (sd). conclusion: there is a non-significant median increase in homocysteine in the pre-diabetes group. further larger cross-sectional population studies would be able to address whether this is a chance effect and also establish statistical significance if present. clinical endocrinology, institute for endocrine pathology problems, kharkiv, ukraine introduction: active acromegaly is associated with increased morbidity attributed by systemic complications such as carbohydrate dysfunction. aims: to evaluate the effects of chronic excess of gh and igf-i on prevalence and structure of carbohydrate dysfunction in patients with active acromegaly. subjects and methods: ninety-seven patients ( men and women; aged - years) with macroadenoma of hypophysis ( somatotropinoma, -somatomammo-tropinoma) were under investigation. blood samples for gh, igf- , immuno-reactive insulin (iri), glucose were taken in fasting state and on min ottg. insulin sensitivity and b-cell function were estimated by homa calculator v. . data are given as m ae se and coefficient of determination (r ) of multiple regression analysis. results: in . % of patients with acromegalia (gh - . ae . ng/ ml; igf- - . ae . ng/ml) different types of carbohydrate dysfunctions (cd) were found out: fasting hyperglycemia ( . %); impaired glucose tolerance ( . %), and diabetes mellitus ( . %). . % of patients have had hyperinsulinemic state. it was no sex differences in the cd structure. iri level was . ae . mu/ml, insulin sensitivity - . ae . %, β-cell activity - . ae . %. homa _ir was positively associated with gh (r = . %, p = . ) and igf- (r = . %, p = . ). homa _b% was positively associated with gh (r = . %, p = . ) and igf- (r = . %, p = . ), and negatively with disease duration (r = . %, p = . ). the gh hypersecretion and length of its pathologic action predetermine the stage of carbohydrate dysfunction from fasting hyperglycemia, impaired glucose tolerance to overt diabetes mellitus. a. vlassopoulos, m. lean, e. combet human nutrition, school of medicine, university of glasgow, glasgow, uk background: protein glycation is a key mechanism behind chronic diseases in both diabetic and non-diabetic individuals. about - % of circulating proteins are glycated in vivo in normoglycaemic blood, but in-vitro studies have hitherto failed to demonstrate glucose-driven glycation below concentration of mmol/l. methods: albumin, mercaptalbumin ( g/l) and plasma was incubated with glucose at different concentrations ( - mmol/l) for weeks at °c. to investigate the effect of oxidation on protein glycation, all protein models were used as native proteins or oxidized proteins (exposed to nmol/l h for h prior to incubation with glucose and throughout the incubation period). fructosamine was measured at and weeks (nitroblue tetrazolium method). oxidised mercaptalbumin and plasma had higher fructosamine concentrations at weeks at mmol/l glucose compared to native controls (p < . ). at mmol/l glucose, the same effect was observed for albumin and mercaptalbumin but not plasma. only oxidized albumin was significantly glycated at weeks with mmol/l glucose (compared to glucose-free control) when native was not. at weeks no effect of oxidation was observed. the current study has for the first time demonstrated the importance of oxidative stress in physiological protein glycation, interacting with glucose and promoting glycation in the early stages of the process. k. elksne , z. paunina , a. jurka , d. rezeberga , p. tretjakovs obstetrics and gynecology, physiology, rigas stradins university, riga, latvia introduction: a growing number of obese women in their reproductive years increases their risk for obstetric complications, but still the exact mechanisms is not known. we created a prospective study in which clinical data were collected from antenatal visits in pregnant women. obstetric outcomes were assessed at delivery. obstetrical outcomes depending on fetal macrosomia and maternal bmi were analysed using the fisher exact test. relationships between pre-pregnacy bmi, gestational weight gain and fetal weight were analysed using spearman rank correlations. results: overweight women had lower total weight gain during pregnancy, but higher risk for obstetric complications such as fetal macrosomia, uterine dysfunction, ceasarean section and ruptures of the birth canal. fetal macrosomia positively correlated with pre-pregnancy weight, but not with gestational weight gain during pregnancy. also male gender is a risk factor for birth weight above g. it is important to increase the number of planned pregnancies, pre-pregnancy visits to doctor in order to inform women about the impact of excess weight on perinatal outcome as fetal macrosomia is associated with impaired maternal bmi. women with bmi normal before pregnancy increased their weight above recommendations during gestation. as excessive weight gain may be a risk factor for long term complications, more information about diet should be provided in antenatal visits. obesity and fetal macrosomia correlate with complications during labour, so additional attention in birth conducting should be paid. background: the obesity epidemic is widely blamed for the rise in type diabetes, but new research suggests it is also linked to the increase in type diabetes (t d). the combination of obesity and t d has a negative impact on metabolic control in patients with t d in particular during pregnancy. aim: to evaluate the rate of overweight or obese women with t d at pregnancy onset according to their body mass index (bmi) and its relation to metabolic control. we performed an analysis of singleton pregnancies of women with t d, who consulted our diabetes outpatient clinic since . results: all women were caucasians with mean age of ae years and average diabetes duration of ae years. only % of all women with t d had a bmi of < kg/m , % were overweight with bmi between . % and . % and % were obese. the metabolic control was similar between the group with normal bmi and bmi > kg/m ( . ae . % vs. . ae . %). in the patients with normal bmi only % started the pregnancy with a hba c < %, which was mainly due to unplanned pregnancies. conclusion: our data revealed a high proportion of overweight women with t d at onset of their pregnancy, confirming the worldwide trend of rising obesity rates and which calls for preventive measures in the preconception counseling. hypertension is more prevalent in hivinfected subjects than in general population, contributing to increased cardiovascular risk in hiv+ patients. moreover, hiv patients more frequently showed metabolic alteration than general population. aim of this study was to evaluate the effect of weeks of administration with telmisartan mg daily in hiv+ patients. we enrolled hiv+ caucasian male patients treated with combined antiretroviral therapy (cart) and discovered to be na€ ıve hypertensive. systolic (sbp) and diastolic (dbp) blood pressure, viro immunological parameters and triglycerides, cholesterol, insulin resistance (homa-ir), inflammatory markers, c-reactive protein (crp), indexes of renal function and cardiovascular risk, microalbuminuria, cystatin c, were measured at baseline (t ), and after (t ), (t ), (t ), (t ), (t ) and (t ) weeks. treatment with telmisartan decreased sbp and dbp levels during the weeks of observation. we also observed improved in totalcholesterol, triglycerides, and in total cholesterol/hdl cholesterol ratio. we also observed an microalbuminuria and cystatin c improvement at the end of study. throughout in the course of the trial our patients showed a significant improvement of the percentage of cd + and cd . telmisartan doesn't interfere with the recovery of immunological parameters in this patients. telmisartan has confirmed durability and effectiveness, excellent tolerability and an high persistance with a good blood pressure control. therefore telmisartan should be the first choice in the treatment of hypertension in hiv+. methods: the subjects studied were patients diagnosed with gdm at ska˚ne university hospital, lund, sweden, - . sera were analyzed for antibody positivity (gada, ia- a and znt a) with commercially available elisa and snps were studied with restriction fragment length polymorphism. results: combinations of two or more autoantibodies ( . %) were less frequent than single positivity for gada ( . %) or znt a ( . %), but not ia- a ( . %). patients that developed t d postpartum often had combinations of autoantibodies. heterozygosity for r w was increased ( %) in patients that developed znt a compared to znt a negative patients ( %). however this was not statistically significant (p = . ). conclusions: the previously reported prevalence of znt a in gdm was confirmed. positivity for znt a did not seem to be a good independent predictor for development of t d. the tendency of increased r w heterozygosity in znt a positive gdm patients is a novel finding and of interest since the snp has been suggested to be of importance in both t d and t d. among several consequences, obesity seems to have detrimental effects on reproductive function, causing low levels of sex hormones and reduced sperm concentration. the excess of lipids on diet influences metabolism and affects testis reproductive function. the relationship between obesity, reproductive changes and metabolic syndrome is not yet fully clarified. thus, the aim of the study was evaluate the effect of high fat diet, containing soybean oil, on body composition and male reproductive system of young rats. wistar rats, at days, received diet containing % (control diet) or % (high fat diet, hf) of soybean oil, until and days of age. food intake and body mass were monitored. at the end, body composition was evaluated by dexa and blood, liver, adipose tissue, testis and epidydimis were collected. glucose, triglycerides, cholesterol, hdl, vldl, insulin and leptin were measured. food intake, body mass gain, lean mass, total fat mass and bone mineral content did not differ between the groups at and days. at days, glycemia and epidydimal adipose tissue mass were increased in rats fed with hf. at days, glycemia, leptinemia and the mass of mesenteric adipose tissue, liver and epidydimis were high after hf ingestion, while tg was low. the excess of lipids reflected negatively on intra-abdominal adipose tissue since days, accompanied by hyperglycemia. the hf ingestion maintained high glucose and leptin concentrations without insulin alteration. at the same time, it could predict some testis function change, once epidydimis mass increased in these young animals. adipose tissue is linked to cardio-vascular and metabolic complications of obesity by increased local production of adipokines.to investigate serum levels of adipokines (adiponectin and leptin) and relationship with obesity anthropometric markers and insulin resistance in overweight/obese patients with type diabetes. two groups of subjects were selected: group with type diabetes mellitus (n = ) and control group (n = ). the first group was subdivided in two subgroups, according with bmi (overweight and obese). in all individuals were assessed bmi, waist and hip circumference, visceral fat index, serum levels of adiponectin, leptin, insulin and proinsulin and homa-ir was calculated. the determined parameters were modified significantly in the diabetic patients vs. control. comparing the obese diabetic patients with the overweight, serum levels of leptin were higher on obese/overweight (p < . ) and levels of adiponectin were lower (p < . ). also, serum levels of insulin and proinsulin were higher in diabetic vs. control group maintained their statistical significance difference in the subgroups of overweight/obese (p < . and, respectively, p < . ). bmi was positively correlated with leptin (p < . ) and adiponectin negatively (p < . ). moreover, leptin was positively correlated with visceral fat index (p < . ), waist circumference (p < . ) and homa-ir (p < . ); adiponectin was negatively correlated with waist circumference (p < . ), visceral fat index (p < . ) and homa-ir (p < . ). in conclusion positive correlation (leptin) and negative (adiponectin) with anthropometric markers of obesity and homa-ir, demonstrating the role of adipokines in the pathogenesis of peripheral insulin resistance in patients with "diabesity." materials and methods: based on research institute of nutrition we randomly chose patients with varying class obesity, who were outpatient for this disease. all patients were tested on the personal scale manifestations of anxiety (d. teylor in adapting t. nemchina). patients were asked to read a set of sentences ( questions) about their traits. if they agreed with the statement they should answer "yes" if they did not agree -"no". the test had a ball-evaluation, in which anxiety is defined as very high, high, medium and low. objectives: the process of converting prediabetes to diabetes remains a matter of debate. the aim of the study was to assess insulin sensitivity/resistance indices and markers of oxidative stress in prediabetic persons. methods: obese non-smoking caucasians, using neither special diet nor medication, without acute and chronic disorders, were qualified for ogtt and assigned to groups: normal glucose tolerance-ngt, impaired fasting glycemia-ifg, impaired glucose tolerance-igt and newly diagnosed type diabetes-t dm, each group n = subjects: f/ m; age : - (median: quartiles - ). plasma glucose (siemens) and insulin (biosource) were determined during ogtt ( ', '). plasma total antioxidant status-tas (randox), thiobarbituric acid-reacting substances-tbars (sigma), lipids and hscrp (siemens), as well as hba c (hplc) were assayed fasting. different indices of insulin sensitivity/resistance, fasting steady-state and derived from ogtt, were calculated. results: the groups did not differ according to age, bmi, waist, blood pressure, lipids and hscrp. insulin sensitivity/resistance indices presented variety of sensitivities and specificities for prediction of dysglycaemia categories, as well as different correlations with metabolic parameters, including oxidative stress, i.e. isi , &tas (r = . ), isi , &tbars (r = À . ) in the population n = . the comparison of ngt-ifg-igt-t dm, showed the highest tas in ifg and the lowest in t dm (p = . ), together with increasing tbars from ngt to t dm (p = . ). the results of roc curves analysis pointed isi , ( % sensitivity; % specificity) for prediction of igt, and tas ( % sensitivity; % specificity) in differentiation between igt and t dm. conclusions: insulin-sensitivity indices predict prediabetes in obese subjects near perfectly, while the development of diabetes is preceded by antioxidant insufficiency rather. m. smiraglia , g. bott a , e. orsi endocrinology and diabetolgy, fondazione ca' granda irccs -ospedale maggiore policlinico di milano, biomolecular sciences and biotechnology, university of milan, milan, italy t dm is a metabolic disorder and evidences show that medical nutrition therapy improving glucose metabolism reducing the risk of complications, leads to an improvement in life quality and increase life expectancy. the aims of diabetes management are normalize blood glucose levels and weight control. obesity influences the development of t dm and complicates its management. the study aim was to value the effect of two different nutritional treatments (nt) on the anthropometric parameters and glucose metabolism in patients with t dm and obesity. the two nt are: the "low gi diet" that promotes the carbohydrates quality and the food choice is made on the glycemic index; the "low-carbohydrate diet" is based on the concept that glucose metabolism is influenced also by the carbohydrates amount. subjects, selected on including and excluding criteria, were randomly divided in two groups, to each of which one of the two nt was assigned. during the study participants were measured three times. all statistic differences in the values were analyzed with the use of anova test. the "low-gi group" showed a significant decrease in hba c (À . %; p = . ). data suggest that this nt positively influences the glycemic control. the "low-carb group" showed a significant decrease in insulin level (À . %; p = . ), a greater reduction in bmi and whr and a homa-insulin resistance index reduction (À . %; p = . ). the daily reduction of carbohydrate intake influenced positively the blood glucose response and significantly reduced plasmatic insulin levels. data suggest that either nt improves glycemic control and peripheral insulin sensitivity. aims of study: the use of metformin to control glucose in pregnant women with gestational diabetes mellitus (gdm) to evaluate its safty use during the first trimester of pregnancy. design: cases report of four patients with gdm from the first trimester of pregnancy non smoking with no family history of congenital malformation disease, aged between ( and ) and have no liver diseases put on metformin were participated in this study and who had indicating good comliance at more than one visit over several month until delivery. result: all four patient in oure study delivered healthy babies. internal medicine, ist medical clinic, umf iuliu hatieganu cluj-napoca, immunology laboratory, emergency county clinical hospital, cluj-napoca, romania introduction: the potential role of oxidative stress (os) in metabolic syndrome (mets) is rapidly evolving. reported results support the concept that increased os may play a key role in the development of atherosclerosis, hypertension and diabetes. study aim: the purpose of the present study was to analyze the impact of mets and its individual components on os and on the antioxidant status. material and methods: seventy-two hospitalized patients with a mean age . ae . years were taken under study between october and june . mets was diagnosed based on aha/nhlbi/idf definition. os was assessed by urinary iso-prostaglandinf a ( iso-pgf a) (immunometric assays) and plasmatic uric acid. antioxidant status was evaluated by plasmatic gluthatione peroxidase (gpx). these data were compared to those of biologically and clinically healthy subjects (mean age . ae . years). results: all biomarkers were significantly higher in mets patients as compared with healthy individuals (p < . ), except gpx which was significantly lower (p < . ). gpx and uric acid were statistically significant correlated. in multivariate analysis iso-pgf a concentrations were influenced by hypertension, fasting glucose and triglycerides, uric acid levels were directly influenced by hypertension, waist circumference, fasting glucose and triglycerides. gpx levels were inversely correlated with blood pressure (all p < . ). only gpx was influenced by the number of mets components. objective: the purpose of this study was to compare changes in the plasma metabolome during an intravenous glucose tolerance test (ivgtt) among persons with low or high insulin sensitivity (si < . or > . ). methods: ivgtts were performed in men and women, ae years, with low si ( . ae . ) and men and women, ae years, with high si ( . ae . ). targeted electrospray ionization, tandem mass spectrometry was used to measure plasma concentrations of amino acids and acylcarnitines during the first phase of the ivgtt. other metabolites (glucose, insulin, etc.) were measured by conventional methods. results: fasting glucose, insulin, triglycerides, glycerol, free fatty acids, leucine/isoleucine, tyrosine, glutamate/glutamine, -hydroxypalmitoleylcarnitine (c : -oh)/dicarboxytetradecanoylcarnitine (c : -dc), and docosanoylcarnitine (c ) were significantly higher in the low si group, whereas ornithine was significantly lower. in response to glucose infusion, rates of disappearance of alanine, proline, valine, leucine/ isoleucine, methionine, and phenylalanine were %, %, %, %, %, and % lower, respectively, in the low si group. there were no group differences in changes in circulating concentrations of free fatty acids, glycerol, triglycerides, or acylcarnitines. conclusions: insulin resistance is associated with lower rates of disappearance of neutral, non-polar amino acids during the first phase of the ivgtt, suggesting insulin-mediated clearance of amino acids and/or suppression of protein catabolism may be impaired. cigarette smoking is worrisome in adults and also in adolescents. actually, smoking rates have grown, especially among girls, and little is known about the damages caused in these organisms still young or the consequences in adulthood. this study aim evaluates the influence of smoking in puberty and the consequences of withdrawal, body composition of female and male mice. at days, mice were exposed to r f cigarette (tobacco and health research institute) smoke, h/day for days (s, n = ). then, half of animals were evaluated and the other half was maintained and evaluated days after stop exposure ( d as). an unexposed group accompanied the events (ns, n = ). body mass, body composition (dexa), food intake, blood, ipgtt and adipose tissue were evaluated. during exposure food intake was similar all groups, however, s groups showed low body mass gain. das, s groups increased body mass and food intake in females. no alterations body composition were in males, while in females, increased total body and trunk fat during exposure and lean mass das. fat was high epidydimal and retroperitoneal in females. in regard blood, males did not alter insulin or ipgtt during exposure whilst females had high insulin levels and glycemia at min. withdrawal induced in males, high insulin and low glycemia the ipgtt and in females normal insulin and low glycemia. the set of results indicates different response cigarette smoke in young that seem to start in females and lead malefic metabolic alterations in adulthood. methods: this retrospective study included children and youths ( boys) from the children's obesity clinic. data were measured at the time for inclusion and included values of body mass index (bmi) standard deviation score (sds), blood pressure, gender, and biochemical measures, including the fasting concentrations of blood glucose, serum insulin, hba c, and serum lipids. the bmi sds was median . (range . - . ) and the age was median . (range . - . ) years. prediabetes was classified as a fasting blood glucose ! . and < . mmol/l. the mann-whitney-wilcoxon test was used for the analyses. results: prediabetes was present in ( boys) patients. these patients were older, age median . vs. . years (p = . ), had a higher bmi sds median . vs. . (p = . ), an increased fasting hba c median vs. mmol/mol (p < . ), an increased fasting serum insulin median . vs. pmol/l (p < . ), and an increased median homa-ir . vs. . (p < . ), respectively, compared to the patients with a fasting plasma glucose < . mmol/l. no differences were found in any of their fasting serum lipid levels or blood pressure (p > . ). in this large group of overweight and obese children prediabetes is prevalent. thus it seems important to identify obese subjects with prediabetes in order to prevent development of diabetes during childhood. introduction: epidemiological spreading of diabetes and developing in early age urge for finding causes and prevention before manifestation. aim of the study was testing accelerator hypothesis t. wilkin and colleges. method: the study is combined retrospective prospective. we examined history and follow up till age of years children who were referred to pediatrician endocrinologist because of obesity or diabetes. results: children from obese mothers and children with lower birth weight have more metabolic disturbances (insulin resistance, neonatal hypoglycemia, obesity, diabetes, precocious puberty, menstrual irregularity). subjects and methods: twenty-two obese women (bmi ae kg/m ) were followed during di that consisted of a days′ very-low-caloriediet (vlcd) and subsequent months low-calorie-diet followed by a months′ weight maintenance diet (wm). mrna expressions of adipokines (leptin, adiponektin, interleukines (il) - ,- ,- , tnfa, macrophage-chemoattractant-protein (mcp- ), haptoglobin) were measured, using rt-pcr, in samples obtained from abdominal scat at baseline and at the end of vlcd and wm, respectively. results: body weight (bw) and plasma crp decreased during vlcd and at the end of wm (bw: . ae . vs. . ae . vs. . ae . kg (p < . ), crp: . ae . vs. . ae . vs. . ae . mg/l (p < . ), respectively). the decrease of plasma crp during the entire months′ di correlated positively with the decreases of mrna expression of mcp- . (r = . , p < . ) and il- (r = . , p < . ) during the entire di and with the decrease of leptin mrna during initial vlcd (r = . , p < . ). no correlations were found for other adipokines. objective: to determine associations between change in lean body mass (lbm), fat mass and muscle strength with is following month of resistance training in obese postmenopausal women. methods: thirty-four ( with and without metabolic syndrome) non-diabetic obese postmenopausal were recruited. participants completed a month resistance training program ( times/week). body composition (dxa), handgrip strength and quadriceps strength were measured. fasting glucose and insulin levels as well as ogtt derived is indices (stumvoll, matsuda) and homa were also measured. non parametric correlations were performed with spss ( . ). results: significant increases in muscle strength, is and lbm as well as decreases in fat mass were observed after the intervention. however, no correlations were observed between changes in is with changes in muscle strength, lbm or fat mass in all participants as well as in subjects with or without the metabolic syndrome. conclusion: our results suggest that the changes in muscle strength, lbm and fat mass may not be associated with changes of is in obese postmenopausal women. therefore, other potential variables seem to be implicated in the changes of is in our cohort. objective: to examine the relation between total work (tw) performed and total heart rate work performed (trimps) with changes in cardiometabolic risk factors after resistance training in obese postmenopausal women. methods: thirty seven postmenopausal women (age: ae . , bmi: . ae . ) completed a month resistance training program ( times/week). body composition (dxa), blood pressure, metabolic risk factors (insulin sensitivity, h glucose, lipid profile and crp) and muscle strength were measured before and after the intervention. moreover, tw was calculated in each session by multiplying the number of repetitions, sets, weight and range of motion. thereafter, we added all training sessions. a heart rate monitor was used to assess trimps during each session. subjects were also categorized into two groups based on the top or lower th percentile of tw and trimps (high (n = ) vs. low (n = )). results: we showed that tw negatively correlated with systolic blood pressure and h glucose levels (p < . ). in addition, crp was negatively associated with trimps (p < . ). furthermore, high workers had lower levels of fat mass percentage and h glucose as well as higher lean body mass content than low workers. as for the high trimps group, we observed lower levels of crp compared to the low tripms group (p < . ). conclusion: results indicate that the quantity of work performed during resistance training is associated with better changes in metabolic risk factors in obese postmenopausal women. research design and methods: this cross sectional study included gestational diabetes patients who were diagnosed with gdm by a g ogtt and who underwent a standardized mixed meal tolerance test (mmtt). patients were divided into three groups according to the number of abnormal hyperglycemic values (group i for values, group ii for values, and group iii for values). glycemic parameters were compared to assess glycemic control (glucose, a c, ga) and gluco-metabolic homeostasis (homa-β, homa-ir). results: a total of gdm patients were recruited for this study. subjects whit a greater number of hyperglycemic values were also more hypertensive and obese, and had decreased insulin secretory functions than those with a lower number of hyperglycemic values (lnhoma-β, . ae . vs. . ae . , . ae . , p < . ). those with higher hyperglycemic values tended to have increased insulin resistance, but this result was not significant (lnhoma-ir, . ae . vs. . ae . , . ae . , p = . ). lnhoma-β correlated negatively with fasting glucose, a c, ga and ga/a c. multivariable regression analysis revealed that age and ga were significant independent predictors for lnhoma-β (standardized β = À . , À . , respectively, p < . ) but not a c. conclusions: korean women with dysfunctional pancreatic β-cells and increased insulin resistance are prone to gestational diabetes. ga, but not a c, is significantly correlated with pancreatic β-cell function. conclusion: altered adipokine profile is associated with increased cvd risk in pcos patients. these markers can serve as potential therapeutic target for decreasing their cv risk. objective: to determine the prevalence and determinants of nonalcoholic fatty liver disease (nafld) in a sample of adult iranian general population. method: this was a cross-sectional study being performed in shiraz, southern iran during a -month period from november to september through cluster random sampling of iranian general population in shiraz region. all individuals underwent anthropometric and blood pressure measurements and thorough medical history and physical examinations. laboratory measurements included fasting blood glucose (fbs), lipid profile, complete blood count (cbc) and liver function tests. nafld was diagnosed by transabdominal ultrasonography. result: overall we included subjects in this study among which there were males ( . %) and females ( . %) with the mean age of . ae . years. nafld was diagnosed in ( . %) subjects. patients with nafld were significantly older (p < . ), had higher proportion of male gender (p = . ) and had higher bmi (p < . ). they also had higher prevalence of hypertension (p < . ), high fbs (p < . ), high cholesterol (p = . ), high triglyceride (p < . ) and high waist circumference (p < . ). taking all these together, patients with nafld had significantly higher prevalence of metabolic syndrome when compared to healthy subjects (p < . ). conclusion: the prevalence of nafld in this group of iranian adult general population is . %. nafld in iranian population is associated with male gender, old age, obesity, and features of metabolic syndrome. a. othman , t. hornemann university hospital zü rich, clinical chemistry, university hospital zü rich, zü rich, switzerland -deoxysphingolipds (dsl) are atypical and neurotoxic sphingolipids which are formed by the enzyme serine-palmitoyltransferase (spt) due to a promiscuous use of l-alanine over its canonical substrate l-serine. pathologically elevated dsl levels were identified as a cause for the rare and inherited sensory neuropathy hsaniwhich is associated with several missense mutations in spt. significantly elevated dsl levels were also found in patients with mets or t dm as demonstrated in various clinical studies. principal component analysis identified the dsls as important descriptors for the mets statecomparable to triglycerides and superior to conventional mets biomarkers like fasting glucose or wcf. partial correlation analysis showed an independent correlation to plasma glucose and triglycerides. strikingly, recent data from prospective clinical studies identified plasma dsls as highly significant and independent predictors for the risk to develop t dm. elevated dsl levels were also confirmed in plasma and liver of stz rats. the dsls are therefore clinically relevant blood biomarkers for an impaired glucose homeostasis but might also be directly involved in the pathology of diabetes related sequelae. like observed in hsan the -dsl formation is significantly suppressed in response to an oral l-serine supplementation. feeding an l-serine enriched diet to stz rats resulted in a significant reduction of plasma dsls, a significant improvement of neuropathic symptoms and reduced cataract formation. our findings strongly support the value of dsls as novel and clinically relevant biomarkers in mets and t dm but also as therapeutic targets for the treatment of the diabetic neuropathy and other sequelae. objectives: prevention of cardiovascular disease focused on the early stages of atherosclerosis, including endothelial dysfunction, should arouse attention of clinicians in dysglycaemia patients especially. the aim of the study was to assess plasma e-selectin concentrations in newly diagnosed type diabetes (t dm) and in t dm patients treated with metformin, comparing with normoglycaemic individuals. material and methods: excess body mass non-smoking males and females, - years old, presented with neither acute nor chronic disease, were enrolled into the study. oral glucose tolerance test (ogtt) was performed to find normal glucose tolerance, group- (n = , age: median ; interquartile range - ) and newly diagnosed t dm, group- (n = , age: ; - ). group- consisted of t dm patients who take medication (metformin) for at least year (n = , age: ; - ) and present no retinopathy, nephropathy and neuropathy, as well as no history of coronary incident or stroke. all participants were measured plasma glucose (g- , g- ), fasting lipids and insulin, and hba c level. e-selectin concentration in plasma was assessed using elisa method (r&dsystems). data are shown as median and interquartile range. results: groups - - did not differ in respect to their age and bmi. the comparison among groups, followed by post hoc analysis, revealed different (p = . ) e-selectin concentrations, ng/ml: group- : . ( . - . ), group- : . ( . - . ), group- : . ( . - . ). in combined group + (n = ) the correlation e-selectin&g- ' was observed independently from bmi and triglycerides (multiple regression β = . ; r = . ; p = . ). conclusion: metformin therapy may limit early stages of atherosclerosis in t dm patients not only works to decrease plasma glucose. aim: to evaluation clinical efficacy of candesartan and its effect on parameters of vascular elasticity, lipid profile, lipid peroxidation and antioxidative protection against a background of single-candesartan therapy in females with arterial hypertension (ah) and abdominal obesity (ao) during menopause. methods: forty-six patients were divided into two groups. group ( subjects) were given candesartan and group ( subjects)enalapril. twenty-four hour blood pressure monitoring (bpm), pulse wave velocity; plasma lipids, diene conjugates (dc), malonic dialdehyde, superoxide dismutase (sod) and homocysteine, uric acid were estimated. the dynamics of all parameters was evaluated initially and in weeks. results: candesartan is a more effective hypertensive drug that has a valid effect on the readings of systolic blood pressure (sbp) and diastolic blood pressure (dbp) measured in the doctor's office and on the parametrs of bpm (daily sbp and dbp, daytime and nighttime sbp and dbp, sbp and dbp variability, the rate of morning rise in sbp and dbp). we revealed a favorable effect of the medication on vascular wall elasticity, valid reduction of cholesterol, low-density lipoprotein cholesterol, triglycerides, dc, homocysteine and uric acid increase in sod in group . the proved antihypertensive effect of the candesartan therapy against a background of normalization of vascular wall elasticity, plasma lipids and processes of lipid peroxidation, in the presence of differently directed correlations between clinical and biochemical characteristics, shows that candesartan has pathogenetic mechanisms of correcting ah in females with ah and ao during menopause. background: high intensity interval training (hiit) may improve insulin action in skeletal muscle, but this has never been shown. objective: to study the effect of hiit on insulin mediated glucose uptake rate in skeletal muscle. methods: four healthy sedentary males [age ae years (mean ae se), bmi . ae . kg/m ] were included. a total of eight one-legged training sessions were performed on an ergometer bicycle as min high intensity exercise (workload > % of one-legged vo -peak, and heart rate > % of maximal heart rate) with min recovery between each interval. lean leg mass before and after the training period was assessed using dual-energy x-ray absorptiometry. forty hours after the last training session, a two-step isoglycemic, hyperinsulinemic clamp was performed in combination with arteriofemoral venous catheterization. blood flow was measured with doppler ultrasonography. data were expressed per kg lean leg mass, and differences were tested by t-test. results: insulin stimulated glucose clearance rates were significantly higher in trained compared with untrained legs in both steps of the clamp (figure). the lean mass of the trained legs did not significantly differ from the untrained legs (p = . ). conclusion: hiit increases insulin stimulated glucose uptake in skeletal muscle in the leg after a very short training period. it is a time-effective training modality which may be attractive in the treatment of insulin resistance and type diabetes. (htgpos) and that this htgpos is related with the degree of insulin resistance. our aim was to characterize the adipose tissue of morbidly obese patients with mild or severe htgpos after a fat overload though the expression of a battery of genes involved in lipid metabolism. methods: we studied morbidly obese patients who had mild or severe htgpos after fat overload (patent p ). measurements of anthropometric and biochemical variables and oxidative stress biomarkers were done. samples of visceral adipose tissue were obtained during bariatric surgery in the morbidly obese patients. the rna isolation from adipose tissues was done using rneasy lipid tissue mini kit and the gene mrna expression levels were assessed by real-time pcr using an abi prism sequence detection system. results: no significant differences were observed in biochemical variables except in triglyceride levels between the two groups of morbidly obese patients with postprandial mild or severe htgpos. the morbidity obese patients with severe htgpos had a higher oxidative stress levels. genes involved in the management of triglycerides or lipid metabolism were up-regulated in morbidly obese patients with severe htgpos. conclusion: morbidly obese patients with severe htgpos had a more active adipose tissue regarding the expression of genes involved in lipid metabolisms, these data could indicate a greater flow of lipids and a greater insulin resistance in these patients. patients and methods: three hundred and nine workers ( m/ f; aged ae ; bmi . ae . kg/m ), without previous cardiovascular events, were enrolled. all subjects were evaluated for biochemical analytes (fibrinogen, c-reactive protein, uric acid, creatinine, triglycerides, t-cholesterol, hdl, ldl, homocysteine, glucose, insulin, hba c, (oh) d). all parameters were routinely assayed in corelab. these parameters together with homa-ir, systolic and diastolic blood pressure, bmi, age, percent of fat and waist circumference were processed by neural networks (autocm). the autocm matrix of connections preserves non linear associations among variables, while at the same time capturing elusive connection schemes among clusters that are often overlooked by traditional cluster analyses. results: with an appropriate pre-processing able to handle each variable according to its high and low values, auto-cm showed a clear association between (oh) d and metabolic status with graph links suggesting a protective role of high (oh) d against increase in bmi, waist circumference and abdominal fat. these associations were not clearly visible with traditional data mining tool. the neural networks map identifies the key role of vitamin d respect to all metabolic parameters considered in our study in the development of prediabetes drawing a physiopathologic road map for obesity and type diabetes. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of omentin and oxldl by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and urine sample was taken for assessment of albumin/creatinine ratio. twenty-four hour holter was also done. the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). omentin was significantly lower, while oxldl was significantly higher than controls. omentin had a significant negative correlation with oxldl and albumin/creatinine ratio and h holter (minimal hr, rms) and positive correlation with vldl. conclusion: a significant reduction of omentin and elevation of oxldl imply that they influence glucose metabolism in type diabetes. omentin had a significant relation to h holter may reflect its role in cardiac affection. while, albumin/creatinine ratio had a significant negative correlation with omentin and positive correlation with oxldl reflect their role in renal affection. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of chemerin, vaspin, adma and oxldl by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and urine sample was taken for assessment of albumin/creatinine ratio. twenty-four hour holter was also done. the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). chemerin, vaspin and oxldl were significantly higher, while adma was significantly lower than controls. chemerin had a significant positive correlation with vaspin, adma and oxldl. vaspin had a significant positive correlation with waist/height ratio, sdann, sdrr and sddrr. albumin/creatinine ratio had a significant positive correlation with chemerin, adma and oxldl. conclusion: a significant reduction of adma and elevation of chemerin, vaspin and oxldl imply that they influence glucose metabolism in type diabetes. vaspin had a significant relation to h holter may reflect its role in cardiac affection. while, albumin/ creatinine ratio had a significant positive correlation with chemerin, adma and oxldl reflect their role in renal affection. patients and methods: the study included type diabetic patients and healthy volunteer of the same age and sex. blood sample was taken for assessment of apelin, nitrous oxide and preptin by elisa technique. also blood sample were taken for analysis of glycosylated hemoglobin, lipid profile and albumin/creatinine ratio in urine. m mode echocardiography was also done. results: the study included patients with type diabetes, their mean age were . ae . years ( . - . years), and mean duration of diabetes were . ae . years ( . - . years). nitrous oxide was significantly lower, while apelin, preptin and albumin/creatinine ratio were significantly higher than controls. nitrous oxide had a significant positive correlation with lvedd, lvesd, pwt and lv mass and negative correlation with preptin and albumin/creatinine ratio. conclusion: a significant reduction of nitrous oxide and elevation of apelin and preptin and their relation to echocardiographic data imply that early assessment of these markers may unmask the initial endothelial dysfunction in type diabetic patients before overt microalbumin and renal impairment supervenes. obesity co-morbidities may appear already early in life in high-risk individuals. today we have no means to identify which obese children who are at highest risk. consequently, we have implemented a study with the objective to identify factors in obese children that could indicate early development of related co-morbidities. in this abstract we have concidered fasting glucose, h ogtt, and degree of obesity as predictors. severely obese children and adolescents treated for obesity between and (n = ), but not undergone bariatric surgery, are included. currently, follow-up measurements have been conducted in subjects. study participants undergo extensive examinations during days including e.g. cardio respiratory fitness, body composition, both oral and intravenous (ivfsgtt) glucose tolerance tests. average age of the first subjects is . years ( . - . ). follow-up time varies from . to . with an average of . years. bmissds at baseline . ( . - . ) correlates with bmi at follow-up (y = . x + . , r = . ). no other correlations with degree of obesity at baseline could be found. fasting glucose at baseline correlates with crp . years later. however, fasting glucose was not correlated with h ogtt, insulin sensitivity, diabetes, or prediabetes at follow-up. no correlations between h ogtt value at baseline and later co-morbidity was found. in the first studied subjects all, but one, of the severely obese children remained obese in early adulthood. higher level of fasting glucose at baseline predicted higher crp at follow-up. analyses from more collected data will be presented. background: obesity acts as an independent cardiovascular risk factor by mechanisms that are not fully understood. elevated levels of the pro-inflammatory cytokines interleukin(il)- , il- and plasminogen activator inhibitor (pai)- are found in obese patients. recent studies suggest that inflammation could be an adaptive response to hypoxia within the expanding adipose tissue mass. in this study we investigated the impact of hypoxia on pai- , il- and il- regulation in human adipose tissue ex vivo and in vitro. methods: primary human preadipocytes and adipocytes were prepared from subcutaneous and visceral adipose tissue. explants, preadipocytes and adipocytes were cultured under hypoxic conditions. pai- , il- and il- antigen were quantified by elisas, mrna levels were determined by realtimepcr. results: pai- , il- and il- secretion was significantly increased under hypoxic conditions in subcutaneous and visceral adipose tissue explants. hypoxia significantly upregulated il- production in preadipocytes and adipocytes up to -fold and -fold. il- and pai- were significantly increased by hypoxia in preadipocytes and adipocytes up to -fold and -fold (il- ) and . -fold and . -fold (pai- ), respectively. these results were confirmed on the level of mrna expression. conclusion: our data show that hypoxia increases il- , il- and pai- production in adipose tissue explants and in cultured human preadipocytes and adipocytes. we therefore hypothesize that hypoxia promotes the pro-inflammatory state seen in obese patients and thus could contribute to the elevated risk for cardiovascular diseases. this study sought to characterize the antioxidant properties and interaction of phenolic (free and bound) extracts from clerodendrum volubile (a leafy vegetable commonly grown and consumed in south eastern part of nigeria), with key enzymes relevant to non-insulin dependent diabetes mellitus (a-amylase and a-glucosidase) in vitro. the free phenolics of clerodendrum volubile were extracted with % acetone, while the bound phenolics were extracted from the alkaline and acid hydrolyzed residue with ethyl acetate; and their interaction with the enzymes were assessed. the phenolic extracts inhibited a-amylase, aglucosidase and fe + -induced lipid peroxidation in pancreas (in vitro) in a dose-dependent manner. however, bound phenolics had significantly higher (p < . ) a-glucosidase inhibitory activities, than free phenolics while there was no significant difference (p > . ) in their a-amylase inhibitory activities. the stronger inhibition of a-glucosidase when compared to a-amylase in both extracts is of pharmacological relevance. the stronger action of the bound phenolic extract on a-glucosidase may explain the possible bioactivity of the phenolics at the brush border end. the phenolic profile in both extracts revealed the presence of phenolic acids and flavonoids. moreover, the inhibitory properties of phenolic rich extracts from clerodendrum volubile on a-amylase, a-glucosidase and fe + -induced lipid peroxidation in pancreas could be attributed to the antioxidant properties of the extracts. from the study, clerodendrum volubile could serve as functional foods and nutraceuticals for early intervention and management of non-insulin dependent diabetes mellitus. department of kinesiology and nutrition, university of illinois at chicago, chicago, il, usa background: alternate day fasting (adf), consisting of a feed day ( -h ad libitum food intake) alternated with a fast day ( % energy restriction), is effective in reducing body weight and modulating adipose tissue physiology. however, the ability of adf in combination with endurance exercise to improve the above variables has never been tested. objective: accordingly, this study examined whether the combination of adf plus exercise produces superior changes in body weight and plasma adipokine levels, when compared to each treatment alone. methods: obese subjects (n = ) were randomized to one of four groups for weeks: . combination (adf + endurance exercise), . adf, . exercise, or . control. results: body weight was reduced (p < . ) by ae , ae , and ae kg, and fat mass decreased (p < . ) by ae , ae and ae kg in the combination, adf and exercise group, respectively. fat free mass was retained in all groups. adiponectin and resistin values did not change in any group post-treatment. leptin levels significantly decreased (p < . ) by ae , ae and ae ng/ ml in the combination, adf, and exercise group, respectively. conclusion: these findings suggest that the combination of adf plus exercise produces superior changes in body weight, body composition and leptin levels, when compared to each intervention alone. the plasma total cholesterol and triglycerides concentration were higher than other groups. adipokines results were that resistin, adiponectin, leptin, and tnf-a were significantly lower than [hf], [br] and [hc] . so it had a effect on anti-obesity. these results showed that functional rice especially giant embryonic components will probably be useful in the management of high fat diet-induced chronic disease. m.g. watve , m.s. diwekar , p. patil biology, indian institute of science eduction and research, physiology, bharati vidyapeeth medical college, pune, india a crucial link in the classical thinking of type diabetes (t d) is that insulin resistance (ir) is primary and hyperinsulinemia develops to compensate. high levels of insulin are associated with an insulin resistant state. there have been alternative suggestions that insulin overproduction is primary and ir develops to compensate it. it is also likely that both are secondary effects of an unknown primary cause. we critically examine the alternative possibilities in the light of theory and evidence. temporally hypoglycemia and/or hyperinsulinemia precede insulin resistance in human and animal iugr models. various gene knockouts show that primary muscle and adipose insulin resistance does not lead to hi. in insulinomas, where hyperinsulinemia is primary, insulin resistance develops almost invariably and removal of such tumors increases insulin sensitivity. if ir sets in first, pancreas must sense the ir and increase the insulin production accordingly. if raised blood glucose mediates the response, we expect a positive correlation between fasting glucose and fasting insulin in prediabetic individuals. however, such a correlation is not seen in a large set of data on normoglycemics. no other mechanisms have been postulated that can measure the level of ir and in turn regulate the insulin secretion by beta cells. on the other hand many pathways exist that can induce ir when beta cells overproduce insulin. overall there is substantially more evidence for the hyperinsulinemia-first hypothesis. this can potentially undermine our current understanding of t d and the entire chain of processes leading to t d needs to be re-examined. non-alcoholic fatty liver disease (nafld) is emerging as the most common liver disease in industrialized countries. the discovery of food components that would ameliorate nafld is therefore of interest. betulinic acid (ba) is a pentacyclic triterpenoid showing many pharmacological activities, but effect of ba on fatty liver is largely unknown. to explore the anti-fatty liver activity and mechanism of ba, insulin resistant hepg cells, primary rat hepatocytes and liver tissue of icr mice fed on hfd were utilized. oil red o staining revealed that ba significantly suppressed the excessive triglyceride accumulation in hepg cells and liver of mice fed on hfd. ca + -calmodulin dependent protein kinase kinase (camkk) and amp-activated protein kinase (ampk) were both activated by ba treatment. in contrast, protein expression of sterol regulatory element-binding protein (srebp ), mammalian target of rapamycin (mtor) and s kinase (s k) were all suppressed when hepatocytes were treated with ba for up to h period. ba activated ampk by phosphorylation, suppressed srebp mrna expression and nuclear translocation and repressed srebp target gene expression in hepg cells and primary hepatocytes, leading to reduced lipogenesis and lipid accumulation. these effects were completely abolished in the presence of sto- (a camkk inhibitor) or compound c (an ampk inhibitor), indicating that bainduced anti-hepatic steatosis was mediated through modulation of camkk-ampk-srebp signaling pathway. taken together, our results suggest that ba can effectively ameliorate intracellular lipid accumulation in liver cells, and thus it may be a potential therapeutic agent for treating fatty liver disease. blood glucose concentration, insulin level, glucokinase, g pase and pepck were significantly decrease relative to the [hf] . in addition, antioxidantresults were that cat, sod and gpx were higher than [hf] . effect of rice supplementation type of giant embryonic on erythrocyte tbars and plasma tbars showed significantly decrease than other groups. these experiments suggest that components of giant embryonic help to lower the level of and blood glucose which reduces the risk of heart disease and diabetes. method: a g o-gtt was performed in normal-weight (n) healthy females, females with overweight and females with obesity (grades - ), with measurements of glucose and insulin. homa-insulin resistance (ir) and belfiore-insulin sensitivity (is) were caldulcated. the th percentile in the n group was used as cut-off. results: ir was present in . % of women with normal weight and in . % of women with overweight/obesity. . %, . % and . % of women have ir in the obesity grade , and , respectively. further risk factors for ir are age, hip-waist ratio, triglycerides, hdl, uric acid, pai- and fibrinogen (p < . ). hba c is irrelevant for the detection of ir. hormonal imbalances (hyperandrogenemia, igf deficiency, hypothyroidism, elevated estradiol) play a major role in obese women. postmenopausal women receiving hormone replacement therapy (hrt) develop hyperglycemia, as expected by age, but not ir. hrt improves is. discussion: ir is the common pathogenetic factor for risk components summarized as "metabolic syndrome": dyslipidemia, hypertension, hyperandrogenism and obesity. the vicious circle is intensified with the degree of ir. during the to -year interval between the onset of ir and the manifestation of dm, significant micro-and macroangiopathies can develop. early detection of ir is therefore crucial for the prevention of dm and cvd. the costs involved for diagnosis are minimal ( - €) compared to the cost of treatment for dm and cvd. the effect of dietary feeding of "superjami" on the glucose metabolism and antioxidative status in mice under high fat diet conditions was investigated. the mice were randomly divided and given experimental diets for weeks: normal control (nc group), high fat (hf group), and high fat supplemented with heukjinju (hf + hj group), suwon (hf + sw group) and superjami (hf + sj group). at the end of the experimental period, the hf group exhibited markedly higher blood glucose level. however, diet supplementation of superjami was found to counteract the high fatinduced hyperglycemia and oxidative stress via regulation of antioxidant and hepatic glucose-regulating enzyme activities. these findings illustrate that superjami was similarly effective in improving the glucose metabolism and antioxidant defense system in high fat-fed mice and they may be beneficial as functional biomaterials in the development of therapeutic agents against high fat diet-induced hyperglycemia and oxidative stress. objective: to evaluate the effectiveness of two types of intervention: personal and group therapy in preventing or delaying diabetes. methods: two hundred and twenty-two pre diabetes adults were assigned to both interventions, which included physicians, dietitians, social workers and physical activity consultants, to modify patients' lifestyle and reduce weight. glucose, total cholesterol, ldl, hdl; tryglesirides and bmi were measured before (t ), immediately after (t ) and post months (t ) of the intervention. mix linear; logistic regression and cox models were employed. results: mean age was . and . (p = . ) for the personal and group therapy, respectively. no significant differences in time trends for all the clinical measurements between the groups were observed. however, (i) reduction (À . p < . ) in glucose for the personal therapy group between t and t ; (ii) reduction in total cholesterol (À . p = . ; À . p < . ) in personal and group therapy, respectively, between t and t ; (iii) significant hdl increase in both groups between t , t and t ; and (iv) significant decline in ldl, triglycerides and bmi between t t and t . . % and . % of the group and personal therapy, respectively (p = . ), developed type diabetes during the study period. no differences to time to onset of the disease between the two groups. conclusion: for patients with pre diabetes, both types of intervention were effective in delaying and preventing the disease. group therapy is recommended since it requires fewer resources and can be implemented for the benefit larger population. methods: the present population-based case-control study was performed in shiraz, southern iran, over a -month period from december to , on a randomly selected study population group consisting of inhabitants of the metropolis of shiraz in southern iran. all the patients underwent anthropometric and blood pressure measurements as well as thorough medical history and physical examinations. laboratory parameters including fasting blood glucose, lipid profiles, liver enzymes and ferritin, in addition to liver ultrasonography and cimt, were performed for all subjects. the cutoff value for the cimt was set at . mm and the measured values were correlated with other risk factors. we evaluated patients with nafld and the same number of controls. subjects with nafld had a significantly higher prevalence of increased cimt (or: . , p < . ). in patients with nafld the age of years represented an appropriate cut-off value for predicting increased cimt. a systolic blood pressure (sbp) of mmhg and a diastolic blood pressure (dbp) of mmhg were shown to be appropriate cut-off values for predicting increased cimt. conclusion: cardiovascular risk factors such as increased intimamedia thickness (imt) occur more frequently among nafld patients when compared to healthy individuals. we recommend a careful evaluation of not only the liver, but also of the cardiovascular system in these patients, in order to prevent later morbidity related to atherosclerosis. mitochondrial capacity of oxidizing fatty acids and increased mitochondrial ros production. the peroxisomal β-oxidation, which starts the oxidation of the long-chain fatty acid and contributes with approximately % of all oxygen peroxide produced in the cell, was increased in ovx mice. these effects could lead to oxidative damage, a condition that was, in fact, evidenced by the reduced levels of reduced glutathione and elevated levels of tbars found in livers of ovx mice. the decreased mitochondrial capacity of oxidizing fatty acids could contribute, at least in part to development of hs in ovx mice. besides, the higher mitochondrial and peroxisomal ros generation resulted in oxidative damage in livers from ovx mice. background: elevations in high-sensitivity c-reactive protein (hs-crp) are associated with an increased risk of insulin resistance (ir). investigation of relationship between hs-crp, parameters of glucose metabolism and leptin in patients with t dm and igt could be help to assess the role of hs-crp in development of ir. aim: of the study was investigation of relationship between hs-crp and hepatic glucose production (hgp), leptin and hba c in women with t dm and igt. materials and methods: forty-eight women with igm ( newly diagnosed t d and igt were observed). hs-crp and leptin were assessed in fasting states. intravenous glucose tolerance test was performed ( . г glucose on kg of body mass). mathematical analysis of results with definition of hgp (the h-index, mmol/l) was done with the special program (accessible in internet: www.diabet.ru/ivgtt). results: bmi was significantly correlated with hs-crp, r = . , p < . and the level of hs-crp in women with bmi > kg/m was almost four times greater compare to hs-crp in women with bmi > kg/m [ . ( . - . ) and . ( . - . ) accordingly, (p < . )]. between hs-crp and hgp and between hs-crp and leptin direct correlation (r = . , p < . ) and (r = . , p < . , accordingly) was revealed. correlation between hs-crp and hba c wasn't found. conclusions: association between hs-crp and leptin level, hs-crp and hgp could be demonstrate the role of hs-crp in development of insulin resistance. institute for sport and physical activity research (ispar), university of bedfordshire, bedford, uk objective: hypertriglyceridemic waist (hw) and waist-to-height ratio (whtr) are simple clinical tools that identify adults at risk of cardiometabolic disorders and cardiovascular disease. whether this applies in youth is under-researched and this study therefore investigated whether the hw phenotype and whtr are associated with cardiometabolic disorders in children and adolescents. methodology: this was a cross-sectional design study. anthropometry, biochemical variables, and cardiorespiratory fitness were assessed in participants ( girls) aged - years from bedfordshire, united kingdom. the hw phenotype was defined as a waist circumference ! th percentile for age and sex, and triglyceride concentrations ! . mmol/l, and a high whtr defined as > . . ancova and logistic regression were used in the analysis. results: in participants with the hw phenotype, clustered risk score was lower (p < . ), the odds of having high cardiorespiratory fitness (ml/kg/min) lower ( . ; % ci . , . ), and the odds of having low hdl-cholesterol ( . ; . , . ), impaired fasting glucose ( . ; . , . ), and ! ( . ; . , . ) and ! risk factors ( . ; . , . ) higher than those without the phenotype. those with a high whtr had lower clustered risk (p < . ), higher odds of having low hdl-cholesterol ( . ; . , . ), high diastolic blood pressure ( . ; . , . ) , and ! risk factors ( . ; . , . ) than those with normal whtr. conclusion: the hw phenotype may be a better simple marker than whtr for identifying children and adolescents at risk for cardiometabolic disorders. treatment with ace inhibitors (acei) and at receptor blockers (arbs) has been shown to reduce the number of new-onset dm , improve insulin sensitivity and reduce adipocyte size , . we investigated additional metabolic effect of renin-angiotensin system (ras) blockade with arb in comparison with acei. specifically we studied the effect of candesartan cilexetil therapy on glucose metabolism and parameters of subcutaneous adipose tissue (sat) in hypertensive subjects. antihypertensive treatment with acei was replaced by candesartan for months in subjects with essential hypertension. experimental procedures involved measurements of anthropometric data, blood pressure, oral glucose tolerance test, ras components and adipokines gene expression in sat obtained by biopsy. intersticial fluid from sat was collected by using microdialysis. six months after replacement acei by candesartan, the systolic blood pressure decreased by . ae . mmhg (p < . ), diastolic blood pressure decreased by . ae . mmhg (p < . ) and fasting plasma glucose decreased by . ae . mmol/l (p < . ). insulin sensitivity index (matsuda) tended to increase (p = . ). among the adipokine and ras genes studied in sat only pparc expression tended to increase (p = . ) after candesartan treatment. as expected, candesartan had blood pressure lowering effects comparable to those of acei. seeing that candesartan reduced fasting glycemia and strongly tended to increase pparc expression in sat, we speculate that arbs treatment might have additional positive effect on glucose metabolism compared to acei. the study is continuing and samples of serum and microdialysate are currently under analysis of ras peptide content. purpose: diastolic dysfunction in the metabolic syndrome/type diabetes (d) is an epidemic without evidence-based treatment strategies. studies on dietary interventions are scarce. we tested the hypothesis, that a low-carbohydrate diet (lc) improves cardiac function in overweight-obese d more than the traditionally recommended low-fat diet (lf). methods: two groups of d without cardiac disease (bmi ae kg/m ) were studied in a parallel and partial cross-over design during a -week rehabilitation program with either lc or lf. the group on lf (carbohydrate %, fat %, protein %) had subsequent weeks on lc ( %, %, %, respectively). cardiac function was assessed as myocardial velocity during systole and diastole (e′) and metabolic control before and h after (pp) a standardized breakfast ( kcal). both groups had supervised aerobic training h a day. results: in the parallel groups, both diets induced similar and significant reductions of weight, hba c and cholesterol. lc considerably improved insulin resistance, triglycerides, systolic and diastolic blood pressure and e′ ( . ae . - . ae . cm/s, p = . ), but lf did not whereas all these variables improved significantly after subsequent lc (e′ from . ae . to . ae . cm/s, p = . ). intact proinsulin was unchanged with lf but decreased with subsequent lc fasting and pp (p = . and . ). conclusions: these data indicate, that a lc but not lf nutrition modulates diastolic dysfunction in overweight diabetics, improves insulin resistance and may prevent or delay the onset of diabetic cardiomyopathy and the metabolic syndrome. methods: we studied adolescents, males (n = ) and females (n = ), who were collected waist circumference, office bp, serum glucose and lipids. they underwent a -h abp monitoring (abpm) to record -hs, awake and sleep bp, and the bpv was calculated as the standard deviation bp. the ms was defined according to the national cholesterol education program, adult treatment panel iii modified for adolescents. statistical analysis: the variance ratio test (f-test) was applied to compare the bpv between adolescents with ms and those without ms. results: the ms prevalence was . % (n = ) in all, . % (n = ) in males and . % (n = ) in females (p < . ). the abp values (systolic/diastolic) were the following: / , / and / mmhg in adolescents with ms; and / , / and / mmhg in adolescents without ms, for -hs, awake and sleep periods, respectively. the highest statistically significant values in systolic and diastolic abp during -hs and awake and systolic abp in sleep were showed by ms group. likewise, adolescents with ms showed significant higher -hs systolic bpv than those without ms ( . vs. . mmhg, p < . ). the ms has important effects on the abp values in adolescents. also, systolic bp variability during -hs is associated with ms. these findings suggest that ambulatory blood pressure monitoring is important in adolescents with ms to detect subjects in cardiovascular risk. montfort hospital research institute, university of ottawa, ottawa, on, canada organochlorine compounds (oc), are chemicals that were mostly used historically as pesticides, solvents, flame retardants, and other applications. oc have been recognized to be of environmental and potential toxicologic concern. due to their persistence and lipophilicity, these compounds will remain present in the environment for decades and accumulate in living organisms. the presence of oc is a major concern since they could act as endocrine disruptors and have recently been associated with the development of hepatic steatosis and lipotoxicity. the objective of this project is to define intra-hepatic molecular mechanisms implicated in the development of hepatic steatosis and lipotoxicity in oc exposed hepatocytes and rats. results: lipid quantification was assessed in human hepatocytes using steatosis colorimetric assay (cayman chemical company). lipid accumulation was higher in hepatocytes exposed to pcb [ . lmol/l] for h compared to chloroquine ( %), a potential lipid droplet infiltration inducer, as well as our control group treated with dmso ( %). conclusion: understanding the emerging role of oc in the physiology of hepatic steatosis and lipotoxicity is of great importance as it is becoming clear that chronic lipotoxicity is strongly related to the suppression of insulin receptor signaling in the liver and activation of the apoptotic pathway. these results only represent the necessary first step on oc and their impact on the liver metabolic activity. experiments in oc-contaminated rats are presently undertaken, as well as protein quantification involved in intra-hepatic mechanisms in cells. nutrition, nutrition research institute, the university of north carolina at chapel hill, kannapolis, nc, usa insulin a precursor of t dm, various cardiocerebrovascular disorders, non-alcoholic fatty liver, alzheimer's disease, and many other major health problems associated with excess calories. to study the mechanism of insulin resistance, we investigated the role of insulin and each category of macronutrients (glucose, fat, and amino acids) in the development of insulin resistance. our results show that glucose (hyperglycemia) does not cause insulin resistance in the absence of insulin in cultured cells or animals. dietary carbohydrate is not necessary for high fat diet (hfd) induction of insulin resistance but a small amount of it can promote insulin resistance in the maximal level in animals on hfd. our results also show that fat is necessary for the development of insulin resistance although fat can't induce insulin resistance in the absence of insulin. supplementation of amino acids such as leucine does not necessary cause insulin resistance in animals on hfd. finally, our results show that insulin can cause insulin resistance through (i) accumulation of long-chain acyl coas and cholesterol in mitochondria, (ii) inhibition of production of new mitochondria; and (iii) turnover of aged/damaged mitochondria. in summary, our results show that insulin and each category of macronutrients are necessary for the development of persistent insulin resistance. wellness institute, cleveland clinic, cleveland, oh, usa background: lifestyle factors are key in the development and progression of chronic disease. here we report outcomes for prediabetic participants in the lifestyle â program, a -month intervention for patients with chronic diseases that integrates education in cooking, nutrition, exercise, and stress management. methods: pre-post changes in biometric, laboratory, and psychosocial variables were evaluated by paired student's t-test or wilcoxon test. results: of participants who met ada criteria for prediabetes (n = ), most were female ( %) and obese ( %) and had hyperlipidemia ( %) or hypertension ( %). one fifth ( %) had depression. average age was ae years. at month , biometric, laboratory, and psychosocial data were available for ( %), ( %) and ( %) participants, respectively. average bmi decreased by % ( . ae . - . ae . ) and there were decreases in waist circumference, blood pressure, resting heart rate, fasting glucose, and hba c (p < . for all). insulin decreased from . ae . - . ae . μu/ml (À . %; p < . ). more diabetic medications were stopped or reduced in dose than were started or increased in dose (ratio . : ). average depression (ces-d ) and perceived stress (pss- ) scores decreased by % and % respectively (p < . for both). physical, mental, and perceived health (measured by veterans rand item health survey) improved from % to % (p < . ). conclusion: participation in a comprehensive lifestyle modification program of adults with prediabetes results in significant and clinically meaningful improvements in biometric, laboratory, and psychosocial outcomes. diabetes is frequently associated with both extracellular and intracellular magnesium (mg) depletion. epidemiologic studies found high prevalence of hypomagnesaemia in subjects with type diabetes, especially with poorly controlled glycemic control. erythrocyte and serum magnesium levels were measured in healthy control subjects, non-diabetic normal glucose tolerant offspring of type diabetic subjects and non-diabetic impaired glucose tolerant offspring of type diabetic subjects in addition to routine laboratory investigations, hba c, lipid profile, fasting insulin by elisa and homa-ir. our study showed that fasting, h postprandial plasma glucose, serum insulin level, hba c, homa-ir index, serum ldl-c, serum triglycerides, serum cholesterol and serum malondialdehyde levels were higher and serum hdl-c and both serum and erythrocyte magnesium levels were lower in impaired glucose tolerant offspring of type diabetes as compared to each of normal glucose tolerant group and control group, while there was no significant difference in those parameters between normal glucose tolerant and control groups. we can conclude that the magnesium depletion and the increase in malondialdehyde level in non diabetic impaired glucose tolerant offspring of type dm were associated with increasing severity of insulin resistance and dyslipidemia and, this may increase the risk of development of type diabetes complications in there offspring. possily use of mg suplemenaion in those subject may delay and prevent the development of type diabetes. obstetrics and gynaecologist, catholic university of sacred heart, rome, italy background and aims: gdm, overweight and gestational weight gain (gwg) are important determinants for an adverse pregnancy outcome and particularly for having large for gestational age (lga) newborn. the aim of this study was to evaluate the pregnancy outcome among women affected by a gdm, belonging four different classes of pre-pregnant bmi and to investigate the specific role of the anthropometric parameters and therapeutic regimen on the foetal growth. material and methods: this was a prospective study including pregnancies affected by gdm. only women with a mean pre-prandial glucose level < mg/dl and h post-prandial values < mg/dl were enrolled. we considered other variables such as gwg, excessive gwg (egwg), therapeutic regimen used and maternal age to investigate their role in foetal growth. results: at the linear univariate analysis, a dependence of neonatal birth weight from pre-pregnant bmi class, egwg, gwg and gestational week at delivery was found (p < . ). the dependence from the pre-pregnant bmi (p = . ) and the egwg (p = . ) was confirmed even when the percentile was considered. at the multivariate analysis the birth percentile resulted associated both with the prepregnant bmi (p < . ) and the gwg (p = . ). conclusions: pre-gestational bmi, gwg and egwg are important parameters involved in fetal growth. their control during pregnancy could be an important way to improve pregnancy outcome even in women with gdm. obstetrics and gynaecologist, internal medicine, catholic university of sacred heart, rome, italy background and aim: continuous subcutaneous insulin infusion (csii) may be an alternative treatment to multiple daily injections (mdi) in pregnant subjects with type diabetes(¹). the aim of this study was to compare metabolic control and obstetric outcome of these pregnancies treated with csii vs. pregnancies treated with different type of insulin analogs administrated by mdi. material and methods: we studied pregnancies in women, three twin pregnancies, affected by type diabetes. thirty-four pregnancies treated with csii and treated with mdi treatment were evaluated. in the group of women treated with mdi women used human analogs, used insulin aspart and used insulin lispro. metabolic control and obstetric outcome were compared between the groups. statistically significant differences were found in metabolic control in term of hba c mean level for each trimester of pregnancy. conclusion: no clear advantage of csii vs. mdi treatment is shown in our study for pregnancies complicated by type diabetes in term of metabolic control or obstetric outcome(²). however, it might be that some selected patients with unstable metabolic control or high hba c levels, who become pregnant with a better metabolic profile after csii treatment, may have a better pregnancy outcome. poblations and methods: a cross-sectional study was performed on children and adolescents ( female and male) between and years old, without cardiovascular, metabolics, oncology and immunology diseases. were excluded all subjects who took drugs with effects on glucose, insulin, lipids or weight. each subject was determined: weight, height, bmi, neck, waist, hip circumferences, adiposity, blood pressure and glucose, insulin, cholesterol, tryglicerides, c-ldl, c-hdl. was performed oral glucose tolerance test to glucose and insulin postprandial. was estimated insulin secretion and insulin sensitivity. conclusi on: neck circumference is a potential marker for to identify children and adolescents with metabolic and cardiovascular risk factors. aim: to assess the efficacy of a lifestyle modification in preventing diabetes mellitus type (dm ) among subjects with risk factors of dm including impaired glucose tolerance and impaired fasting glucose (igt/ifg), obese adults and first-degree relatives of patients with diabetes. materials and methods: the study included patients ( m, f) - years old at risk factors of dm . all patients received recommendation on a balanced diet and physical activity. we measured fasting plasma glucose (fpg), -h plasma glucose concentrations. fasting serum insulin (fi) levels were detected by sensitive elisa. index homa-r were used as the index of insulin resistance. results: in weeks our study patients carried out this recommendations (research group) and patients did not it (control group). patients of the research group demonstrated mean reduction of weight (À . kg), bmi (À . kg/m ) and whr (À . ) (p < . ) and persons of the control group had significant increase these parameters (p < . ). among subjects with igt, glucose levels normalized in % of patients from the research group and . % in control group (p < . ). fi and homa-r in research group decreased from . ae . to . ae . lu/ml and from . ae . to . ae . accordingly (p < . ). in control group the specified parameters had increased significantly (p < . ). the risk reduction of development dm among patients of the research group was . % comparer the control group. conclusion: thereby, lifestyle modifications are effective in preventing dm development in individuals at risk living in belarus. objectives: it is suggested that the kind and frequency of snacks as well as dairy consumption can influence body weight and composition. as the number of students are increasing rapidly in iran and regarding their unhealthy food habits, we decided to carry out this study. methods: one hundred and twelve female students who were selected from university dormitories inhabitants randomly, participated in this cross-sectional study. weight, height and waist circumference (wc) of the participants were measured. demographic and food frequency questionnaires were filled face to face. data were analyzed using spss # . the results showed that . % of participants were under weight, % normal and . % overweight. besides, . % and . % had normal and above normal wc respectively. sixty-one percent of female students had just one snack. fruits ( %) and confectionaries ( %) were the most popular snacks. mean ae sd of the dairy consumption was . ae . serving per day. there were no correlations between bmi and wc and snacking pattern or dairy intake. conclusion: it is assumed that as most of our subjects had normal weight and wc, we did not find any correlation between bmi and wc and snacking pattern or dairy intake. conducting similar studies, using both overweight and normal weight subjects is suggested. obstetrics and gynaecologist, catholic university of sacred heart, rome, italy background and aims: the management of pregnancies complicated by t dm has changed with the introduction of new short acting insulin analogs. the aim of this study was to have a comparison of obstetric outcome among the different insulin regimens. methods: one hundred and sixty singleton pregnancies were assessed. seventy-four women were treated with human analogs, with insulin aspart and with insulin lispro. results: no significative differences were found in term of incidence of pre-eclampsia, iugr, large for gestational age newborn, cesarian sections, preterm delivery, apgar score < , mean week at delivery, mean birth percentile. a significative difference was found in term of incidence of newborn infants with a birth weight ! g ( . % in the human analogs group, . % in the aspart group t and . % in the lispro group; p = . ); a trend (p = . ) was observed comparing the mean birth weight among the groups ( . ae . g in human analogs group, . ae . g in aspart group and . ae . g in lispro group). no significative differences were found in term of hba c mean levels for each trimester of pregnancy. conclusions: the use of insulin aspart is correlate with a lower incidence of fetal macrosomia and with a lower mean birth weight. in vitro observations highlighted that lispro and aspart have a similar affinity for insulin receptor; regarding the affinity for igf- receptor lispro is . fold more potent than human insulin in binding igf- receptor. further investigations are necessary to explain the correlation between insulin affinity for igf- receptor and fetal growth. methods: this study was performed on women diagnosed with gdm (gestational dm) - months after delivery. the jewish and bedouin women were divided into, intervention and control groups. the intervention group was instructed in healthy lifestyle habits every several months by a dietician and sports instructor. the control group was informed of the potential risks for diabetes following gdm and advised to improve lifestyle. all women had fasting insulin, glucose and lipid level tests - months post partum. height, weight, bmi, blood pressure, waist circumference were measured. food frequency and exercise questionnaires were filled. the same tests were repeated at and years follow up. results: the prevalence of gdm was . % in jewish and . % in bedouin women. lack of pregnancy care was greater among the bedouin. all the metabolic tests post gdm period improved in the intervention group in both ethnicities compared to control. there was a decrease in insulin, glucose, ldl, triglycerides and homa-ir (homeostasis model assessment) values and an increase in hdl. a significant decrease in carbohydrate consumption, calorie consumption, fat consumption and increase in protein consumption was observed and an increase in physical activity. the intervention program significantly improved the metabolic indices measured in both jewish and bedouin populations. the results underscore the need to provide lifestyle optimization guidance to women with gdm in order to reduce the risk of type diabetes. introduction: fatty liver is strongly associated with type diabetes. however, it is unclear whether hepatic triglyceride accumulation causes diabetes, or merely is a consequence of excess adipose tissue, that is related to insulin resistance. we aimed to investigate the association between hepatic triglyceride content (htgc) and insulin resistance, and whether this association could be explained by measures of adiposity. methods: in this cross-sectional analysis of the netherlands epidemiology of obesity (neo) study, fasting glucose and insulin concentrations were measured. abdominal fat depots were measured using mri, htgc using mrs. we performed linear regression analysis of htgc with the updated homeostasis model assessment (homa -ir), adjusting for age, sex, ethnicity, education, smoking, alcohol consumption, visceral adipose tissue (vat) and total body fat (tbf). results: after exclusion of participants with missing data (n = ) or known diabetes (n = ), alchohol consumption > glasses/day (n = ), participants were included with a median (iqr) age of ( . ) years, mean fasting glucose: . ae . mmol/l, % men. per sd htgc ( . %), the homa -ir increased with % ( % ci: %, %), this attenuated to % ( % ci: %, %) after adjustment for vat and to % ( % ci: %, %) after additional adjustment for tbf. per sd vat ( . dm ) the homa -ir increased with % ( % ci: %, %), this attenuated to % ( % ci: %, %) after adjustment for htgc and to % ( % ci: %, %) after additional adjustment for tbf. the association between hepatic fat and insulin resistance was for a large part explained by vat. vat may be most important in the etiology of insulin resistance. the aim was to carry out complex estimation of mutual relations between the proinflammatory condition and basic components of the metabolic syndrome (ms) in patients with ischemic heart disease hospitalized for coronary artery bypass grafting. forty-three patients were examined by standard methods and were divided into three groups depending on presence of separate ms components: st group with abdominal obesity (ao), arterial hypertension (ah), type ii diabetes, dyslipidemia; nd group with ao, ah, hyperglycemia; rd group with ao, ah, dyslipidemia. indicators of chronic subclinical inflammation have been revealed before operation in all groups of patients. the strongest ones have appeared in the nd group of patients. hyperuricemy was more frequently registered in patients of the rd group ( . %). the correlation analysis revealed authentic interrelations of uric acid level with lipid profile and inflammation markers. a strong inverse relation with triglycerides, a strong direct relation with low density lipoprotein cholesterol and inverse one with total amount of leukocytes were revealed in the st group. the strong direct relations with segmented neutrophils and the inverse ones with lymphocytes were registered in the nd and rd groups. the average direct correlation with crp was revealed in the rd group. activation of inflammatory process was noted in patients of all groups after operation, and it was already of acute nature in the rd group that allows attributing it to a risk group. the study of expressiveness of inflammatory reaction depending on presence of the ms components allows revealing risk groups among patients. introduction: the soft drink intake has increased worldwide and its high consumption is associated with the development of metabolic syndrome. objective: to estimate the association between the consumption of sugar-sweetened beverages (ssb) and the burden metabolic syndrome diseases (bmsd). a cross-sectional telephone survey was conducted with adults ( . % men and . % women, mean age . years) in the urban area of belo horizonte, brazil. data from the telephone-base brazilian surveillance system for chronic diseases was used (vigitel - / ). burden metabolic syndrome diseases were defined as the self-reported of at least two of the following factors: diabetes, dyslipidemia, hypertension and obesity. the intake of ! days/week soft drinks and artificial juices was assessed. sociodemographic, selfreported health status and lifestyle habits were also used. odds ratios (or) and % confidence intervals were estimated by multivariate logistic regression. results: in this sample, . % of participants consumed ! days/ week sugar-sweetened beverages (ssb). the prevalence of bmsd in the sample was . %. the prevalence of bmsd in people who consumed ssb ( ! days/week) was lower than people didn't consume the beverages (or: . ; % ci: . - . ) five or more days per week. the final model was also adjusted for physical activity, education, marital status, poor self-reported health and poor consumption of fruits and vegetables. obesity is an heterogeneous condition due to fat distribution and storage. the aim of our study was to compare the predicting role of homa index and of bmi on early vascular impairment in morbidly obese subjects (bmi . ae kg/m ) before and after sleeve gastrectomy (sg). glycemia, insulinemia, lipids, flow mediated dilatation (fmd), carotid intima media thickness (imt) and visceral fat area (vfa) by ultrasound were performed in all subjects. patients were divided on the basis of homa-ir median values: ! . group , < . group . group had significantly higher values of bmi (p < . ), waist circumference (p < . ), vfa (p < . ), triglycerides (p < . ), glycemia (p < . ), and lower hdl-c (p < . ) than group ; fmd was significantly lower (p < . ) and imt significantly higher (p < . ) than in the group . the same population divided on bmi median values did not show any difference in lipids, imt and fmd. at stepwise regression analysis vfa was the independent predictor of reduced fmd (β À . , p . ). homa-ir (beta . p < . ) was the independent predictor of imt (beta . , p = . ). in patients, re-evaluated months after sg, bmi, vfa and homa were significantly reduced (p < . ); fmd significantly increased only in the subgroup with homa-ir pre intervention ! . (p . ). bmi, index of overall adiposity, seems less useful in the prediction of early atherosclerosis in morbidly obese; homa-ir, strictly related to visceral fat, is expression of metabolic impairment thus able to predict early vascular damaging. methods: swiss albino mice were given a high fat diet containing lard (h) ( . % wt/wt), supplemented with as or f and in combination alongwith h (f + as + h) for weeks. the control mice (c) were fed with normal diet. after the treatment period the physical, physiological and cellular parameters were evaluated by body weight, liver weight, biochemical estimation, western blot, pcr or ihc. results: the h mice exhibited increased body and liver weight; treatment with f or as and (f + as + h) in the diet significantly counteracted the hfd induced body and liver weight gain, hyperlipidemia; hepatic lipid profile; level of ros; hyperglycemia; hyperinsulinemia; tnf-a, il- level; nuclear translocation of nf-jb; lipid peroxidation. activities of antioxidant enzymes (sod, cat, gsh, frap) were up regulated significantly in f or as and (f + as + h) mice. therefore simultaneous treatment with as or f and their combination protected against hfd induced weight gain and oxidative stress. conclusion: this novel approach of combinatorial preventive medicine is validated not only with the parameters of metabolic syndromes yet it is evidenced with oxidative stress and crucial molecular targets. this study illustrates for the first time that as and f has relatively similar hypolipidemic, antioxidative, anti inflammatory actions and the as + f combination along with hfd has shown prominent preventive effects as compared to other treated groups. s. sivapraksh , i. shabir , n. gupta , j. john , a. ammini aiims, department of endocrinology, aiims, new delhi, india background: insulin resistance/hyperinsulinemia is associated with a variety of reproductive endocrine dysfunction in girls. however, there is a scarcity data regarding hypothalamic pituitary testicular axis functioning among boys with hyper insulinemia. aim: aim of this study was to assess effect of hyper insulinemia on pubertal development in boys. subjects and methods: children of subjects with type diabetes mellitus (t dm) were invited to participate in this study. children and adolescent with any chronic medical condition were excluded. detailed medical history, physical examination including anthropometry, haemogram, liver, renal functions, oral glucose tolerance test (ogtt), insulin, lh, fsh, prolactin and testosterone were done for all subjects. results: seventy-four boys, - years of age participated in this study. results are given in table . thirty boys (all except were overweight) had gynaecomastia. objectives: to find out the prevalence and factors associated with dyslipidemia among adults aged years and above in a resettlement colony located in central delhi. a cross sectional study, that included a random sample of adults, was designed. a study tool based on the world health organisation (who) stepwise approach to surveillance of noncommunicable diseases and their risk factors (steps) questionnaire was used. fasting venous blood sample was collected. criteria based on the third report of the national cholesterol education program expert panel on detection, evaluation and treatment of high blood cholesterol in adults (ncep atp iii), were used to define the cut offs for dyslipidemia. data was analysed using the statistical package for social sciences (spss) version . results: out of a total of study subjects, % had raised cholesterol levels ( ! mg%). thirty-eight percent had raised low density lipoprotein (ldl) levels ( ! mg%), % had raised triglyceride levels (triglycerides ! mg%) and % had low high density lipoprotein (hdl) levels (< mg%). age, hypertension, alcohol consumption and abdominal obesity were found to be associated with increased odds of dyslipidaemia, using the logistic regression model. aim: in the present study we explored whether oral consumption of the probiotic lactobacillus casei shirota bacteria in form of the yakult probiotic drink has any effects on energy metabolism in patients with impaired metabolic functions. a cross-over-study with daily intake of one portion yakult light during weeks was carried out in patients with impaired glucose regulation or metabolic syndrome. fasting blood samples were collected, anthropometric parameters were measured and a frequently sampled oral glucose tolerance test was performed at time points (week , and ). effects on the human gut bacterial communities were studied via t-rflp fingerprinting of s rrna genes amplified from microbial dna preparations from fecal samples. our results reveal a significant increase of total cholesterol (mean increase: . mg/dl; p = . ), triglycerides (mean increase: . mg/dl; p = . ) and a significant decrease of hdl-cholesterol (mean decrease: . mg/dl; p = . ) after weeks of daily intake of yakult. no significant influence of yakult light consumption on indices of insulin sensitivity, hba c and ldl-cholesterol could be demonstrated. a small decrease of fasting glucose levels after yakult consumption was revealed (mean decrease: . mg/dl; p = . ). no consistent changes in the community profiles of the gut microbiota were observed following weeks of yakult light consumption. in mexico, breakfast is one of the most important meals during the day, but changes in food consumption habits, also known as nutritional transition have been associated with a poor food quality intake. scholars, during the recess use to buy some food in internal shops of schools and this food are not generally the healthiest. the aim of this study was to evaluate the quality of the food consumed during the recces by scholars in tepic nayarit, mexico. scholars ( , about - years) from different public schools were evaluated by means of food register questionnaires during days, there has determined the ingestion of nutrients and nourishment healthy index (ias) using the nutrition program dial. anthropometric data were measured for weight and height, and body mass index (bmi) was calculated. the bmi showed that . % of children have low weight for height, . % have normal weight and . % overweight/obesity. twenty percent of scholars declared that they did not take breakfast until the hour of recess. energy intake during recess was on average % of the daily requirement. the foods most frequently consumed were sweetened beverages ( ml) containing g of simple sugars, fried-wheat snacks ( g/ g fat), candies ( g/simple sugars) and some fruit such as mango, apple or watermelon ( g/portion) with chilli. these combinations of foods are risk factors to the development of diabetes in scholars were the prevalence of overweight/obesity is in high levels. introduction: incidence of type , and gestational diabetes mellitus (gdm) are increasing worldwide. given that women with previous gdm have a higher risk of diabetes development later in life compared to women with a physiological pregnancy, the aims of our study were (i) to ascertain a frequency of early postpartum conversion of gdm into permanent diabetes or persistent impaired glucose tolerance and (ii) to find an eventual significant predictive factors from those routinely measured during the gdm follow up. methods: we carried out a retrospective epidemiological analysis of anamnestic, anthropometric, biochemical and clinical data of female patients (n = ) from faculty hospital brno with gdm diagnosis during the - period that underwent repeated ogtt up to year after the delivery. results: any degree of impairment of glucose tolerance postpartum was detected in . % subjects, of those . % had manifest dm ( . % t dm and . % t dm). glycaemia in all three time-points of baseline ogtt, area under the curve (auc ogtt ) and baseline hba c were significantly associated (p < . , mann-whitney) with the postpartum disorder. using regression analysis predictive risk model was developed using these baseline parameters. conclusions: parameters of glucose metabolism measured during - th week of pregnancy fulfilling criteria of gdm diagnosis exhibited highly statistically significant differences between women with and without persistent postpartum glucose metabolism abnormality and conferred significant predictive potential. considering generally lowcompliance of gdm women any more specific assessment of future risk stratifying gdm population could enable more effective screening of postpartum glucose metabolism disorder. institute of molecular biomedicine, comenius university medical faculty, department of health, bratislava self-governing region, regional public health office, bratislava, slovak republic background and aims: in the adults, microalbuminuria is considered as biomarker of present/future cardiovascular and/or renal disease. the roots of these diseases extend back into childhood/adolescence. data on prevalence of microalbuminuria, renal excretion of albumin (albumin/creatinine ratio, acr) and its relationship to obesity and blood pressure in apparently healthy adolescents are scares. methods and results: fourteen to -years-old apparently healthy students of secondary schools in bratislava district were enrolled (n = , boys: %). acr was determined in a spot urine sample. in underaged subjects overweight/obesity was classified according to age-and sex-based slovak population tables from . blood pressure values were recorded. acr (iqr: . - . mg albumin/ mmol creatinine vs. . - . mg albumin/mmol creatinine, p < . ), and the prevalence of microalbuminuria ( . % vs. . %, chi-square: p = . ) were higher in girls than in boys. prevalence of overweight ( . % vs. . %) and obesity ( . % vs. . %), as well as blood pressure values in pre-hypertensive ( . % vs. . %) and hypertensive ( . % vs. . %) ranges were higher in boys if compared with girls. in underweight subjects, particularly boys, acr was significantly higher if compared with the overweight/obese subjects. acr correlated inversely with the markers of peripheral and central obesity. conclusions: our data suggest the need of specific interpretation of data on acr in the adolescents, and the need of further analysis of this (in the adults risk) marker in population of adolescents with regard to other important determinants of acr, such as insulin sensitivity and other metabolic syndrome risk factors. inclusions criteria were bmi between and kg/m , morbidities as diabetes type more than years in oral treatment and without control, hypertension in oral treatment too, moderate or severe liver steatoses diseases and lipid diseases. results: all patients in a both of groups (laparoscopic and robot approach) had a effective loss of weight, with mean about - kg ( - %) after year period. one case of robot approach presented a staple line bleeding at first postoperative day, without transfusion. morbidity rate after rasg was %, but no gastrointestinal leaks occurs. conclusions: rasg can be a safely and feasible tool to the surgical treatment of obese patients and co-morbidities, with good results and satisfactory outcomes. results: patients were nine males and six females with mean age of years (range - ). seven patients were under insulin treatment and with oral medications only. glycemia at months post-surgery ( . ae . mg/dl; n = ) was significantly reduced (p = . ) compared to time ( . ae . mg/dl). the same occurred with hba c at months ( . ae . %; n = ) compared to time ( . ae . %) (p = . ). bmi was also reduced at month ( . ae . ; n = ) compared to time ( . ae . ) and months ( . ae . ; n = ) compared to time ( . ae . ) (p = . ). only one patient remained under insulin after surgery. the procedure was considered safe and significantly improved metabolic control of non-obese t dm patients, although moderate weight loss was also observed. recent studies have shown that the practice of a proper diet provides health benefits. also, it has been observed that the body weight gain is associated with consumption of unbalanced diets. the objective of this study was to evaluate the quality of the diet in adult residents of tehcnological institute of tepic and establish differences for normal weight (nw) and overweight/obesity (ow/ob). forty two adults > years were evaluated, they were taken anthropometric data for weight, height and body mass index (bmi, kg/m ) was calculated. for the diagnosis of nw and ow/ob, were taken established by world health organization (who). it was used a -day dietary record, for diet analysis was used dial software, which contains tables of food composition mexicans. dietary data were adjusted for the degree of discrepancy between energetic intake and energy expenditure obtained estimate. for statistical analysis was used the program rsigma babel and statistical differences were established < . . the caloric profile was unbalanced in % of the study population: a high consumption of fat in detriment of carbohydrates. the difference between groups were not significant (p > . ) in the caloric profile, but nor in lipidic profile. the analysis of the discrepancy intake/energy expenditure describes a probable undervaluing of the diet in both groups, but higher in adults with ow/ob compared to nw ( patients with long standing diabetes had a higher leptin, hsp , hba c and triglyceride than controls. serum leptin levels were significantly lower in patients with newly diagnosed diabetes. women with type diabetes had a higher leptin levels compared to men, both before and after treatment. we showed a positive correlation between leptin-hsp in women with type diabetes. the correlation was highest in women with newly diagnosed diabetes (r = . ) and was attenuated in women who were on treatment (r = . ). the significance of this correlation was only observed in women with type diabetes. there was no correlation between leptin and hsp in men. the positive correlation between leptin and hsp is observed in chronic inflammation such as type diabetes. it could be hypothesized that the observed correlation between serum hsp and leptin imply a higher state of chronic inflammation. materials and methods: carotid atherosclerosis (measurement of intiamedia thickness -imt) and the presence of steatosis were assesed using ultrasonography in subjects ( . % men and . % women, mean age . ae . years), selected from a rural population (were excluded those with known liver disease and those with alcohol consumption > g/day). results: . % of subjects had different degrees of steatosis: . % mild, . % moderate, . % severe. the metabolic syndrome and all its individual traits, were significantly more frequent in nafld patients, especially in those with severe steatosis (p < . ). the mean value for imt was . ae . mm, increasing in parallel with the severity of steatosis. also, subjects with ms had significantly higher imt values than those without ms (p < . ). in the group without ms, imt mean was significantly higher in patients with steatosis than in those without steatosis (p = . ), and in patients with moderate/severe steatosis than in those with mild steatosis (p = . ). by multiple regression analysis, larger waist circumferince (r = . ), increasing alcohol consumption (r = . ) and the presence of steatosis (r = . ), were significant predicting factors for increased imt. conclusions: these data confirm the hypothesis that the presence of steatosis, independently of the ms, is associated with a significant risk for development of atherosclerosis and its detection should be an alert for the existence of an increased cardiovascular risk. the prevalence of the metabolic syndrome (ms), a cluster of central obesity, hyper/dyslipidemia, hyperglycemia, and hypertension is constantly increasing worldwide. although, the exact mechanisms underlying the development of the ms are not completely understood, modern lifestyle of physical inactivity and unhealthy nutrition, obesity, and their interaction with genetic factors are considered largely responsible. this study was carried out to identify the association between physical inactivity and burden metabolic syndrome diseases (bmsd) in an urban brazilian population. a cross-sectional telephone survey was conducted with adults ( . % men and . % women, mean age . years) in the urban area of belo horizonte, brazil. data from the telephone-base brazilian surveillance system for chronic diseases (vigitel - / ) was used. burden metabolic syndrome diseases (bmsd) was defined as the self-reported of at least two of the following factors: diabetes, dyslipidemia, hypertension and obesity. physical activity (pa) indicators were evaluated in free time (leisure), work, home and transportation domains. sociodemographic, health status and lifestyle habits were also used. odds ratios (or) and % confidence intervals were estimated by multivariate logistic regression. in this sample, . % of participants were physically inactive in all domains and the prevalence of bmsd in the sample was . %. physical inactivity was independently associated with bmsd (or = . ; %ci: . - . ), adjusted to age, schooling, poor selfreported health and gender. in this sample, bmsd is a significant public health problem. the evidence from this study shows that physical inactivity was independently associated with proxy of metabolic syndrome. aim: to assess the prevalence of insulin resistance (ir) and glucose homeostasis alterations (gha) in overweight and obese children and the risk factors for ir and gha. method: we collected data from subjects: girls and boys aged . - . years (median: . ). gha was measured by fasting glucose. glucose ! mg/dl was treated as high normal fasting plasma glucose (hnfpg). ir was estimated by homeostasis model assessment (homa-ir), quantitative insulin sensitivity check index (quicki) and fasting glucose/insulin ratio (fgir). we adopted the following cut-off points for diagnosing ir: homa-ir ! . , quicki . and fgir . . results: table . fasting glucose, insulin and ir-indexes. in obese children we observed a significant (p < . ) positive correlation between homa-ir and age (r = . ), bmi (r = . ), fasting insulin (r = . ), triglycerides (r = . ), crp (r = . ) and a negative correlation with birth weight (r = À . ) and hdl the results provide evidence for an association between pd and sm in the adolescent population, which would mean that depression may influence ms in this group that is more vulnerable to pd due to hard changes typical of their life stage. the aim of this study was to evaluate the electrical activity of the pelvic floor muscles (pfm) in women with polycystic ovary syndrome (pcos) diagnostic and insulin resistance (ir). through a crosssectional study, it was recruited women with pcos. the total pcos patients was divided into two groups according to the presence of ri (group a) and without ir (group b). the diagnosis of ri was made through fasting insulin. the muscle tone (mt) and maximal voluntary contraction (mvc) was evaluated by electrical activity, that it was measured by surface electromyography. among the pcos patents, . % had insulin resistence. there was significant difference between the tone (p = . ) and cvm (p = . ) between groups a and b. the correlation test showed a strong negative correlation between muscle tone and fasting insulin levels in group b (r = À . , p = . ). considering the results, it seems that the presence of insulin resistance may adversely affect the electrical capacity of the pelvic floor muscles. central hospital of the army, cpmc, algiers, algeria the polycystic ovary syndrom is a disorder affecting approximatively - % of reproductive age women. hyperinsulinemia and insulinore´sistance are common features of a larger number of patients affected by pcos. objective: the objective of this study was to characterized the prevalence of the insulinore´sistance in a cohort of algerian women with pcos. methods: a total of patients with evidence of pcos defined by the rotterdam consensus were recruted for a prospective study. all women had a standard oral glucose tolerance test with the mesure of glycemia, insulinemia and shbg. the prevalence of insulinore´sistance grows significantly with bmi (p = . ) but didn't change with age (p = . ). the non hyperandrogenic phenotype is less insulinoresistant ( . % vs. . %). conclusion: in our population of pcos near half of them are insulinresistant and need to be treated in order to avoid metabolic features. the aim of this study was to analyze the parameters of glycemic index (ig) in foods intended for feeding patients with impaired glucose metabolism. for this purpose, a new design selected food products, characterized by a higher nutritional value, that pass attempts technological and toxicological studies and have been classified as human food. the food consisted of inulin, buckwheat, pumpkin seeds, buckwheat hulls, the addition of mulberries, kale and beans. the products were characterized by nutritional value and composition. designed food products were the nature of small snacks, designed to supplement the basic diet and enriching it with ingredients desirable from the standpoint of prevention of civilization diseases. characterized by elevated natural origin and health-related properties. the study took part of healthy, non smokers volunteers between and years of age, with proper blood biochemical parameters. the results allow to characterize these foods as relative low glycemic index and possible to use to enrich the diet in the components with pro-health effect. for all the products the dose and single-serving size consumption was described and proposed. the possible potential changes in glucose levels after consumption were characterized. the results are the test pilot study of the project aimed to the creation of the increased food with bioactive healthy properties and are the result of the first stage of the researchclinically-nutritional studies of those products. financial supported by the ue project nr po ig . . . - / . one of the fastest growing trend in food production is designing of health promoting foods, including so-called bioactive food. only food products enriched with bioactive components of natural origin might be perceived as bioactive. it is highly possible that well established technological process of bioactive foods production leads to obtain products useful in prevention and non-pharmacological treatment of metabolic diseases. the project aims to designing these kind of prohealth food, which would simultaneously be organoleptically attractive to the consumer and be an equivalent of conventional, habitually eaten products. the important aspect of bioactive foods is their antioxidant potential, which positive impact on various diseases (obesity, diabetes mellitus and hypertension) is already well known from prior literature. in the studies the antioxidant capacity of the selected bioactive foods designed in the project was assessed. the method used for assessment of antioxidant potential was orac, as the most widely applied and the most reliable one. the analysis included products from three following groups of enriched foods: fruit and vegetable juices, bakery products and confectionery, and meat products, as well as the corresponding placebo products. most of the products enriched in bioactive components was characterized by significantly higher orac values in comparison to placebo correspondents. the results support the correctness of applied production technology and proper selection of bioactive components. based on the antioxidant potential of new products, one can decided which of them should be use for further controlled clinical trial. background: obesity in adolescent tends to persist into adulthood which associated to metabolic disease thereby increasing mortality and morbidity. objective: to investigate the association between central obesity and inflammation marker, insulin resistance and dyslipidemia in adolescent with central obesity. methods: this study was case-control study, compared central obesity adolescent and normal to hscrp, homa-ir, triglyseride, ldlcholesterol, hdl-cholesterol, and sdldl-cholesterol. results: sixty two adolescent were included, were central obesity and were normal. we found that they were with bmi > kg/m had hscrp level higher compared with non obesity, p-value < . (or: . ; % ci: . - . ) and homa ir, p-value < . (or: . ; % ci: . - . ). adolescent with wc ! cm for boys and ! cm for girls, had hscrp levels, homa-ir and hdlcholesterol higher than they were with wc < cm, p-value < . (or: . ; %ci: . - . ), p < . (or: . ; %ci: . - . ) and p-value < . (or . ; %ci: . - . ), respectively. the visceral fat was associated with hscrp levels, p < . (or: . ; %ci: . - . ), and hdl cholesterol p < . (or . ; %ci: . - . ). triglyceride and sdldlcholesterol had not significanty for bmi, wc and visceral fat, however ldl-cholesterol significantly association with visceral fat, p < . (or: . ; %ci: . - . ). conclusion: central obesity adolescents showed increased inflammatory markers and insulin resistance with consequent increased the risk of metabolic diseases so that early intervention in obese adolescents should be done. aims: consumption of high fat diet (hfd) leads to accumulation of intramuscular ceramide (cer). cer is implicated in induction of muscle insulin resistance. the initial step in the de novo cer synthesis is catalyzed by serine palmitoyltransferase (spt). the aim of the present study was to elucidate the role of hfd, myriocin (an spt inhibitor) and metformin on the content of skeletal muscle cer and key proteins implicated in lipid and glucose metabolism in hfd insulin resistant rats. the experiments were performed on male wistar rats, divided into groups: cfed standard rodent chow (control); hfdfed high fat diet; hfd/myrfed hfd and treated with myriocin; hfd/myr/metfed hfd and treated with both the myriocin and metformin. muscle cer and plasma free fatty acids (ffa) were analyzed by lc/ms/ms. content of spt, carnitine palmitoyltransferase (cpt a), fatty acid transporters (cd , fabppm) and glucotransporter (glut ) was measured by wb. results: compared to control values, plasma ffa and muscle cer content and expression of all lipid-related proteins were elevated in hfd group. myriocin decreased muscular cer but increased plasma ffa and the expression of both the spt and cpt a. introducing metformin to hfd/myr group decreased the plasma ffa and muscular cer, lowered the expression of spt, cpt a, cd and fabppm, but increased muscular glut expression as compared to hfd and hfd/myr group. conclusions: simultaneous treatment with myriocin and metformin decreases the plasma ffa and muscular cer and improves glucose tolerance by augmentation of muscle glut expression. internal medicine, new london hospital, new london, nh, usa hyperglycemia, and hyperlipidemia. understanding whether side effect profiles differ between the most commonly prescribed agents could greatly inform prescribing decisions. objectives: to quantify differences in weight gain and metabolic side effects between aripiprazole, quetiapine, and risperidone in adults and children requiring chronic antipsychotic therapy. selection criteria: randomized controlled trials that compared at least two of the three atypical antipsychotics of interest and reported change in weight. all dosing ranges were included and there were no age or diagnosis restrictions. data collection and analysis: two blinded clinicians independently completed data extraction with a piloted, standardized data collection form. study quality was assessed through the cochrane risk of bias tool. we calculated weighted mean differences (wmd) and % confidence intervals (ci) using random effects models on review manager . main results: of studies identified through our search, published trials involving study participants met full inclusion criteria. quetiapine resulted in more weight gain than risperidone and risperidone resulted in more weight gain than aripiprazole). no trials directly compared aripiprazole to quetiapine, but an indirect method of comparison demonstrated that quetiapine causes more weight gain than aripiprazole. similarly, quetiapine led to a greater increase in glucose levels, a greater increase in blood pressure, and a greater increase in total cholesterol than risperidone. non insulin dependent diabetes mellitus (niddm) as a most common form of diabetes is a major public health problem; there is a subgroup of niddm patients which develops the disease at an early age and shows a dominant mode of inheritance. this type is nominates maturity onset diabetes of the young (mody). the prevalence of mody is difficult to access as patients with mody genes mutations are often identified during routine screening for other purposes. mody was linked to mutations in glucokinase gene (gck), and account for - % of mody, with the highest prevalence being found in the southern europe. the aim of this study was to examine the prevalence and nature of mutations in gck gene in iranian paients. we have screened gck mutations by single stranded conformation polymorphism (sscp) technique of polymerase chain reaction (pcr) in iranian families with clinical diagnosis of mody, included patients (eight males and females) and their family members. pcr products with abnormal mobility in denaturing gradient gel electrophoresis (dgge) were directly sequenced. we identified six novel mutations in gck gene in iranian families (corresponding to . % prevalence). our findings and the last study on mody highlight that in addition to gck, other mody genes such as mody and modyx may play a significant role for diabetes characterized by monogenic autosomal dominant transmission. this is clear that the knowledge of the specific defect can be used to pre-symptomatically identify family members at risk for developing mody. background: several epidemiological studies proposed an association between helicobacter pylori (h. pylori) infection with insulin resistance (ir) and metabolic syndrome (mets). however, up to date there is no conclusive evidence regarding this association. objectives: to investigate the prevalence and correlates of h. pylori infection among lebanese adults and to evaluate its association with ir and mets. materials and methods: stored blood samples of adults participating in the national nutrition and non-communicable diseases risk factors survey conducted in lebanon were used for this study (n = ). h. pylori-specific immunoglobulin g antibody titers were measured by elisa. data available included, in addition to anthropometric measurements, sociodemographic and lifestyle characteristics, blood pressure, biochemical indices (serum insulin, hdl, ldl, tag, glucose). a homa -ir level was used to assess insulin resistance. the international diabetes federation criteria were used to classify study participants with mets. results: the prevalence of h. pylori infection in the study sample was % ( % ci: . - . %). a higher crowding index was associated with a % increase in the odds of infection (or: . , ci: . - . ). blood pressure, waist circumference, serum hdl, ldl, tag, and glucose levels were comparable between h. pylori positive and negative subjects. the odds of ir and mets were not significantly different between the two groups. comparable to other developing countries. furthermore, our findings suggested no association of h. pylori infection with ir or mets. eradication of h. pylori infection to prevent ir or mets is not warranted. the economic burden resulting from diabetic neuropathy (dn) consumes a major portion of resources allocated for health-care services. the present study was undertaken to assess the costeffectiveness of medical intervention in patients with dn. two hundred patients with dn were purposively selected from out-patient department of birdem hospital, bangladesh. of them were late in detection of dn (ldn) and were detected early (edn). in ldn group, % had diabetic peripheral neuropathy (dpn), % had diabetic autonomic neuropathy (dan), % had diabetic proximal neuropathy (dpxn) and % had diabetic focal neuropathy (dfn). in edn group, % had dpn and % had dan. the average annual cost of care was us$ (direct us$ and indirect us$ ), with an average us$ per patient. among the average annual cost ldn consumed us$ (us$ per patient) and edn us$ (us$ per patient). the annual medical costs increased with the increased number of complications from us$ to to and to in ldn with one, two, three and more than three complications which is increasing at a rapid rate and us$ to to and to in edn respectively, increasing at a diminishing marginal rate. the regression equation showed that medical cost is significantly related to complications tested in both univariate (p < . ) and multiple linear regression analyses (r = . ; f- . , p < . ). proper management with regular screening substantially reduces the expenditure related to care and complications. a. alizadeasl , z. ojaghi-haghighi , r. azarfarin tabriz university of medical sciences, tabriz, rajaei hospital, tehran, iran background: metabolic syndrome (ms), the combination of hypertension obesity, dyslipidemia, and insulin resistance, is a precursor of diabetes mellitus (dm) and highly prevalent among patients with acute myocardial infarction (ami). diabetes mellitus is associated with larger infarct size and worse outcomes after ami. this study examind the clinical presentation and hospital outcomes among nondiabetic patients with ms following ami. this investigation is prospective analytic study (cohorts type) in consecutive infarct survivors who admitted to our heart centers through years ( ) ( ) ( ) . patients with diabetes (n = ) were excluded. those with ms (n = ) included patients with three or more of the following criteria: hypertension, elevated fasting blood glucose, hypertriglyceridemia, low high-density lipoprotein, and obesity [body mass index (bmi) >or = ]. the control group (n = ) included patients without ms or dm. results: baseline characteristics were similar except for hypertension, bmi, and dyslipidemia, which by study desing were higher in the ms group. the nondiabetic ms group had larger left ventricular dimension (p = . ), left atrium dimension (p = . ) and higher rate of ejection fraction % ( % vs. %, p < . ). also nondiabetic ms patients had higher rates of in-hospital death ( . % vs. . %, p < . ); post infarction angina ( . vs. . , p < . ) and more frequent left main coronary artery or three-vessel disease than the control group ( . % vs. . %, p < . ). conclusion: nondiabetic metabolic syndrome is common in patients with ami and strongly associated with poor outcome of them. background: this study assessed the prevalence of the metabolic syndrome (ms) and its impact on hospital outcomes in patients with acute myocardial infarction (ami) using both ncep atp iii and idf definitions. this investigation is propective analytic study (cohort type) in consecutive ami survivors (mean age: . ae . years; men and women), who admitted to our heart centers through years ( ) ( ) ( ) . results: q-wave myocardial infarction (mi) was present in . % of patients and non-q-wave mi, in . %. the ms was found in . % of the patients and was significantly more common in women than in men ( . % vs. . %, p = . ). one component of the ms was found in . % of patients; two, in . %; and none, in . %. . % of the patients had four or five components. hypertension was the most common component of the ms ( . %). . % of ms patients had triple-vessel disease on coronary angiography in comparing with . % in non-ms, ami patients (p < . ). the ms group had larger infarct size as determind by peak creatine kinase-mb ( . ae . vs. . ae . , p < ). overal inhospital complications (mechanical and electrical) were higher in patients with ms ( . % vs. . %, p = . ). ms is associated with a . -fold increased risk of acute renal failure after mi (p = . ). conclusion: ms in patients with ami is prevalent and associated with larger infarct size, more in-hospital complications, and marked increase of acute renal failure. background and aims: according to current views metabolic syndrome (ms) and obesity, especially with increased amount of visceral fat is characterized by prothrombogenic changes of hemostasis and fibrinolysis. methods: cross-sectional observational study included postmenopausal women (age - ) with ms. coagulant system was assessed by measurement of parameters of plasma haemostasis [activated partial thromboplastin time (aptt), fibrinogen concentration], and the activities of coagulant factors vii (fvii), viii (fviii) and ix (fix) in plasma. in order to investigate the functioning of anticoagulant system the activities of antithrombin iii. also we assessed adiponectin (adp) and homocysteine (hm) concentrations in plasma. results: prothrombotic alterations were observed in . % women. the aptt was decreased in . %, hyperfibrinogenemia was revealed in . %, the increased activity of: fviiin . %, fviiiin . %, fixin . %, and the decreased activity of antithrombin iiiin . %. the hm levels was increased in . %, the adp levels was decreased in . %. there were a significant positive associations between some of revealed prothrombotic alterations (fvii, fviii and fibrinogenemia) and anthropometric markers of visceral obesity and ms (weight, body mass index, and waist circumference). the adp levels were inversely correlated with the hm levels (r = À . , p < . ) and the activity of fvii (r = À . , p < . ). conclusion: results of our study demonstrate high prevalence of various prothrombogenic abnormalities in coagulation and anticoagulation systems in patients with visceral obesity and ms. plasma b-type natriuretic peptide (bnp) and blood urea nitrogen (bun) are elevated in heart failure. renal function is known to be an important factor related to bnp and bun determination. the aim of the present study was to examine whether bnp and bun are associated with left ventricular diastolic dysfunction (lvdd) in patients with type diabetes (t dm) without chronic kidney disease (ckd). the subjects in this study were consecutive patients with t dm [ men ( %); age ae years old (mean ae sd); diabetic duration ae years; hba c . ae . %]. subjects with overt heart failure or nyha class > , history of coronary artery disease, severe valvulopathy, chronic atrial fibrillation, and estimated glomerular filtration rate < ml/min/ . m were excluded from the study. all patients underwent clinical evaluation, laboratory tests including bnp determination, and echocardiographic examination. doppler echocardiographic indices including peak early diastolic mitral annular velocity (e′) and early diastolic myocardial velocity (e) were obtained in each patient. none of the patients exhibited systolic impairment of left ventricular function (ejection fraction > %), whereas lvdd (e/e′ > ) was detected in cases ( . %). e/e′ correlated with age (r = . , p < . ), sex (r = . , p = . ), diabetic retinopathy stage (r = . , p = . ), systolic blood pressure (r = . , p = . ), bnp (r = . , p = . ), and bun (r = . , p = . ). in multiple regression analysis, age (b = . , p = . ), sex (b = . , p = . ), bnp (b = . , p = . ), and bun (b = . , p = . ), correlated independently with e/e′. bnp and bun could be useful tools to screen for preclinical ventricular diastolic dysfunction in patients with t dm without ckd. h. kawano, y. nagayoshi, y. kinoshita objective: this study compared the effects of combination statin and fibrate therapy with either statin or fibrate monotherapy on lipid profiles in patients with impaired glucose tolerance (igt) and a high risk for cardiovascular disease. methods and patients: forty-five patients with igt and dyslipidemia (men , women , mean age . ae . years) were assigned randomly to the three treatment groups for a -month period. results: after months of treatment, low density lipoprotein levels decreased in every group, especially the statin and statin + fibrate groups. triglyceride levels also decreased in all three groups, especially the fibrate and statin + fibrate groups. high density lipoprotein cholesterol and fasting blood glucose levels did not change in any group. the levels of remnant like cholesterol particles decreased in the fibrate and statin + fibrate groups. there was no change during the study in the levels of creatine phosphokinase, lactate dehydrogenase, or creatinine. conclusion: combination statin and fibrate therapy results in greater improvement in lipid profiles than monotherapy with either drug. no marked adverse effects were observed with combination therapy during the study. background: gout is considered a metabolic disease and ranked among the diseases connected with obesity, such as an arterial hypertension, coronary artery disease, stroke, and type diabetes mellitus (who, ) . it has been proven that intake of a considerable quantity of meat products is predictor of acute gouty arthritis. for this reason there is great interest in studying the prevalence of gout among inhabitants of the republic of sakha (yakutia) where a lipid-protein diet prevails. this is a preliminary report on the incidence of gout requiring hospitalization in - . objectives: patients hospitalized in the yakut city hospital with gouty arthritis were studied. methods: patients are being studied by means of a questionnaire developed by the institute of rheumatology (moscow). results: forty-four patients were registered ( men and two women). the majority of patients (n = ) are inhabitants of yakutsk city. median age of the subjects is years, with a range of - years; four patients are over . secondary forms of gout and relapses of disease are common. accompanying pathology includes: ah in patients, cad in seven patient, type dm in four patients, glucose intolerance + obesity in one patient, metabolic syndrome + obesity in one patient, uncomplicated obesity in one patient, metabolic syndrome without obesity in one patient, chronic renal insufficiency in one patient, and cardiovascular accidents in three patients. the research proceeds. results will be used for characterization of the incidence and diagnostic features of gout in yakutia especially among young patients with accompanying metabolic abnormalities. background: the prevalence of obesity, a major public health problem, is rising in many countries including iran. non-drug dependent interventions for obesity management include physical activity, dietary restriction and acupuncture. primary study objective: we examined the effects of body electroacupuncture and low-calorie diet on plasma leptin in obese and overweight individuals with the excess or deficiency pattern (according to chinese medicine). methods/design: the case group received authentic electroacupuncture and the placebo group received sham acupuncture. both groups consumed a low-calorie diet for weeks. settings: this study was conducted in nutritional clinic of ghaem hospital, mashhad, iran. participants: people (n = ), aged between and years with body mass indexes (bmi) between and kg/m were randomized into two groups. interventions: comparison of either real or shame electro acupuncture combined with a low caloric diet was investigated in this trial. primary outcome measures: plasma leptin, body fat mass (bfm), body weight and body mass index were measured before and after treatment. results: in volunteers in the case group with both the excess and the deficiency patterns, we found a significant reduction in plasma leptin ( . %, p = . ) and bfm ( . %, p = . ). in the placebo group, we found a less significant reduction in leptin and bfm. the difference between the two groups was significant for leptin (p = . ) but not for bfm (p = . ). conclusions: body electroacupuncture with a low-calorie diet may reduce plasma leptin concentration; through a mechanism that will require further clarification. m. darbandi , , s. darbandi , , a.a. owji , p. mokarram , m. ghayour mobarhan effects of auricular acupressure combined with low-calorie diet on the leptin hormone level. methods: volunteers (n = ) with body mass indexes (bmi) between and kg/m were randomised into a case (n = ) or a control (n = ) group. the participants in each group received a low-calorie diet for weeks. the case group was treated with auricular acupressure and the control group received a sham procedure. plasma leptin levels, body fat mass, body weight (bw) and bmi were measured before and after treatment. results: participants who received auricular acupressure showed significant reductions in their plasma leptin levels ( . %, p < . ) as well as in their body fat mass ( %, p < . ). these changes were not observed in the control group. the reduction in leptin was significantly greater in the acupressure group than the controls. conclusion: auricular acupressure combined with a low-calorie diet significantly reduced plasma levels of leptin. however, the mechanism of this reduction is not clear. background: premature arteriosclerosis may be one of the mechanisms linking pre-diabetes mellitus (pre-dm) and cardiovascular disease. we assessed premature arteriosclerosis in pre-dm using arterial stiffness indices and analyzed the associated contributors of this process. methods: we collected clinical data of patients without dm, pre-dm patients, and dm patients. both the compliance index (ci) and stiffness index (si) were measured to indicate large and peripheral arterial stiffness. results: patients with pre-dm and dm had lower ci ( . ae . vs. . ae . units; p < . and . ae . vs. . ae . units; p < . , respectively) and higher si ( . ae . vs. . ae . m/s; p < . and . ae . vs. . ae . m/s; p < . , respectively) than patients without dm. both pre-dm and dm patients had higher glucose and hemoglobin a c , higher homa index, higher hscrp, and a lower adiponectin level than patients without dm. using multivariate linear regression analysis, age, heart rate and homa index were independent determinants for si (whole model: r = . , p < . ), whereas male gender, hscrp, and homa index were independent determinants for ci (whole model: r = . , p < . ). conclusions: homa index was an independent determinant for arterial stiffness. increased insulin resistance may associate with increased arterial stiffness both at large and peripheral arteries in pre-dm patients. king's college london, london, uk, uppsala university, regional cancer centre, uppsala, sweden, guy's & st thomas' nhs foundation trust, london, uk, karolinska institute, stockholm, sweden background: impaired glucose metabolism has been linked with increased cancer risk, but the association between serum glucose and cancer risk remains unclear. we used repeated measurements of glucose and fructosamine to get more insight into the association between the glucose metabolism and risk of cancer. methods: we selected , persons (> years old) with four prospectively collected serum glucose and fructosamine measurements from the apolipoprotein mortality risk (amoris) study. multivariate cox proportional hazards regression was used to assess standardized log of overall mean glucose and fructosamine in relation to cancer risk. similar analyses were performed for tertiles of glucose and fructosamine and for different types of cancer. results: a positive trend was observed between standardized log overall mean glucose and overall cancer risk (hr = . ; % ci: . - . ). including standardized log fructosamine in the model resulted in a stronger association between glucose and cancer risk and a statistically significant protective effect of fructosamine (hr = . ; % ci: . - . and hr: . ; % ci: . - . , respectively). the highest risk for cancer was among those in the highest tertile of glucose and lowest tertile of fructosamine. similar findings were observed for prostate, lung, and colorectal cancer. the contrasting effect between glucose, fructosamine, and cancer risk suggests the existence of distinct groups among those with impaired glucose metabolism, resulting in different cancer risks based on individual metabolic profiles. further studies are needed to clarify whether glucose is a proxy of other lifestyle-related or metabolic factors. patients in two groups were compared according to age, parity, prepregnancy weight, family history of diabetes mellitus, history of macrosomia in their previous pregnancies, history of hypertension, previous malformed fetus, history of iufd and abortion. based on the obtained results there was a statistically significant difference between two groups in terms of age (p < . ), parity (p < . ), prepergnancy weight (p < . ), family history of diabetes mellitus (p < . ), previous macrosomia (p < . ), history of hypertension (p < . ), previous malformed fetus (p < . ) and previous iufd (p < . ), but abortion was not significantly different. older age, parity (three or more) obesity, family history of diabetes mellitus, history of macrosomia, hypertension, malformed fetus and also previous iufd are risk factors for gestational diabetes. therefore, these women should be screened and handled for gestational diabetes in their pregnancies, and controlled for possible diabetes mellitus in the future. methods: this family based study was conducted on nuclear families from among tehran lipid and glucose study with two biological parents and at least two offspring ( parents and offspring), aged - years. selected families had at least one person with overweight or obesity. all obesity-related variables (height, weight, hip, waist circumference (wc), body mass index (bmi), body size (bs), resting energy expenditure (ree), waist to hip ratio (whr)) were measured and calculated. the heritability estimate of continuous variables was calculated using a standard quantitative genetic variance-components model which was implemented in the solar software. results: the heritability estimates for obesity-related variables such as height, weight, hip, wc, whr, bmi, bs, and ree, after adjustment for sex, age were %, %, %, %, %, %, %, and %, respectively. the h for the above mentioned variables, expect of bs, after adjustment for sex, age, and body size varied to %, %, %, %, %, %, and %, respectively (p < . ). we clearly demonstrated a significant heritability of obesity-related variables among tlgs families. the results of the present study confirmed the important impress of genetic factors on the obesity-related variables phenotype. method: pwv determined with bpuls apparatus using left external carotid and left dorsalis pedis arteries as "central" and "peripheral" points respectively. pulses picked up by infrared sensors and recorded simultaneously with single lead ecg. time difference between pulses measured. shorter time delay or faster pwv indicates decreased arterial elasticity. materials: nine hundred and fifty-seven asymptomatic filipinos studied. males- , females- . age - years. three hundred and twenty-seven hypertensives. classified into groups according to bmi and wc. average pwv time (adjusted for height) for each group noted. relationship of increased bmi and wc to variations in pwv time determined. results: elevated bmi does not significantly influence pwv time in: all subjects-(p < . ); females-(p < . ); normotensives-(p < . ); and, hypertensives -(< . ). however, for every centimeter increase of wc there is a corresponding decrease of pwv time by: . s (p < . ) in all subjects; . s (p < . ) in females; . s (p < . ) in normotensives; and, . s (p < . ) in hypertensives. discussion: abnormal pwv is a high cvd risk factor. in four groups above, elevated bmi does not significantly influence pwv time. however, in the very same groups, increased wc significantly affects pwv time. this indicates that if we rely solely on bmi to predict cvd we will miss cases which are at high risk as shown by abnormal wc. correlation (r = . ). an increased risk of cvd and cancer was identified with elevated levels of ggt or crp or both markers (ggt-crp score ! ); the greatest risk of cvd and cancer was found when ggt-crp score = (hr: . ( %ci: . - . ) and . ( . - . ) compared to ggt-crp score = , respectively). conclusion: while ggt and crp have been shown to be associated with metabolic abnormalities previously, their association to the components investigated in this study (hyperglycaemia and dyslipidaemia) was limited. results did demonstrate that these markers were predictive of associated diseases, such as cancer and cvd. metabolic syndrome is the aggregation of conditions that together increases the risk of cardiovascular disease and diabetes mellitus in both normal glucose tolerance (ngt) and impaired glucose tolerance (igt) subjects. it is estimated that around - % of the world′s adult population have the metabolic syndrome. over the last years the prevalence of metabolic syndrome has steadily increased in all populations, and making it one of the major global public health challenge. the objective of this study is to estimate the prevalence of metabolic syndrome and cardiovascular risk factors in impaired glucose tolerance (igt) subjects. two hundred and four impaired glucose tolerance and normal glucose tolerance subjects of both genders were selected for the present study according to the american diabetes association ada criteria, on the base of h glucose tolerance test. anthropometric characteristics like waist circumference, bmi, systolic blood pressure, and diastolic blood pressure were measured with standard techniques. biochemical parameters like fasting blood sugar, fasting insulin, cholesterol, triglycerides, hdl-c, and ldl-c were determined by standard techniques, the homa-ir values were calculated with the help of formula. it is concluded from the present study that the prevalence of metabolic syndrome is significantly increased according to aace, atpiii definition criteria's in impaired glucose tolerance subject, the study emphasizes strongly that ms is major factor to enhance the incidence of type diabetes and cardiovascular diseases in impaired glucose tolerance subjects. it is suggested that preventive measures and treatment can reduce incidence of cvd, type diabetes in our population. anthropology, vidyasagar university, midnapore, india waist circumference (wc) and waist-hip ratio (whr) were reported as imperative abdominal obesity related measures having influence on many cardiovascular disease (cvd) risk factors. present study attempts to evaluate the possible association of abdomen circumference (ac) with hypertension and dyslipidaemia among the bhutias, a tribe residing the sub-himalayan state of sikkim, india. five hundred and eleven bhutias of both sexes aged ! years inhabiting gangtok, the state capital and its neighbourhood were systematically selected to participate in the study. after providing informed consent data on blood pressures, blood lipids, anthropometrics and other lifestyle related variables such as perceived stress, diet, energy expenditure, socioeconomic status and so on were collected following standard methods. the results evidently indicate that the ac is the best predictor of the selected cvd risk factors. after log transformation, the effect of age on cvd risk factor variables and anthropometrics was found and regressed out through linear regression. data was pooled for sex as significant sex difference was absent for most of the variables. after adjusting for significant lifestyle related predictors, multiple logistic regression was carried out to evaluate the significant obesity related predictors of hypertension and dyslipidaemia. receiver operating characteristic (roc) curve finally showed ac as the best predictor of hypertension and dyslipidaemia. although wc and whr were found to be important abdominal obesity related predictors of cvd risk factors in many studies, present population based cross sectional study has proved the importance of considering ac as a central obesity related predictor of different cvd risk factors. the achievement of therapeutic goals is of great importance in patients with chronic diseases such as diabetes mellitus (dm), because of its impact on morbidity and mortality. objective: to explore the relationship between therapeutic adherence and metabolic control in patients with dm- , who were seen at a hospital in the city of medellı´n (colombia). methods: cross-sectional study involving patients with the following selection criteria: age ! years, diagnosis of dm- ! months, who signed informed consent. the summary of diabetes self-care activities (sdsca) score was applied for the measurement of therapeutic adherence and duke-unc score for the assessment of perception of social support. glycosylated hemoglobin (hba c) was processed by turbidimetric inhibition immunoassay (tinia) cobas c- equipment. adequate metabolic control was defined as value of hba c %. version . of the spss program was used for the statistical analysis. results: seventy patients studied: % are female, % suffer from hypertension, % have dyslipidemias and % smoke. in addition, % are insulin dependent, % have inadequate glycemic control and % has no social support. items with the highest proportion of adherence were: medication ( %), foot care ( %) and diet ( %). whereas the lowest were: hba c ( %) and exercise ( %). hba c correlated significantly (p < . ) with adherence to diet, blood glucose monitoring, foot care, social support and sex. conclusion: therapeutic adherence was associated with metabolic control in patients with dm- . mellitus. however, it is unclear if severity of dr is associated with lvdd, which is recognized to result in subsequent heart failure. the subjects in this study were consecutive patients with type diabetes mellitus (t dm). all patients underwent clinical evaluation, laboratory tests, and echocardiographic examination. doppler echocardiographic indices including peak early diastolic mitral annular velocity (e′) and early diastolic myocardial velocity (e) were obtained in each patient. the patients were divided into three groups according to presence of dr and its severity: no diabetic retinopathy (n = ), simple retinopathy (n = ), and preproliferative or proliferative retinopathy (n = ). no patients showed systolic impairment of left ventricular ejection fraction (lvef > %), whereas impaired lv diastolic function (e/e′ > ) was detected in cases ( %), furthermore lvdd (e/e′ > ) was detected in cases ( %). e/e′ was correlated with age (r = . , p = . ), sex (r = . , p = . ), diabetic duration (r = . , p = . ), dr stage (r = . , p = . ), systolic blood pressure (r = . , p = . ), and serum creatinine level (r = . , p = . ). in multiple regression analysis, age (b = . , p < . ) and dr stage (b = . , p = . ) were independently correlated with e/e′. in this study, we showed that almost all subjects had asymptomatic lvdd, and severity of dr was associated with lvdd in patients with type diabetes mellitus. objectives: this study explores the contribution of the sasang constitutional types as a risk factor for hypertension by examining the prevalence and risk for hypertension across different constitutional types (se, sy, te, and ty types) and investigating whether certain constitutional types can increase the risk of hypertension in an individual. design: this retrospective chart review evaluated the charts of patients who had visited the clinic for routine physical check-up. subjects: among , visitors, those aged between and , with complete data concerning the past medical and social history, blood pressure and body size measurements, results of blood test, and confirmatory constitutional typing (excluding the ty type) were included in the final analysis group (n = ). results: especially, even after adjusting for the different variables, the odds ratio for hypertension in the te type was found to be . (ci . - . ) (taking the se type as the reference group), indicating that the te constitutional type can act as a risk factor for hypertension. moreover, when comparing the te type to non-te types, the odds ratio was found to be . (ci . - . ), implying a weak but valid contribution of the te constitutional type toward increasing the risk of hypertension. the results of this study show that the prevalence of hypertension differs across different constitutional types, and that the constitutional type (the te type) can act as a risk factor for hypertension independently of other possible variables. a.b. shetty , p.k. roy physical therapy, university of st mary, leavenworth, ks, bon secours hospital, baltimore, md, usa introduction: the purpose of this research was to determine whether habits of individuals contributed to changes in metabolic rate. as the daily physical activity levels increase, there is an increase in the metabolic rate and caloric expenditure. it can be inferred that people who are overweight may not participate in physical activities due to social, psychological, and physical reasons. they may spend more time in less physically demanding activities during their leisure time. hypothesis: it was hypothesized that the individuals who like to read for pleasure during leisure will have higher body-mass-index. subjects: a group of college aged, - , females volunteered to be the subjects for the study. method: each subject's weight and height were collected to determine bmi. the leisure time activities that were included were reading, sleeping, watching television, use of computers, and sports and physical activities. a likert scale questionnaire was developed and had four levels of answers for each of the leisure time activities. a person-product moment correlation was used to determine the relationship between bmi and five leisure time activities. the results indicate that a positive correlation of . between bmi and leisure time reading habits. there is a negative correlation of À . between bmi and sports and physical activities. conclusion: this research demonstrates that the bmi is significantly higher for individuals who like to read during their leisure time activities. therefore, it is also important to develop physical activities as habits during early years that may carry into adulthood. objectives: the main goal of this retrospective cohort study was to compare the incidence of over-all and site-specific cancers among israeli arabs with diabetes mellitus (dm) with that of israeli arabs without dm. methods: a retrospective cohort study was conducted in northern israel, involving all arab subscribers of clalit healthcare services (chs), which is the major hmo service in the region, serving over % of the concerned population. results: during a period of years ( - ) of follow-up, and incident cases of cancer were found among , people with dm and , adults free of dm, respectively. the follow-up time involved , person years. dm was associated with a standard incidence ratio (sir) of . ( %ci: . - . ) and . ( %ci: . - . ) for pancreas cancer in men and women, respectively. a significantly reduced sir was observed for esophageal, stomach and intestine cancer . ( %ci: . - . ) in men. our findings support an association between dm and increased risk cancer of the pancreas in arab men and women. a significantly reduced risk of all other cancers was observed only in arab men. a.e. berezin , o.a. lisovaya methods: seventy-two mild-to-moderate arterial hypertension patients within - weeks after ischemic stroke were enrolled to the scrutiny at baseline. both vegf- and mmp- plasma levels were measured at the study entry and in months after baseline by elisa. we has been assessed all new cardiovascular events including myocardial infarction (mi), unstable angina (ua), recurrence stroke (rs), tia, advance heart failure (hf) during study period. results: analysis of obtained outcomes have been shown that all cases (n = ) of new cardiovascular events identified during first weeks after start of observation are correlated well with vegf- plasma levels (r = À . ; p < . ) measured at baseline. on the other hand, -weeks survival rate was . % and . % respectively for group subjects (p < . ) with top and low quartile of vegf- plasma level at baseline. however, lack of tightly interrelationship between cardiovascular outcomes and vegf- (r = . ; p = . ) in months after study entry. the mean mmp- plasma levels were significantly higher in dead patients in comparison to survival subjects of the study end. both new events associated with rs and tia incidences independently study period are correlated well with vegf- (r = À . ; p < . and r = À . ; p < . respectively) only. we has been proposed that circulating vegf- might have more predicting value in comparison with mmp- concentration among hypertensive patients during early ischemic stroke period. introduction: clinician should change the health care system from on diseases treatment to prevention of diseases. obesity increase mortality, morbidity and psychological problems through life but beneficial effects of risk reduction by changing life style have been documented. objective: sedentary life style is the most important factor for promoting weight gain in people. it's clear that obesity occurs when calorie intake exceeding calorie output. obesity is common in families but seems environmental factors can affect body weight beside genes role. a main factor of life style change is energy balance. we recommend one simple healthy life guideline for managing of environmental factors in obese people that includes a diet and physical activity program. body weight should be reduced - % during first year by following of this guideline and continued until achieving to optimal body weight. obese people are visited and monitored some parameters for program adjusting and changed each item basis on individual response. objective: to assess trend and associations between blood sugar level, blood pressure, overweight/obesity and lifestyle among tribe of northeast india experiencing transition. method: cross-sectional study was carried out among tangkhul nagas, aged between and years. subjects were divided into five decadal age groups to assess age trend in biological and socioeconomic variables. height, weight, waist circumference, hip circumference, random blood sugar level, bp, bmi, wsr and whr were evaluated. result: the prevalence of prediabetes and diabetes were . % and . % respectively. diabetes was found among older age groups only. hypertension was highly prevalent with higher percentage among males ( %) than females ( . %). mean bp was higher among males but sugar level among females, which corresponds to their higher adiposity level. prevalence of overweight/obesity in females was . % while in males, it was . %. sugar level and bp had positive correlation with age, bmi, wsr and whr. the prevalence of hypertension and prediabetes/diabetes were higher among centrally obese subjects. central obesity indices were stronger predictors of diabetes and hypertension than general obesity. odds ratio showed urbanization, higher socioeconomic status and sedentary lifestyle as significant risk factors for development of overweight/obesity, which in turn was risk factor for development of diabetes and hypertension. conclusions: tangkhul nagas has been experiencing socioeconomic and lifestyle change which led to the increasing prevalence of overweight/obesity and cardiometabolic health problems, contributing to the escalating global epidemic of obesity and metabolic syndrome. there was close associations between socioeconomic status, age, overweight/obesity, hypertension and blood sugar level. background and aims: trace elements play an essential role in metabolism of carbohydrates, lipids, etc. these results stipulated the present work. we studied patients (eight females, males, age - years) with type diabetes mellitus. duration of the disease varied from month to years. as a control data the hair composition of practically healthy individuals (n = ) were used. as an analytical method instrumental neutron activation analysis (inaa) was used. results: data obtained shows statistically significant decrease of cu, cr, and zn and increase of na, fe, br, and sb levels in hair in the group with a blood glucose concentration < mmol/l. in the group with a blood glucose concentration more than mmol/l levels of cu and la were decreased and na, fe, co, br, and i levels increased. in the group with a blood glucose concentration more than mmol/l glucose concentration correlates with sc (r = . ), cr (r = À . ), and mn (r = + . ). conclusion: it was found that mn level in blood increases with diabetes. this may be a manifestation of mn metabolism dysfunction in diabetes and excretory role of hair. it is also confirms the important role of some elements, especially cr, in diabetes. concentration of this element significantly decreases especially in the first year of illness. unexpected are correlations for sc. usually sc is considered as an element that has no biological role. these findings are additional reasons to study the biological role of less studied ultra trace elements. objective: investigate the prevalence of hyperglycemia in patients undergoing coronary angiography. methods: six hundered and ninety-five consecutive brazilian subjects undergoing coronary angiography were assessed for fasting plasma glucose and hba c (hplc) levels and for previous history of diabetes mellitus (dm). we classified those without previous diagnosis in three groups according to hba c levels (hplc): normoglycemic (n); hba c -< . %; prediabetes (pd) -hba c . % À . %; and dm (d) -a c ! . %. cad defined by any visible lesion ! %. we also classified glycemic status using fasting glucose levels by ada criteria. results: patients were aged . ae . years, . % male. the group had a high prevalence of cardiovascular risk factors: dyslipidemia - %, hypertension - %, % overweight/obese, metabolic syndrome (idf) in % of subjects. cad was detected in . % of them. dm was newly diagnosed using hba c in . % of the whole sample ( individuals) and pd in ( %). in those without dm according to hba c, ( . %) had glucose levels ! mmol/l and ( . %) had glucose ! . mmol/l. in this particulary population with coronary artery disease and/or cardiovascular risk factors we observed a high prevalence of undiagnosed hyperglycemia -dm or prediabetes ( - %) depending on the criteria used for identification/diagnosis (fasting glucose or hba c). this finding reinforces the importance of implementing a systematic screening for hyperglycemia in this high risk population. national university of singapore, singapore, singapore, university of sydney, sydney, nsw, australia objectives: to evaluate associations between metabolic syndrome (mets) components and mortality and whether these associations change over time. methods: three thousand eighty-six eligible residents aged ! years were prospectively followed in the blue mountains eye study, west of sydney, australia. mets components were measured at baseline ( - ) , and after -years and -years ( - ) . using cox proportional hazards and competing risks models with mets as a time-dependent covariate, we estimated effects of mets on all-cause and cause-specific mortality. receiver operating characteristic (roc) curve analyses were used to identify which individual or combined mets components best predicted mortality. . roc analysis suggested that glucose, body mass index (bmi) and blood pressure (bp) best predicted all-cause and chddeath, bmi and bp best predicted stroke-death and glucose and triglycerides best predicted cancer-death. national university of singapore, singapore, singapore, university of sydney, sydney, nsw, australia objectives: to investigate the effect of metabolic syndrome (mets) and its components on the incidence of different sub-types of cataract (cortical, nuclear and posterior subcapsular cataract (psc)) over years and whether these associations change with time. methods: a prospective cohort of elderly aged ! years were followed up over a period of -years in the blue mountains eye study, west of sydney, australia. mets components were measured at baseline ( - ), -years ( - ) and -years ( ) ( ) ( ) . the incidence of different types of cataract was obtained from standard photographic grading at -and -year (n = ). using random-effect complementary log-log regression model with cataract status as interval-censored data, we estimated the effect of mets on the incidence of different types of cataract at different time-intervals. results: after taking into account the changes in mets (components) and controlling for possible confounders, mets was found to be associated with increased -year incidence of cortical cataract [hazard ratio (hr) . , % confidence interval (ci) . - . ] and psc (hr . , % ci . - . ). amongst the five components of the mets, high glucose and obesity predicted the -year incidence of cortical cataract and at -year, high glucose and low-hdl was associated with increased incidence of psc and cortical cataract, respectively. conclusions: changes in mets predicted the -year incidence of cortical cataract and psc. different mets components predicted the incidence of different sub-types of cataract at varying time-intervals. material and method: this study was a done on a sample of isfahan cohort study (ics) participants. subjects which met atpiii criteria, entered in our study. aobesity indices such as body mass index (bmi), waist circumference (wc), waist to hip ratio (whr) and waist to height ratio (whtr) measurements were done by trained nurses. serum lipids, fasting blood glucose, interleukin- (il- ) and interleukin- (il- ), adiponectin ghrelin, and crp were measured. the mann-whitney u-test was used for comparisons between the level of inflammatory markers in obese subjects with and without mets. then subjects with mets were selected and correlation between inflammation biomarkers and obesity indices correlation coefficients were obtained by pearson correlation test. results: wc and bmi were significantly higher in subjects with mets (p < . ). the median (iqr) of crp was significantly higher in subjects with mets (p < . ). the correlation between inflammatory markers and obesity indices was determined by nonparametric analysis. mets subjects had a significantly positive correlation between il and whtr (r = . , p = . ). no significant relationship found between il- , ghrelin, adiponectin and crp with, bmi, whtr and waist. significant negative correlation was observed for adiponectin and the waist (r = À . , p = . ). negative correlation between adiponectin with whr, whtr and bmi among subjects without mets (r = À . , r = À . and À . respectively). conclusion: present study indicate that the observed inflammatory concentrations cannot be explained by type of obesity. objective: the incretin effect is known to be decreased in type diabetes (t d). however, no study has directly measured the incretin effect in non-caucasian subjects. because asian patients with t d are characterized by decreased insulin secretion, this study set out to examine the incretin effect in korean subjects with normal glucose tolerance (ngt) or t d. research design and methods: we performed g ogtts and corresponding isoglycemic intravenous glucose infusion (iigi) studies in subjects with ngt (n = ) or t d (n = ). the incretin effect was calculated based on the incremental area under the curves (iaucs) of insulin, c-peptide, or insulin secretion rate (isr). the plasma levels of total glucagon-like peptide- (glp- ) and glucosedependent insulinotropic polypeptide (gip) were measured by elisa. results: the incretin effect was not different between the subjects with ngt and t d ( ae % vs. ae %, p = . by insulin; ae % vs. ae %, p = . by c-peptide; ae % vs. ae %, p = . by isr, respectively). however, the gastrointestinally mediated glucose disposal (gigd) was decreased in t d ( . ae . % vs. . ae . %, p < . ). the plasma levels of the total glp- and gip during the ogtts were comparable between the two groups. conclusions: in koreans, the secretion of glp- or gip during ogtts and the incretin effect were comparable between subjects with ngt and t d, whereas the gigd was significantly decreased in patients with t d. a.e. berezin , a.a. kremzer internal medicine, clinical pharmacology, state medical university, zaporozhye, ukraine the aim of this study was to evaluate the interrelation between circulating osteoprotegerin (opg) and coronary vasculature damage in type diabetes mellitus patients. methods: one hundred and twenty-six subjects with stable diabetes mellitus type with previously angiographic documented asymptomatic cad were enrolled to the study. vessel-wall and plaque geometrical and compositional parameters were measured on contrast-enhanced ct angiography. the volume of intramural calcium of > hu in major coronary vessels was measured in coronary segments with a highly standardized method. coronary artery calcification was quantified by calculating the agatston' score index and calcification mass measurement. opg plasma levels were measured with elisa. results: circulating opg level was increase in patients [ pg/ ml [ % confidence interval (ci) = - pg/ml] and was normal in subjects ( pg/ml; % ci = - pg/ml; p < . ). the relationship between coronary artery calcium by agatston' score index and percent atheroma volume (pav) was determined by linear regression. pav and remodeling index were significantly higher in patients with elevation of opg plasma level when compared with those who have normal opg [adjusted odds ratio (or) = . ( % ci = . - . ); p = . ]. there was significant correlation between agatston' score index and pav [r ( ) = . , p = . ]. in conclusion, we demonstrated that opg plasma level can associate with vessel-wall thickening, percent atheroma volume, and agatston' score index value in type diabetes mellitus patients with previously angiographic documented cad. along with the prevalence of diabetes continues to grow, the occurrence of microvascular chronic complications caused by diabetes has increasingly become a serious social problem. diabetic cardiomyopathy, a microvascular disease, results in chronic heart failure and causes a heavy economic burden. endoplasmic reticulum as an intracellular organelle, which occurs the stress leads to cell apoptosis. recent studies indicate that bis(maltolato)oxovanadium can alleviate the endoplasmic reticulum stress to protect cell function. in this study, stz ( mg/kg)-induced diabetic rats were divided into two groups, the diabetic control group, and diabetes + vanadium group; the normal group without diabetes were randomly divided into two groups, normal group and the normal + vanadium group. the bis(maltolato)oxovanadium significantly improve the endoplasmic reticulum stress in stz-induced diabetic rat heart cells and reduce the cardiac damage. in this study, bis(maltolato)oxovanadium can reduce the endoplasmic reticulum stress in diabetic myocardial cells delay the development of diabetic cardiomyopathy. it can be a new way to explain the mechanism in the function of bis(maltolato)oxovanadium. between mets and type diabetes families without diabetic family related. subjects and methodology: forty-three mets subjects with type diabetes parental ( st group), mets subjects without type diabetes parental ( nd group) and no mets subjects but with type diabetes parental ( rd group). this study was conducted over months at diabetologia department hospital. diabetes screening was achieved by oral glucose tolerance testing (ogtt). metabolic parameters were determined by spectrophotometry, insulin by radioimmunoassay. insulin sensitivity was also assessed by the homeostasis model assessment (homa) approach (glucose insulin/ . ). results: in the st and the nd groups there is a significant hyperinsulinemia and to a lesser extent in the rd group ( %, % and %, respectively). the homa model confirms an acute insulin resistance ( %, % and % increase respectively). hypertriglyceridemia was observed only in the nd group. hdl dyslipidaemia has been identified in women of the nd group (< . g/l). our study seems to confirm that type diabetes genetic predisposition is not the only factor, but also environmental factors with or without diabetes family. aims: to examine, the predictors of incident chronic kidney disease (ckd) in a community-based cohort of middle east population, during a mean follow-up of . years. methods: in a sample of non-ckd iranian adults ! years the estimated glomerular filtration rate (egfr) was calculated at baseline and at year intervals during three consecutive phases. the egfr < ml/min/ . m was defined as ckd. multivariate logistic regression analysis was used to determine the independent variables associated with incident ckd. results: the incidence density rates of ckd were . and . per , person-year, among women and men, respectively. female gender per se was associated with higher risk of ckd, compared with males. among women, age, egfr, known diabetes, being single or divorced/widowed, hypertension (marginally significant) and current smoking were independent risk factors for ckd; however the intermediate degree of education and family history of diabetes decreased the risk by % (p < . ). among male subjects, independent predictors of developing ckd included aging and hypertension (with significantly higher risk than in women, p for interaction < . ), egfr, new diagnosed diabetes, high normal blood pressure; abdominal obesity decreased the risk of ckd about % which was marginally significant. in the iranian population, > % of individuals develops ckd each year. our findings confirmed that sex-specific risk predictors should be considered in primary prevention for incident ckd. introduction: obesity is a silent killer and a forerunner of many complications if persists long. various studies with animal model have identified the role of leptin, the hormone of adipose tissue; in obesity and its associated complications like diabetes and atherosclerosis inlater stages. the exact mechanism to know how leptin influences insulin action in body and thereby leading to diabetes or post diabetic atherosclerosis is still not completely evaluated. hypercholesterolemia was only found common to all these three states. aim and objectives: the present study, therefore, evaluated the role of obesity on the expression of ldlr receptor, insulin receptor and leptin receptor. method: receptor expression was done by immunohistochemistry/ western blot. the serum level of lipids were measured by enzyme based kit method. the serum level of insulin and leptin and its soluble receptor were measured by elisa based kit. the blot for insulin expression shows no chamge with body weight; the blot for leptin receptor shows decrease expression with weight gain and blot for ldlr shows decrease expression with weight gain. the serum levels of insulin and leptin are increased with weight gain but soluble receptor for leptin did not change significantly. even the obese group showed decrease tyrosine phosphorylation of insulin receptor. background: visfatin and apelin are two new adipokines that recently gained special interest in diabetes research. however, the relationship between them has not been elucidated and their role in coronary artery disease (cad) complication of diabetes has not been adequately studied. objective: this study was conducted to study the interplay between these two novel adipokines and to study their correlation with other inflammatory and biochemical parameters in type diabetic (t d) postmenopausal women with cad. the levels of visfatin, apelin and other parameters were measured in t d patients without cad, both nonobese and obese t d patients with cad, together with healthy nondiabetic control subjects. visfatin and apelin were measured by enzyme-linked immunoassay (elisa). results: visfatin was found to be significantly higher in the following groups: t d patients without cad, non-obese and obese t d patients with cad, ( . ae . , . ae . and . ae . ng/ml respectively) when compared to control group ( . ae . ng/ml) at p < . . apelin was found to be significantly lower in both non-obese and obese t d patients with cad ( . ae . and . ae . ng/ ml respectively) when compared to control group ( . ae . ng/ml) at p < . . furthermore, visfatin and apelin were found to be significantly associated with each other and with other biochemical parameters in both simple and multiple regression analyses. the current study provides evidence for the novel interplay between visfatin and apelin through the inflammatory milieu characteristic of t d and sheds light on their possible role in the pathogenesis of cad complication of t d. aim: the aim of this study was to investigate the relationship between hscrp, il- , and hcy levels and cardio metabolic risk factors in subjects with and without mets in a sample of tehranian population. in this cross-sectional study, individuals including men and women, aged ! years were selected randomly from among participants of tlgs. the sera of il- , hscrp and hcy were determined using elisa method. results: of the total subjects, aged mean . ae . year, mets was presented in ( . %) individuals. the levels of hscrp, hcy, and il- were higher in subjects with mets compared to normal group. a gradual significant increase just in the level of hscrp with increasing number of mets components was found after adjustment for sex and age. a strong linear augmentation in hscrp levels was observed as the number of mets components increase from to ! with median hscrp levels of . , . , and . (ng/ml) (p trend = À ). also, an increase of . in hscrp levels (ci %: . - . ; p = À ) was observed with an increase in each components of mets in linear regression analysis adjusted for age and sex. the best predictor for hscrp, il- , and hcy, in subjects with mets was hip, whtr, and height, respectively, compared with whtr and wrist which were the best predictors for hscrp and hcy levels in the subjects without mets. conclusion: hip and whtr are significant predictors of the hscrp and il- elevation associated to mets, respectively. methods: in a nested case-control study, conducted on a group selected from participants of the tehran lipid and glucose study, those cases with new diagnosed type diabetes during the . year follow-up ( subjects) were matched to controls for age, sex, body mass index andseason of entrance to study. multivariate conditional logistic regression analysis was used tocalculate the odds ratio (or) with % confidence interval of type diabetes for vitamin dcategories, vs. the first quartile ( . ng/ml) as reference. results: the unadjusted ors of type diabetes were . ( . - . ), . ( . - . ) for the second and third tertiles, respectively. after adjustment for family history of diabetes, systolicblood pressure, triglycerides to high density lipoprotein cholesterol ratio, and fasting plasmaglucose, the corresponding ors were . ( . - . ) and . ( . - . ) for second and third tertiles respectively. multivariate cubic spline modeling analysis indicated that ng/ml hydroxyvitamin d levels was the optimal cut point for distinguishing those who were at risk ofdeveloping diabetes and those who were not. also addition of vitamin d to multivariate model, improved the net reclassification by cut-point based nri of %. discussion: in a prospective cohort study, we demonstrated a nonlinear independent associationof vitamin d with incident diabetes, with prominent increase in risk at a cut-off < ng/ml. research department-ayush projects, svyasa university, bangalore, india type diabetes mellitus (t dm), the seventh leading cause of death, is a biggest challenge for mankind. despite of fascinating advances in pharmaco-therapeutic agents, the prevalence of t dm is growing every year. complementary and alternative medicine (cam) as classified by national centre of cam have documented various positive results of t dm. whole ancient medical systems like ayurveda, siddha, and tcm etc use natural herbs either as a single drug therapy or in the form of formulations, depending upon principles of respective medical system. studies done on various herbs and mind body intervention like, yoga, acupuncture etc are found to be beneficial for t dm. this resulted, large number of physicians either referring to or practicing some of the more prominent and well known forms of cam. the concepts proposed and used by these cam systems (that are kept alive by cam practitioners for thousands of years) appear very mysterious to the present day biomedical practitioners. these models of therapies seem to have evolved through several phases of internal research just like the present day drug trials that go through four phases of intensive statistical evaluation. it appears that today's scientists need to follow the footsteps of research used by the ancient seers of tcm, ayurveda, siddha, yoga or homeopathy to unravel these mysterious theories. this review talks about generating evidence not only for the efficacy of these holistic systems but also in carrying out systematic research by biomedical scientist who have the knowledge of both the western and eastern sciences. background: the epidemic of obesity, over the last two decades, in the middle and high income countries is associated with marked rise in the incidence of metabolic syndrome. objective: to measure the prevalence of metabolic syndrome (ms) and determine its association with ratio of omega- /omega- fatty acids in the diet. design and methods: cross-sectional surveys were conducted in urban streets in the city of moradabad, india. randomly selected subjects with ms aged years and above were evaluated and graded according to omega- /omega- ratio in the diet. physical examination, sphygmomanometer, questionnaire and blood tests were done. results: the overall prevalence of ms was . % (n = ) without any gender difference. the prevalence of ms, type diabetes, cad and hypertension showed a higher rate, in relation to omega- /omega- ratio in the diet. subgroup analysis showed that subjects eating low omega- /omega- ratio (< . ) diets had significantly lower prevalence of ms, and related components compared to higher ratio diets, among both sexes. multivariate logistic regression analysis after adjustment of age showed, that hypertriglyceridemia (odds ratio . in men, . in women) was strongly (p < . ) associated with ms. hypertension, hdl-c, and central obesity were weakly associated with ms in both sexes. hypercholesterolemia was weakly associated with ms only in women. conclusion: ms has become a public health problem in india. higher w- /w- ratio is a major risk factor of ms and cad. it is possible that a low w- /w- ratio in the diet (< . ) may be protective against ms. objective: investigate the differences in clinical and laboratory features (including some adipocytokines) among hyperglycemic patients with or without cad. methods: five hundred and sixty-one consecutive hyperglycemic subjects undergoing coronary angiography. hyperglycemia [diabetes mellitus (dm)/pre-diabetes (pd)] previously known dm or diagnosed at the moment of recruitment by an hba c (hplc) levels-! . - . %-pd, ! . %-dm (ada criteria). cad defined by any lesion ! % on angiography. results: . % were men. age was . ae . (mean ae sd), cad was detected in . % of individuals. patients with cad were older ( ae vs. ae years, p = . ), more often male ( % vs. %, p = . ). additionally, they showed a worse metabolic profile, with higher hba c ( . ae . % vs. . ae . %, p = . ), fasting plasma glucose ( ae vs. ae mg/dl, p = . ), triglyceride [ ( - mg/dl) vs. ( - mg/dl), (p = . )] and plasma visfatin/nampt levels [( . ( . - . ng/ml) vs. . ( . - . ng/ml), (p = . ), median/interquartile range], and lower hdl-cholesterol levels ( ae vs. ae mg/dl, p < . ), even after correction for statin use (except for hdl and visfatin/nampt). diabetic patients with cad had greater diabetes duration than diabetic individuals without cad: . ( . - ) vs. . ( - ) years, median and interquartile range, (p = . ). systolic and diastolic blood pressure, homa%-s, homa-ir, total and high-molecular weight adiponectin levels were similar in both groups. conclusions: patients with hyperglycemia and cad have a worse glycemic and lipid profile and higher visfatin/nampt levels as compared to those without cad. one hundred and sixty-nine patients (p) with the mets were studied to find out the incidence of cardiovascular events, especially myocardial infarction and strokes. the mean age was years. fifty-five percent were males and females. the mean body mass index was kg/m . the mean fasting blood sugar was mg/dl. ninety-seven percent were diabetic type ii and % diabetic type i and the lipid profile was normal. the studied population showed a higher incidence of atrial fibrillation, when compared with a comparison group of diabetics ( % vs. . %) p < . . no ventricular tachycardia was observed. the mets group showed a subnormal ejection fraction ( ae %) when compared with a comparison group ( ae %) p < . . no myocardial infarctions or strokes were detected. coronary angiography was done in % of the (p) all were negative except one. the lower ejection fraction was explained on basis of diabetic cardiomyopathy. the genetics profile of the puertorrican, a hispanic population, is more of an european, indian and african. probably, this produces a culture less sensitive to the atherosclerotic factors, producing a less aggressive mets syndromeless myocardial infarcts or strokes. this suggest that genetics and culture is an important aspect of the expression of mets, especially in the hispanic world. objectives: controversy surrounds the annual progression from prediabetes (impaired glucose regulation) to type diabetes. current uk statistics suggest a % progression rate. our aim was to assess subjects in our locality at high-risk of progression from pre-diabetes to type diabetes within a month period. this will establish whether current recommendations for follow-up of high-risk subjects successfully identify those with pre-diabetes. methods: analysis was performed on data from high-risk subjects who underwent ogtt with baseline clinical and biochemical measurements. the ogtt and biochemical measures were repeated at months. results: of the subjects, ( . %) developed diabetes within the month period, significantly higher than the estimated annual progression rate (p . ). as expected, baseline fasting plasma glucose was higher for subjects that progressed to diabetes (diabetes vs. no diabetes: . ae . vs. . ae . mmol/l; p . ), as was h post-prandial plasma glucose (diabetes vs. no diabetes: . ae . vs. . ae . mmol/l; p . ). additionally, baseline hba c was higher for those that developed diabetes [diabetes vs. no diabetes: . ( . - . ) vs. . ( . - . ) %; p = . ]. interestingly, both sbp and dbp were significantly higher at baseline in those that developed diabetes (sbp: ae . vs. ae . mm hg; p = . ) (dbp: ae . vs. ae . mm hg; p = . ). conclusions: within this cohort, progression to type diabetes was almost twice the current estimated annual rate. fasting, h-glucose, hba c and blood pressure were associated with progression from prediabetes to type diabetes over months. methods: tissue lysates from visceral fat samples of subjects undergoing abdominal surgery (predominantly bariatric and routine non-acute for non-malignant conditions) were collected from subjects categorised as l ( ), o ( ) or odm ( ). a commercially available comet assay (cell biolabs, inc) was used to assess cellular dna damage using a single cell gel electrophoresis method. additionally, results indicate a greater percentage of dna migration from the comet "head" to its "tail" within odm samples (l vs. o vs. odm: . vs. . vs. . %; p = . ). in conclusion, results suggest that visceral fat from obese subjects with type diabetes are subject to higher levels of oxidative burden resulting in a higher proportion of damaged dna. community medicine, faculty of medicine, kuwait university, jabriya, kuwait background: the prevalence of overweight and obesity are high in kuwait. metabolic syndrome is associated with both. it is expected to find the syndrome to higher than in other countries. objective: to assess the prevalence of ms using two different diagnostic criteria, the international diabetes federation (idf) and the national cholesterol education program-third adult treatment panel modified for age (ncep-atp iii). study design: a multi-stage random sample study. methods: the analysis of data for this study was based on a sample of male kuwaiti adolescents, - years of age selected from intermediate and high schools. anthropometric measurements and biochemical tests on blood samples were carried out. the idf criterion requires waist circumference (wc) plus two of the following criteria: triglycerides (tg), high density lipoprotein (hdl), fasting blood sugar (fbs) and blood pressure (pb). the atp iii criterion requires three of the above parameters. the parameters mentioned must show increase in their values except for hdl which must show decrease in either criterion used. results: each of the two criterion revealed that the prevalence of ms was . % and . %, using the idf and the atp iii criteria, respectively. hdl decreased in each of the two diagnostic criteria and the other four parameters increased, satisfying the diagnostic requirements of either criterion. conclusions: significant implications may be drawn from these results, especially when it comes to being at risk of type diabetes (t d) and cardiovascular disease (cvd). m. saghebjoo , j. shabanpour omali , r. fathi university of birjand, birjand, mazandaran university, babolsar, iran background and aims: resistance training has been shown to be beneficial in older adults. however, very little data exist on the effects of resistance training in older diabetics. chemerin is a adipokine that has been shown to induce insulin resistance in skeletal muscles. here we investigate the role of weeks of progressive resistance training (prt) on plasma chemerin levels in older men. methods: a total of sedentary men with type diabetes, aged between and years, were randomized to the weeks supervised prt (n = ) and control (n = ) groups. chemerin, insulin, glycosylated hemoglobin (hba c), and fasting blood glucose (fbg) were measured before and h after the training period. results: plasma chemerin levels decreased significantly (p = . ) in the , and exhibited significant reductions in plasma insulin (p = . ) and fbg (p = . ). fbg decreased by . % in prt group. conclusion: reduced plasma chemerin concentration may contribute to improved insulin sensitivity. these results recognize that increased intensity of exercise may produce greater benefits, but may not be appropriate for some individuals. some studies have demonstrated the presence of metabolic syndrome in children and adolescents, but few have investigated this syndrome in brazilian children. the aim of this study was to investigate the prevalence of metabolic syndrome in children and its association with gender and nutritional status. this transversal epidemiological study involved children of both genders between . and . years old. there were collected sociodemographic, anthropometric, metabolic and hemodynamic data. the nutritional status was obtained according to the body mass index. to diagnose metabolic syndrome was used the criteria proposed by the national cholesterol education program′ s adult treatment panel iii adjusted for age. there were used two separate proposals (cook et al., ; ferranti et al., ) . the prevalence of metabolic syndrome ranged from . % to . %, depending on the criterion. the nutritional status showed . %, . % and . % of children with normal weight, overweight and obesity, respectively. significant association was observed between the metabolic syndrome and nutritional status, but not in relation to gender. metabolic syndrome was present in different nutritional status of children, especially those with excess body weight, thus indicating the importance of early diagnosis and the adoption of primary prevention measures already in pediatric patients. introduction: ifg (fpg . - . mmol/l) is a risk-factor for developing type diabetes and cardiovascular disease. we quantified changes in ifg prevalence (post-hoc analysis) from a double-blind, placebo-controlled trial investigating the effects of liraglutide . mg on maintenance of diet-induced weight loss (primary endpoint). methods: overweight/obese adults ( ! years, bmi ! or ! kg/m with comorbidities) who lost ! % weight after - week run-in with low-calorie diet ( - kcal/day) and exercise were randomised to once-daily subcutaneous liraglutide (n = ) or placebo (n = ), plus kcal/day deficit diet and exercise. the full-analysis-set comprised of randomised individuals [age . ae . years, bmi . ae . kg/m (mean ae sd)]. during run-in, participants lost . ae . kg weight and ifg prevalence decreased from % ( / ) to % ( / ). at week , liraglutide-treated participants lost an additional . kg from randomisation (table ) , whereas placebo-treated participants lost no additional weight [treatment-difference À . kg ( %ci À . ; À . ); p < . ]. moreover, the proportion of participants with ifg at week was lower for liraglutide ( . %) than placebo ( . %; odds-ratio . [ . ; . ]; p < . ). at week , after weeks off treatment, the liraglutide group regained~ kg lost weight and ifg prevalence increased. mean weight loss remained greater for liraglutide vs. placebo [treatment-difference À . kg (À . ; À . ); p < . ] but ifg prevalence did not differ (odds-ratio . [ . ; . ]; p = . ). conclusion: liraglutide decreases ifg prevalence in overweight/obese individuals who have already lost weight by diet and exercise, potentially due to additional weight loss and weight-loss independent mechanisms. objective: we wanted to explore the association between polymorphisms of irs (rs ), tcf l (rs and rs ), adrb (rs ), pparg (rs ), and hhex (rs ) genes with insulin resistance, lipid profile and atherogenic risk in mets patients from the mexican social security institute. methodology and results: four hundred and thirty-one mets patients and controls were selected. the association between the snps and the atherogenic index was evaluated by multiple linear regression and multinomial logistic regression models. adrb c/g were associated with an increase in ldl-c levels (β = . , % ci = . , . p = . ), the hhex t/c variant were statistically associated with an increase in total cholesterol levels (β = . , % ci = . , . p = . ), and with an increase in ldl-c levels (β = . , % ci = . , . p = . ). the adrb gene showed a statistically significant association with high-risk atherogenic index, (or = . , ic % . - . ; p = . ) for the arg/gly variant and for the dominant model (or = . , ic % . - . ; p = . ). conclusions: the arg gly polymorphism of the adrb gene may be a good biological marker to predict the risk of developing cardiovascular diseases given a high-risk atherogenic index. aims: describe the knowledge of major risk factors for type diabetes held by primary health care (phc) nurses involved in the community management of diabetes. methods: random sample ( %) of phc nurses in auckland. information was collected from postal and telephone questionnaires, on education, experience, knowledge and diabetes management practice. results: responses were received from phc nurses ( % response) comprising practice nurses (pns), district or homecare nurses (dns) and specialist nurses (sns). most nurses ( %) were able to identify excess body weight as a major risk factor for type diabetes. only % of sns and a third of pns and dns identified lack of physical activity, and fewer than % of sns and pns, and only % of dns identified hypertension as risk factors. even fewer respondents were able to identify individual lipidsalthough significantly more sns identified elevated triglycerides ( %, p = . ) and reduced high-density-lipoprotein cholesterol ( %, p = . ) as major risk factors compared with only - % of pns and no dns. risk factors for diabetes-related complicationsapart from hyperglycaemia identified by %were not well identified, particularly smoking ( %), hypertension ( %), triglycerides ( %) and reduced high-density-lipoprotein cholesterol ( %). in general, phc nurses had a good knowledge of overweight as a risk factor for type diabetes and hyperglycaemia as a risk factor for diabetes-related complications, but poor knowledge of cardiovascular risk factors, particularly smoking. yoga and life sciences, swami vivekanand yoga anosandhana samsthana (s-vyasa university), bangalore, india metabolic syndrome is clustering of different metabolic abnormalities which encompass central obesity, insulin resistance and hypertension. it is characterized by an overdrive of the sympathetic nervous system, increased oxidative stress, elevated pro-inflammatory enzymes, and impaired circadian cycle. lack of physical exercise, improper eating habits, and psychological stress are also common contributing factors to this condition. thus, life style change which includes adequate exercise, proper diet and stress management are the keys in prevention control and treatment of metabolic syndrome. yoga, one of the ancient sciences on earth, is known to bring balance at all aspects of human existence. its different components like asana (physical postures), pranayama (breathing techniques), meditation and relaxation techniques (yoga nidra) etc have been proven to influence body and the mind towards balance and equanimity. recent scientific studies on yoga have proven its safety and efficacy in the management of many metabolic disorders which includes diabetes mellitus, obesity, hypertension and atherosclerosis. yoga therapy has also caused reduction in the pro-inflammatory cytokines in such conditions. yoga reduces sympathetic tone as well as oxidative stress; it helps in reducing insulin resistance by enhancing secretion of melatonin and hepatic insulin sensitizing substance through bringing the parasympathetic dominancy. thus, we propose that yoga has an important role in prevention and treatment of metabolic syndrome as a complementary or as an alternative to conventional line of treatment. s. debnath , s. addya medical laboratory technology, women's polytechnic, medical officer, government of tripura health services, agartala, india introduction: saliva is an excellent biological matrix that offers several opportunities for scientific inference of diagnostic, toxicological and in forensic importance. numerous salivary metabolites proffer great potential in clinical and epidemiological research. sample collection is non invasive and analysis require simple modifications. establishing good correlates is the need. objective: our objective was to study the association between anthropometric measures (ams) with salivary metabolites in a subsample (n = ) of college women in suburban north east india. method: saliva and blood samples were photometrically analyzed for glucose, protein and urea. ams as bmi and waist circumference (wc) were measured in female students of menstruating age ( - years) following who guidelines. ams were correlated (pearson's correlation, ′r′) to salivary biochemistry. results are reported with intra assay coefficient of variation (cv < % all assays) in the text. ′ four day diet dairy′ was maintained over the period. results: salivary biochemistry found to be significantly correlated to ams in the studied subsample. salivary protein was negatively correlated (′r′ = À . ) with bmi and with wc (′r′ = À . ) whereas salivary glucose (′r′ = . with bmi and ′r′ = . with wc) and urea (′r′ = . with bmi and ′r′ = . with wc) had positive correlation. all assays performed in triplicates .we observed very good repeatability of results. medicine -cardiology, massachusetts general hospital, boston, ma, usa introduction: obesity is an independent risk factor for cardiovascular disease. supine bike stress echocardiography is suggested to be of particular utility for evaluating for coronary artery disease (cad) in obese individuals given the lack of mechanical impact with this modality. database for all recumbent bicycle stress echocardiography examinations performed between january , and july , . all tests performed to evaluate for cad were reviewed. two groups were formedpatients achieving ! % of maximum predicted heart rate (mphr) and those achieving < % mphr. medical records of these patients were then reviewed. comparisons between groups were made using unpaired t-tests and correlations between patient characteristics and hr were assessed using pearson's correlation. results: four hundred and sixty tests were done to evaluate for cad. one hundred and eighty-one ( . %) patients failed to reach % mphr during testing. forty-three percent of patients failing to achieve % mphr were obese (bmi > ) vs. % of all patients referred for stress testing. image quality among obese patients was not notably worse compared to leaner patients. those failing to achieve % mphr had a significantly higher bmi ( . vs. . ; p = . ) than those with adequate hr response. bmi exhibited a negative correlation with percent mphr (r = À . , p = . ). conclusion: obesity is associated with failure to achieve ! % mphr during supine bike stress echocardiography done to evaluate for cad. use of adjunctive pharmacologic agents should be considered when evaluating an obese patient for cad with stress echocardiography. ( ): - ), though the extent to which body weight may act as a confounder or as mediator in this relationship is uncertain. the aim of this study was to analyze whether the association between crf and mets risk is mediated by body mass index (bmi). methods: cross-sectional study including schoolchildren, - years old from the province of cuenca, spain. we measured height, weight and crf ( -m shuttle run test). a validated mets index (diabetes care ; : - ) was estimated by summing standardized z scores of waist circumference, triglyceride-to-hdl-c ratio (tg/hdl-c), mean arterial pressure (map), and fasting insulin. to test whether the association between crf and mets index and its components was mediated by bmi, linear regressions models were estimated according to baron and kenny procedures for mediation analysis (j pers soc psychol. ; : - ) . results: in girls, bmi acts as a fully mediator for the relationship between crf with mets index and all its components, except for tg/ hdl-c ratio. in boys, bmi acts as a fully mediator for the relationship of crf with tg/hdl-c ratio and map; and partial mediator for the relationship between crf with mets index and the rest of components. the obesity mediates the association between crf and mets in schoolchildren. good levels of crf are associated with lower mets risk, but only when accompanied by weight reduction. pre intervention measurement was applied. no statistical differences were found for prediabetes knowledge, physical activity, eating habits, bmi, weight, waist circumference and clinical parameters (glucose, triglycerides and total cholesterol) between both groups in basal measurement. the control group received the usual care from health centers. in the study group, the intervention was developed during months per patient (received usual care plus remote care model′s components). the rct will end at january , and the final results will be presented. chronic conditions. this study compares the prevalence of the metabolic syndrome (mets) between genders in the workplace. methods: as part of the established "prosiect sir gâr" initiative in south wales, uk, female and male employees from either the local steel works or local health board were screened and their data analysed. anthropometric data, blood pressure, self-reported physical activity (gppaq) and smoking status were all recorded. in addition, blood samples were obtained and analysed for high-densitylipoprotein cholesterol (hdl-c). presence of the mets was determined based on the following idf criteria: central obesity (females waist circumference: ! cm; males waist circumference: ! cm), reduced hdl-c levels (females: < . mmol/l; males: < . mmol/l) and either systolic ( ! mmhg) or diastolic ( ! mmhg) hypertension. results: a higher proportion of males were diagnosed with mets than females ( . % vs. . %; p < . ) despite the males being more physically "active" or "moderately active" ( . % vs. . %; p < . ). rates of central obesity and systolic hypertension were comparable between genders (p > . ), however prevalence of diastolic hypertension, reduced hdl-c levels, current smokers and individuals either overweight or obese were higher in the male cohort (p < . ). conclusion: despite being more physically active, males were more susceptible to the mets than females, likely due to a higher percentage of smokers and either overweight or obese. conclusions: the addition of glp analogues to insulin therapy seemed to be superior to the enhancement of insulin therapy regarding to weight loss, decreases of hba c, hypoglycemic episodes and requirements of insulin. it was also observed a significant improvement in insulin sensitivity and in beta cell function. background and aims: type diabetes is often associated with nonalcoholic fatty liver disease (nafld). patients with nafld may be at greater risk for cvd than those without. the relationship between nafld and metabolic syndrome (ms) is very well recognized. the aim: to determine the association of nafld and cvd between type diabetic patients with and without ms. materials and methods: one hundred and thirty type diabetic patients (m: , f: , mean age . + . ), were studied. all subjects were assessed for diabetes duration, the obesity degree, cv risk factors, hba c, c reactive protein and lipid profile. nafld was assessed by patient history and ultrasound. ms was defined based on ncep-atp criteria. the previous and current cvd (myocardial infarction, angina or revascularization) was assessed. we categorized four groups: ms (À) and nafld(+), ms(À) and nafld(À), ms(+) and nafld(+), ms(+) and nafld(À). results: the prevalence of cvd in type diabetic patients with nafld was higher than in those without nafld ( . % vs. . %). the prevalence of chd in type diabetic patients with ms was higher than in those without ( . % vs. . %). the risk of chd in patients with ms was significantly increased by the presence of nafld ( . % vs. . %). in type diabetic patients with ms(+) and nafld(+) the number of components of ms, bmi, and systolic bp were positively associated with chd. conclusions: what this study suggests to us is that the presence of nafld increases the risk of cvd in type diabetic patients with ms. and to determine associations between the levels of fasting blood sugar and its comorbid conditions. this is a retrospective study and uses chart review in the outpatient section of the family medicine clinic. it also uses percentages, means and its standard deviations, and chi square to detect associations. there were patients with impaired fasting glucose aged between and years old (mean age . ae ) and all were of filipino ethnicity. there were more females than males. the mean body mass index was . ae . kg/ m and the mean fasting blood sugar (fbs) was . ae . mg/dl. there was no association between the fbs level and obesity (p > . ) and hypertension (p > . ) in this study. however, fbs > mg/dl was associated with the presence of family history of diabetes in this population (p < . ). it seemed that ifg can occur to young, nonobese patients with family history of diabetes. this study recommends that screening for ifg among filipinos should be done to all patients with a strong family history of diabetes regardless of age, gender, bmi status or presence of hypertension. h. hasan, v.l. raigangar, a.r. abdullah methods: a cross-sectional study of young females (mean age . ae . years. leptin, insulin, high sensitivity c-reactive protein (hs-crp), c-peptide, ua, bg, hdl-cholesterol and triglycerides were estimated from a fasting blood sample. anthropometric parameters (wc, height and weight) and bp were measured. homa-insulin resistance was also calculated. results: mean wc of the studied population was . ae . cm, % (n = ) had wc > cm. for the subjects, all studied parameters were within normal limits except leptin which was high; . ae . ng/ml. ua showed highly significant positive correlation with wc (r = . , p < . ), significant positive correlations with cpeptide, hs-crp and leptin with (r = . , p = . ), (r = . , p = . ) and (r = . , p = . ) respectively. ua demonstrated significant negative correlation with hdl only (r = À . , p = . ). multiple linear regression revealed that wc was the only significant predictor of ua levels (b = . , p = . , ci %: . - . ). conclusion: this study stresses the importance of ua levels in cvd particularly due to its strong association with wc, the main indicator of abdominal obesity in mets that is often missed. ua may hence be considered a valuable biomarker for early prediction/detection of mets in young females. background: adipocyte-secreted cytokines are associated with inflammation and metabolic disturbances but it is unclear how their snps interfere on the response to lifestyle interventions. we assessed associations of selected snps with the changes induced by interventions. methods: this -month intervention on diet and physical activity included brazilians at cardiometabolic risk (prediabetes or metabolic syndrome without diabetes). changes in clinical variables were analyzed according to the presence of the tnfa- g/a, il- - g/c and adipoq t/g snps; individuals with at least one variant allele were grouped and compared with the reference genotype. afterwards, individuals carrying simultaneously the genotypes associated with no glycemic response were grouped and compared to the remainder sample. results: the entire sample ( . ae . years) had lower energy intake, higher physical activity, and improved anthropometric and metabolic variables after intervention. carriers of the tnfa variant allele but not the reference group decreased plasma glucose. il- and adipoq variant allele carriers had worse glucose, lipid and inflammatory responses. grouping the subset of carriers of tnfa- g + il - c + adipoq g, they showed a significant increase in mean fasting glucose after intervention. this increment differ significantly from the behavior of the remainder sample (+ . % vs. À . %, p = . ). the tnfa- g/a but not the adipoq t/g and il- - g/c may predispose a better response of glucose metabolism to a lifestyle intervention. the combination of three worst genotypes can maximize the adverse effect on glucose metabolism in at-risk brazilians. further studies are needed to direct lifestyle interventions to specific subgroups of individuals. obesity is a metabolic disorder, which is associated with an increased risk of various conditions, including sexual dysfunction. objective: to investigate anthropometric indicators of body fat in postmenopausal women influencing their quality of life. material and methods: the study was performed at the scientific and clinical study of endocrinology, uzbekistan public health ministry. a total of women (mean age of years) was examined. bmi, waist circumference and waist to hip ratio were obtained for anthropometric evaluation. lipid specters, glycemia and insulin were the parameters to evaluate. we have used a menopause quality of life questionnaire and female sexual function index questionnaire (fsfi). the quality of life of the obese and overweight patients was compared by age, education, marriage and matched with healthy normal weight controls. results: overweight and obesity were observed in of women. values of wc > cm were above normal levels in %, . %, respectively, and hdl was normal in . %. homa -ir was measured in . % of the women. women with overweight and obesity had worse general health-related quality of menopausal symptoms, life and psychological and sexuality scores than athletic and lean women (bmi ! ). in fsfi it was significant differences in such as scales as desire and orgasmic disorders in women with metabolic syndrome (ms) in comparison with the controls (p < . ). aim: to determinate groups of high cardiovascular risk and start early hypolipidemic therapy due to genetic polymorphism of lipoproteidlipaseone of the main enzymes of lipid metabolism in metabolic syndrome and nafld patients, treating with combined therapy of statins and ursodeoxycholic acid (udca). background: health staff receive more health messages and information in working hours than others. moreover, they are supposed to be healthy models for the community. we conducted a screening of metabolic syndrome on shahid beheshti university health department staff (who are responsible for health affairs of more than million people in tehran province, iran) to assess their health level. we invited all of the health staff for screening on "the world heart day". weight, height, waist circumference, systolic and diastolic blood pressure were measured and a fasting blood sample was taken for lipid and glucose level testing. results: fifty percent of the staff ( person) participated in the screening. the mean age was . ae . years. only % were in normal weight range. overweight, obesity class and class rates were %, . % and . %, respectively. . % of all and . % of normal bmi cases had a high waist circumference. metabolic syndrome was identified in . % of men and . % of women. high blood pressure was detected in . % of the cases. in . % of all and . % of overweight or obese cases fasting blood glucose was elevated. these rates for blood total cholesterol level were . % and . %, for triglyceride were . % and . %, and for ldl were . % and . %, respectively. conclusions: contrary to our expectations, a high rate of metabolic syndrome was identified in this group. it seems that interventional programs targeting nutritional habits and physical activity of the staff are needed along with routine educational programs. introduction: physiologically, brain natriuretic peptides (bnp) and lipolysis are closely linked. obesity is been identified as a major risk factor for the development of cardiovascular diseases (cvd) and has been reported to have an impact on bnp in apparently healthy subjects but also in cvd patients. thus, we speculate that bnp could play an important role in lipid metabolism and may affect the pathophysiology of obesity in cvd patients. methods: serum samples were obtained from cvd elderly patients distributed in two groups: i-non-obese and ii-obese. the plasma mature form of brain natriuretic peptide (nt-probnp) was measured by a sandwich enzyme immunoassay with spectrophotometric detection at nm. conclusion: overall, these data demonstrates that obesity is an important and independent determinant of bnp expression in patients with cvd. inverse relationship between bnp and body mass index may suggest "beneficial" effects of obesity, but clearly lower levels did not confer a more favourable prognosis. the precise mechanisms linking obesity to cvd remain unsolved and may be due either to release attenuation or increases in clearance receptors. these effects should be taken into account for appropriate bnp reference values, so lower cut-points should be used for obese patients and a higher cutpoint for lean patients to increase specificity. v. mladenovic , a. djukic , s. djukic , n. arsenijevic , s. zivancevic simonovic aim: the aim of this study was to investigate dynamic of changes of oxidative stress during acute myocardial infarction depending on development phases of metabolic syndrome x. method: the research included patients; inclusion criteria were diagnosed metabolic syndrome and acute myocardial infarction. according to the movements of glycemia and insulinemia all patients were divided in four development phases of metabolic syndrome x. to evaluate oxidative status we determinated: lipid peroxids (malonyldialdehide), total antioxidative status, as well as oxidative stress coefficient. results: during hospitalisation in patients with acute myocardial infarction concentration of lipid peroxids increased, with maximum in the day th of hospitalisation, mostly in hyperinsulinemic phases of metabolic syndrome. at the st day of myocardial infarction total antioxidant status increased, and decreased during next days. these changes are independent on the phase of metabolic sindrome x. as result of inverse dynamic changes of these parametars, during period of exam came to progressive increase of oxidative stress coefficient, particularly in patients in hyperinsulinemic phase of metabolic syndrome x. conclusion: during first days after acute myocardial infarction lipid peroxids concentration progressively increased, with decrease of total antioxidant status, that results in increase of oxidative stress. these changes are most distinctive in patients with hyperinsulinemic phases of metabolic syndrome x. introduction: glp- (exenatide -lilly) is a good therapy for overweight or obese type diabetic patients, but bid administration might not be effective over h. aim: we intended to evaluate h effectivness of this drug in our outpatients using continuous glucose monitoring (gcm-medtronic). methods: we asked our outpatients to undergo a continuing glucose monitoring for days. twelve of them accepted [ f and mol/l, median age (range - ), median disease lenght years (range - )] and signed an informed consense; they had stable metabolic control with hba c < mmol/mol and had been on therapy with exenatide for months at least. results: glycemic profile demonstrates that no patient had experimented prolonged hypoglycemia and all subjects, expept for one, had mainteined a long period of euglycemia in range - mg/ dl during the blood glucose monitoring. conclusions: it′s our opinion that these data demonstrate exenatide can be surely used in type patients to obtain a good and stable metabolic control during all h inspite of the bid somministration and, moreover, the age or the disease lenght are not to be considered a contraindication to its use. several parameters of vascular function and structure have a predictive value for cardiovascular morbidity-mortality and for the presence of associated target organ damage in diabetic and hypertensive patients. superoxide dismutase (sod) is an intracellular antioxidant defense mechanism, which catalyses the dismutation of superoxide radical into h o and oxygen, and it is easily detectable in human plasma; oxidative stress is associated with cardiac and vascular defects leading to hypertension and atherosclerosis and with diabetic cardiomyopathy. on the other hand, osteoprotegerin (opg) is an indicator of diabetes-associated vascular pathologies as hypertension, endothelial dysfunction and cardiovascular risk. we have assessed the relationship between serum levels of sod, opg and parameters of vascular function and structure as well as cardiovascular risk in type diabetic patients with and without hypertension. there are negative correlations between sod and endothelial dysfunction (evaluated by pressure wave velocity, peripheral and central augmentation index and ambulatory arterial stiffness index), pulse pressure, diastolic and systolic night/day ratio, serum opg and plasma hdl-cholesterol, as well as positive correlations between sod and plasma uric acid, liver enzymes got, gpt and ggt, triglycerides and haemoglobin. on the other hand, serum opg is correlated to endothelial dysfunction, intima media thickness, pulse pressure, systolic night/day ratio and d′agostino cardiovascular risk index. our study shows that both sod and osteoprotegerin plasma levels are indicators of cardiovascular events and target organ damage associated with diabetes and hypertension. objective: we investigated the future coronary artery disease (cad) event rate in diabetic patients with and without chest pain in a prospective cohort study performed in a korean population. we also investigated the impact of chest pain on cad risk according to the presence or absence of diabetes mellitus. research design and methods: the ansung-ansan cohort was established for a prospective large-scale community-based epidemiologic study to investigate chronic diseases in korea. the data from a baseline survey performed from to and two subsequent prospective biennial surveys were analyzed. results: among subjects ( men and women) without a history of cad, . % and . % of non-diabetic and diabetic subjects, respectively, reported newly developed cad events during years of follow-up. diabetic patients had a significantly higher risk of future cad events (age-and sex-adjusted odds ratio, . ; % confidence interval, . - . ; p = . ). although the presence of chest pain at baseline was also significantly associated with an increased risk of cad of more than -fold in both non-diabetic and diabetic subjects (p < . ), the hazard ratio for cvd event in asymptomatic diabetic patients compared to non-diabetic subjects with chest pain was not significantly different from . (hazard ratio, . ; % confidence interval, . - . ). conclusions: diabetes and the presence of chest pain are independently and significantly associated with future cad event risk. asymptomatic subjects with diabetes have a comparable risk of cad events to non-diabetic subjects presenting chest pain. aim: the aim of the study was to select and analyze patients with diabetes mellitus and acute stemi or nstemi myocardial infarction from all patients hospitalized in cardiology department in . results: more patients with nstemi underwent pci in the history than patients with stemi (n = , . % vs. n = , . %); p = . and more pci and cabg (n = ; . % vs. n = ; %); p = . . concentrations of cpk (nstemi vs. stemi) (u/l) ( ae vs. ae ) p < . , ckmb (u/l) ( ae vs. ae ), p < . , glucose on admission (mg/dl) ( ae vs. ae ), p < . . patients with nstemi had less critical changes in the left anterior descending artery (lad) ( . % vs. . %); p = . , less bare metal stents (bms) implanted to the lad ( . % vs. . %one stent), and ( % vs. . %two or more stents), p = . . management of this patients shows figure . patients with stemi require more intensive treatment of more advanced concomitant metabolic disturbances. revascularization should by performed urgently because of higher death rate. during qualification for invasive diagnostic and treatment (pci and/or cabg), not only the risk of death and cardiovascular events should be taken into account, but also a history of revascularization modalities (pci and cabg). methods: a total of diabetic patients both sexes aged . ae . years were studied. the levels of total cholesterol (tc), triglycerides (tg), hdl-cholesterol (hdl-c), ldl-cholesterol (ldl-c), vldl-cholesterol (vldl-c), hba c and renal function tests were assessed. patients were classified as normoalbuminuric (albumin excretion rate < mg/ h, n = ), microalbuminuric (albumin excretion rate - mg/ h, n = ) and proteinuric (albumin excretion rate > mg/ h, n = ). results: the duration of diabetes was . ae . years. the level of tc was significantly highest in proteinuric ( . ae . mmol/l), followed by microalbuminuric ( . ae . mmol/l) and followed by normoalbuminuric ( . ae . mmol/l), (p = . , p = . , respectively). patients with proteinuria had significantly higher level of ldl-c compared to the patients with normoalbuminuria ( . ae . vs. . ae . mmol/l, p = . ). patients with microalbuminuria had significantly higher level of ldl-c compared to the patients with normoalbuminuria ( . ae . vs. . ae . mmol/l, p = . ), as well. the level of hba c in normoalbumiuric patients was significantly lower than in microalbuminuric ( . ae . vs. . ae . %. p = . ). there were no significant differences in levels of tg, hdl-c, vldl-c between patients with normoalbuminuria, microalbuminuria and proteinuria. conclusion: we showed that higher levels of ldl-cholesterol and tg were associated with microalbuminuria and proteinuria in patients with type diabetes. lowering atherogenic lipids may retard nephropathy progression in these patients. s. bonakdaran , b. kharaqani endocrine research center, mashhad university of medical sciences, mashhad, iran background: the relationship between elevated serum uric acid level and metabolic syndrome (ms) has been debated. we aimed to determine the prevalence of hyperuricamia and its association with ms in type diabetes mellitus (dm). methods: this was a cross-sectional study in diabetic patients. hyperuricamia was defined as uric acid ! and ! . mg/dl for men and women respectively. diagnosis of metabolic syndrome was based on atpiii criteria. clinical and biochemical parameters in hyperuricaemic and normouricaemic patients compared with other. results: the prevalence of hyperuricaemia and metabolic syndrome was . % and . % respectively. the prevalence of ms significantly increased in the highest quartile of uric acid levels compared with lowest quartile ( . % vs. . %, p < . ). serum uric acid had positive association with cholesterol, triglyceride, non-hdl cholesterol and a negative association with fasting blood sugar (fbs), glycosylated hemoglobin (hba c) and hdl cholesterol. possible biochemical predictors of hyperuricamia were cholesterol, triglyceride, creatnine and fbs. conclusion: the prevalence of ms and its components increase with increasing levels of uric acid in type diabetes. regular assessment of uric acid could give information for predicting of ms and prevention of atherosclerosis in type diabetes. materials and methods: in subjects (aged . ae . ) who have received recommendations on hypotensive and hypoglycemic therapy at diabetes school. psycho-correctional work has been carried out with people (group ) in order to increase treatment motivation and the work has not been carried out with people (group ). the effect has been evaluated after months according to the results of -h blood pressure monitoring ( -h bpm). results: according to moriski-green test % appear to be nonadherent to treatment. as a result only in group there has been recorded reduction in variability indices sbp (mm hg) at night ( . ae . vs. . ae . ; p = . ), daily index sbp ( . ae . vs. . ae . %; p < . ) and dbp ( . ae . vs. . ae . %; p = . ), rate in morning increase sbp ( . ae . vs. . ae . mm hg; p = . ) and dbp ( . ae . vs. . ae . mm hg; p < . ), which are high risk indicators of cardiocerebral catastrophe. after months of patients have become adherent to treatment in group (p = . ), only patients of in group (p = . ) (moriski-green test). conclusion: psycho-correctional training improves adherence to treatment, which is accompanied by positive dynamics of -h bpm indicators. introduction: quality of life is particular decreased in elderly with diabetes mellitus (dm), even not associated with other chronic illness. the purpose of the study was to analyze the quality of life in a group of elderly diabetic patients without major complications. the study group consisted of patients, males and females, aged over years old [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , diagnosed with type dm. they had no severe dm complication, nor other debilitating chronic diseases. the romanian version of the sf- questionnaire was used to measure quality of life (qol). diabetic subjects were compared with age-and gender-matched controls from a random standard population sample of the romanian population. results: reliability of scales by coefficient alpha cronbach was > . for all scales except social functioning. qol scores for study group were significantly lower compared with controls. there are no significant differences between patients following insulin therapy and patients with other therapeutic protocols. role limitations due to emotional problems correlate with disease duration and female gender. there is a significant correlation between energy/fatigue scores and female gender, hba c, fasting plasma glucose and obesity. there are no other statistically significant correlations between sf- scores and analyzed variables. discussions and conclusions: patients with dm have statistically significant impairment of all aspects of qol. dm put a substantial burden on affected individuals. insulin use didn't seem to have a negative impact upon qol. glycemic control is crucial in preventing long terms complications and provides better qol for diabetic patients. the study involved patients with nstemi and with ua hospitalized in cardiology department in . the data obtained from patients were statistically analyzed to determine the significance of the differences between the groups. results: glucose on admission was lower in patients with ua ( ae mg/dl) than with nstemi ( ae mg/dl), p = . . treatment of dm in patients with nstemi and ua shows figure . patients with nstemi presented lower left ventricular ejection fraction ( ae %) vs. ua ( ae %); p < . and higher mortality during hospitalization. seven patients ( . %) with nstemi died, whereas no patient died in ua group (p = . ). . to determine whether aaa patients found to be at higher risk of osa were also at increased risk for cardiometabolic disease, compared to those at low or no risk of osa. design: the berlin questionnaire to estimate osa was administered to elderly patients with or at increased risk of aaa disease along with several measures of cardiometabolic risk, including the lipid accumulation product (lap), a measure that combines triglyceride levels with central obesity (waist circumference), also known as hypertriglyceridemic waist. results: in this sample (n = ), subjects ( . %) scored clinically positive for risk of osa on the berlin questionnaire. next, individuals were separated into groups based upon the three subclasses of the berlin questionnaire: snore (frequent loud snoring), eds (excessive daytime sleepiness), and htn-bmi (hypertension and high bmi). the combination of snore + eds subclasses, when used to differentiate subject's risk levels for osa, was highly accurate for discriminating low, moderate, and high cardiometabolic risk, based upon significant differences in bmi, insulin (lu/l), waist circumference (cm), waist/hip ratio, low density lipoprotein cholesterol (ldl-c mg/dl), and lap (anova; p < . ). conclusions: these results give credence to the clinical use of the snore + eds portions of the berlin questionnaire to provide simple estimates of increased risk of t dm and cvd and/or need for further evaluation such as polysomnography or oral glucose tolerance. materials and methods: from to , t dm were cumulatively collected for study. accordingly, anthropometric and biochemical data, lifestyle measurements (lifestyle i : no smoking, no alcoholic and regular exercise; lifestyle ii : smoking and/or alcoholic and/or no exercise), total daily caloric intakes and macronutrient consumptions were recorded. the eating habits were classified by fat consumption, high fat diet (fat > %) and low fat diet (fat %). the mets defined was based on the atp iii criteria. patients were obligatorily classified into six groups, mets with waist component, waist required and non-waist required; mets without waist component, with two and more than two components; non-mets with waist and without waist component. each component of mets in these six groups with different combination of lifestyle and eating habit, were presented by case number and percentage distribution. or for the clustering of each metabolic component in these six groups were analyzed. results: the case number, percentage distribution and corresponding or for the clustering of each metabolic component in these six groups were shown in table and . the clustering of metabolic components of tg, hdl-c and bp were significantly higher in lifestyle ii, lifestyle i and high fat diet eaters respectively. objectives: early detection of metabolic syndrome is important in minimizing morbidity and motility. we conducted a study to detect wether serum leptin can be used as a biological marker to detect metabolic syndrome. methods: a group of healthy pre-menopausal females, aged - years was selected from the local community, randomly, stratified according to their bmi. leptin was assessed by the elisa method and, blood pressure was measured using digital blood pressure monitor and chemical analysis for fasting blood, glucose and lipid level were conducted using colorimetric method. body weight and height, hip and waist circumferences were measured, using standard protocols. in subjects with and without metabolic syndrome mean serum leptin values were . (ae . ) and . (ae . ) ng/ml respectively. compared with subjects without metabolic syndrome, subjects with metabolic syndrome had a higher serum leptin level (mean difference À . , and % confidence interval À . to À . , p = . ). conclusion: subjects with metabolic syndrome had a higher serum leptin level in comparison with subjects without metabolic syndrome therefore leptin can be utilized as a surrogate marker to predict metabolic syndrome. conducted a study to detect relationship between serum leptin and cardiovascular risk factors in obese and non obese individuals. methods: a group of healthy pre-menopausal females, aged - years was selected from the local community, randomly, stratified according to their bmi. body weight and height were measured, using standard protocols. serum leptin was assessed by elisa and, blood pressure was measured using digital blood pressure monitor and chemical analysis for fasting blood, glucose and lipid level were conducted using colorimetric method. results: there was a statistically significant inverse correlation between serum leptin level and mean blood pressure in obese (bmi ! ) individuals and subjects with systolic blood pressure > mmhg. corresponding r values were r = À . and r = À . (p < . for both). in subjects with bmi < or in normotensive subjects, there were no statistically significant correlations between serum leptin and mean blood pressure. correlations between serum leptin and total cholesterol, triglycerides, hdl, ldl, cho/hdl and fasting plasma glucose were . , . , . , . , . , . respectively and not statically significant (p . for all). conclusion: due to the presence of inverse correlation between serum leptin and mean blood pressure in obese, and individuals with high systolic blood pressure, it can be concluded that serum leptin may play a different role in pathogenesis of cardiovascular diseases in such individuals. r. irzma nski, j. błaszczyk, l. pawlicki, j. kowalski the aim: the aim of our study was to assess the influence of metabolic syndrome (ms) risk factors on vascular complications in patients with ms. material and methods: the study comprised patients ( women and men, avg. age . ae . years) with ms, which was diagnosed according to idf criteria . results: the prevalence of micro and macrovascular complications was assessed: vascular changes in the fundus of the eye - %, ischaemic heart disease - . %, egfr < ml/min - . %, diabetic foot - . %, cerebro-vascular accident - . % of patients. the negative correlation between hdl concentration, creatinine levels and level of vascular changes in the fundus of the eye was found. moreover the level of obesity and fasting glucose level had positive correlation with the intensitz of vascular changes in the fundus of the eye. objectives: to estimate malnutrition prevalence among newly hospitalized overweight/obese patients; to characterize malnutrition by body weight category; and to assess associations between bmi, duration of hospitalization and in-hospital death in malnourished patients. methods: this cross-sectional survey assessed nutrition status in all adults newly admitted to internal medicine and surgical departments at the e. wolfson medical center, holon, israel. data were recorded during the -week data acquisition period and screening for malnutrition risk was performed using the nrs . an age-adjusted score of ! on the nrs defined malnutrition. malnutrition was compared across body weight categories: underweight (bmi < . kg/m ), normal (bmi . - . kg/m ), overweight (bmi - . kg/m ) and obese (bmi ! kg/m ). overweight/obese subjects were compared by malnutrition status. results: a total of individuals were analyzed, of whom were overweight/obese (bmi ! kg/m ). of these, ( . %) were malnourished. compared to adequately nourished overweight/obese subjects, malnourished overweight/obese patients had significantly prolonged duration of hospitalization: . ae . (median , - days) vs. . ae . (median , - days), (p = . ). in-hospital mortality was . % among malnourished vs. . % among adequately nourished overweight/obese patients, p = . . malnutrition increased duration of hospitalization and in-hospital mortality risk in both overweight/obese and normal weight patients. discussion: malnutrition is a frequent finding in newly hospitalized overweight/obese adults. elevated bmi does not affect duration of hospitalization. in-hospital mortality rates are similar for normal weight and overweight/obese individuals. background: the purpose of this study was to examine differences in rmr in lean and obese subjects and to determine correlation between rmr and cardio metabolic risk factors. methods: ninety nine healthy subjects ( normal; obese and over weights) participated in this case-control study. sex and physical activity were matched. blood pressure, plasma insulin, glucose, homa-index, lipid profile, uric acid and c-reactive protein concentrations, anthropometric measurements, body composition, rmr and macronutrient intake were measured. result: fpg (p = . ), uric acid (p = . ), crp (p = . ), insulin (p < . ), homa index (p < . ), systolic and diastolic blood pressure (p = . ; p = . ), anthropometric measurements (except height and whr) (p < . ) and body composition (p < . ) were significantly higher in case group. there were no significant differences between both groups by the means of dietary intake. in obese and overweight group, rmr was statistically higher than control group (p = . ). there were no significant difference between both groups in adjusted rmr for ffm and fm (p = . ). with multiple linear regression, rmr was significantly associated with ffm (p < . ) and uric acid (p < . ) and negative significant correlation was observed between rmr and waist circumference (p = . ) and hdl (p = . ). the finding of a similarly specific metabolic rate in obese and lean subjects at first sight contradicts the idea that a low rmr is a main cause of obesity. one reason for the undetected association between low rmr and obesity may be that obesity-related metabolic risk factors mask the lower metabolic rate that initially contributed to weight gain. background: pain may cause some patients to avoid self-monitoring, which could impair glucose control. cooling the fingertip prior to puncture may reduce pain. objectives: to examine the efficacy of coolsense, a device designed to cool the fingertip prior to puncture for glucose self monitoring. methods: adults with type diabetes treated at the e. wolfson medical center diabetes unit outpatient clinic were randomized to treatment with the coolsense device or a sham device which appeared identical to the active intervention but did not cool the fingertip. patients completed a demographic and medical history interview and were asked to rate the device for discomfort and satisfaction. results: a total of patients were recruited and randomized to intervention group (coolsense vs. sham, n = in each group). participants were ae . years of age, had been diagnosed with diabetes ae . years prior to study onset and had mean hba c of . ae . %. patients reported performing . ae blood glucose checks per day. the extent to which glucose checking caused pain was rated at . ae . out of a possible five points, one being most severe. the coolsense device was a significant independent predictor of pain reduction, even after controlling for age, sex, hba c, aspirin, neuropathy and baseline rating of pain associated with glucose check. conclusions: cooling the fingertip with the coolsense device significantly reduced pain at the puncture site compared to a sham device. it is possible that this reduction in pain will increase glucose self monitoring events in patients with diabetes. f. saad , , a. yassin , , g. doros results: after years the following changes were observed: weight (kg) decreased by . kg from . introduction: testosterone treatment in hypogonadal men is standard therapy, particularly in younger men with congenital forms of hypogonadism. methods: three hundred thirty-three patients ( with primary hypogonadism including patients with klinefelter's syndrome, with secondary hypogonadism and with late-onset ("mixed" or "metabolic") hypogonadism aged - years (mean ae years) received intramuscular injections of mg of testosterone undecanoate during a maximal treatment time of years, overall corresponding to treatment years. hypogonadism was defined as total testosterone below nmol/l and occurrence of symptoms. physiological functions of bile salts include modulation of cholesterol and triglyceride metabolism, insulin sensitivity, the intestinal endocrine response to meals and energy homeostasis. several of these functions are mediated via the membrane g-protein coupled receptor tgr (also called gpbar and gpr ) which has been shown to promote release of glucagon like peptide- from enteroendocrine cells and increase energy expenditure in brown adipose tissue. methods: based on comprehensive discovery platform developed at satrx several in vivo active tgr inhibitors were discovered. active scaffolds were identified during the high throughput screening campaign of , tgr biased small heterocyclic molecules library that was optimized for medchem parameters and cell permeability. confirmed selective hits were evaluated for functional activity of glp secretion in nci-h endocrine cell line. in vivo activity was confirmed in db/db mice diabetes model. active compounds were administered chronically at doses , and . mg/kg and produced stable and statistically significant anti-diabetic effect. results: the most active compound showed efficacy comparable to mg/kg doses of sitagliptin. the actual activity data and experimental details will be provided. the interaction between excess of body fat (total and abdominal) and increased cardiovascular risk is well established in all age groups [ , ] . however, there are few studies that analyze the pattern of body fat distribution and its association with cardiovascular risk factors (crfs) in a population with more advanced age. objective: to analyze the presence of crfs according to the pattern of body fat distribution, in brazilian aged years or older. methods: one hundred and thriteen subjects, randomly selected, . ae . years, of both sexes. the percentage of total and abdominal body fat, hypertension and lipid profile were used for characterization of crfs. the chi-square test was used to assess proportions of crfs and mann-whitney test was used to compare the results between distributions of adiposity. results: eutrophic subjects showed lower triglycerides (p = . ), total cholesterol (p = . ) and prevalence of hypertension (p = . ) and hypertriglyceridemia (p = . ). subjects with higher abdominal adiposity showed higher total cholesterol (p = . ) and prevalence of hypertriglyceridemia (p = . ) and hypercholesterolemia (p = . ) than no excess of abdominal adiposity. higher value of one outcome already reflects the higher prevalence of hypertension (p = . ) and, the higher values of both outcomes reflect the high values of total cholesterol (p = . ) and triglycerides (p = . ). conclusion: that obesity, whether abdominal or total, is associated, in the same way, with dyslipidemia and hypertension in the subjects aged years. background/aim: there is growing consensus in the literature that inflammation plays a central role in the pathophysiology of obesity and type diabetes mellitus (t dm) and cardiovascular complications. neutrophil-to-lymphocyte ratio (nlr) provides a simple method for assessment of inflammatory status and it is a new, inexpensive marker. the aim of the present study was to investigate the predictive value of preprocedural (before the ogtt) nlr on development of prediabetes (pd) and type diabetes (t dm) in morbid obesity patients (mop). methods: mop and normal weight patients with normal ogtt [fasting plasma glucose (fpg) < mg/dl. two-hour glucose during ogtt < mg/dl] were evaluated in this study. results: the mean ae sd nlr of mop were significantly higher than that of patients with normal weight healthy patients ( . ae . vs. . ae . , p < . , respectively). in receiver operating characteristics curve analysis, nlr > . had % sensitivity and % specificity in predicting pd and nlr > . had % sensitivity and . % sepesifity in predicting t dm. logistic regression analysis showed that elevated nlr (or: . , % ci: . - . , p < . ) was an independent variable for predicting t dm in mop. conclusion: mop have higher nlr than healthy controls. high nlr is a powerful and independent predictor of pd and t dm in mop. elevated nlr levels are usually considered as an inflammatory marker. the results of this study suggested that inflammation plays a role in the pathogenesis of pd and t dm with mop. division of human nutrition, wageningen university, wageningen, general surgery, rijnstate hospital, arnhem, gastroenterology, rijnstate hospital, arnhem, the netherlands objective: endoscopic implantation of a duodenal-jejunal bypass liner (djbl), or endobarrier, is a novel bariatric technique to induce weight loss and remission of type diabetes (t d). placement of the djbl mimics the duodenal-jejunal bypass component of the roux-en-y gastric bypass (rygb) procedure. as gut hormones are known to change substantially after rygb surgery, in our study we now evaluated gut hormone responses after implantation of the djbl. methods: fourteen (eight male, six female) obese t d subjects (bmi . ae . kg/m , duration of type diabetes . ae . years) were selected for implantation of a djbl. fasting plasma levels of glucose, c peptide, hba c and gut hormones ghrelin, gip and glp- were analysed before and at and days after djbl implantation. results: plasma hba c levels were significantly decreased after djbl implantation and a % reduction was found in diabetes medication usage (p < . ). ghrelin was found significantly elevated, with the highest induction in the first days post-implant. although the gip response showed high variation between subjects, gip tended to decrease days after implantation (p = . ). glp- levels showed a significant "dip" at day post-implant, which correlates with the intake of solely pureed/liquid food in the first week post-implant. conclusions: implantation of a djbl results in an early substantial remission of t d, comparable to results seen after rygb surgery. interestingly, in contrast to rygb surgery, implantation of the djbl seems to preserve normal physiological responses of gut hormones that are related to nutritional status. conflicting data exists as to the association between body mass index (bmi) and the rate of chronic kidney disease (ckd). in a cross sectional analysis of database from a screening center in israel we assessed the rate of ckd defined as estimated glomerular filtration rate (egfr) < ml/min per . m in relation to increasing bmi subcategories. the study population included , subjects, % women aged - , out of whom men and women had ckd. subjects with a bmi of - . (kg/m ) compared to subjects with bmi < (kg/m ), had an odds ratio (or) [ % confidence intervals (ci)] for ckd of . ( . - . ) and . ( . - . ) for men and women respectively. for subjects with a bmi of - (kg/m ) the or were . ( . - . ) and . ( . - . ) for men and women respectively. for subjects with bmi > (kg/m ) the or rose to . ( . - . ) and . ( . - . ) for men and women respectively. this association became insignificant in men after multivariate adjustment for age, hypertension and diabetes mellitus but persisted in women even after multivariate adjustment. the correlation between bmi and ckd in women was attributed to the subcategory of severely obese women with bmi above (kg/m ). our study suggests that for both men and women a positive correlation exists between the degree of bmi and the rate of ckd. this correlation persisted in severely obese women even after multivariate adjustment, suggesting that in women, obesity may be an independent risk factor for developing ckd. the enteroendocrine cell line pgip/neo stc- was used to evaluate the effects of gspe on glp- secretion in different nutrient conditions. a cytotoxicity detection kit (ldh) and brdu labelling and detection kit iii (roche) were used to determine cytotoxicity and cell proliferation, respectively. glp- levels in cell culture medium were determined using a glp- (active) elisa kit (millipore). cytotoxicity and proliferation cell assays (n = ) demonstrated that the maximum non-toxic gspe treatment for these cells was mg/l gspe over a period of h. surprisingly, after h of gspe treatment, glp- secretion (n = ) was significantly inhibited. this inhibitory effect was observed at concentrations as low as mg/l. furthermore, inhibition of glp- was also observed when stc- cells were co-incubated gspe and lmol/l dihomo-ϒ linoleic acid. in conclusion, acute gspe incubation decreases glp- secretion in cultured enteroendoncrine cells. interestingly the effect occurs under either on basal or nutrient (fatty acid) stimulated conditions. c. higa , f. novo , m.s. donato , n. rizzo , g. ciambrone , e. korolov , p. comignani coronay unit, hospital aleman, buenos aires, argentina introduction and aim: there is no data available respect of the prognostic value of albumin:creatinin ratio (acr) in non-st-segment elevation acute coronary syndrome (nseacs). the purpose of our study was to evaluate the long term prognostic value of acr in patients with nseacs. methods: we analyzed a prospective cohort of nseacs in whom acr was determined at admission. roc curves were constructed to determine best cut off value associated with primary end-point of death or nonfatal myocardial infarction (d/ami). independent variables for d/ami were assessed by a cox regression model. : seven hundred ten patients with nseacs were analyzed. thirty percent were female and median age was years. median follow up time was months. best cut-off point of acr for primary end point was mg/g. thirty-four percent of patients had acr ! mg/g. acr correlated with higher incidence of primary end point both in diabetics and in non-diabetic patients: or . (ic . - ), p = . and or . (ic % . - ), p = . , respectively. by multivariable cox regression analysis, acr was an independent predictor of d/ami at long-term follow up: hr . (ci % - ), log rank p < . in a model that included age, female gender, diabetes mellitus, serum creatinine, creatinine clearance, glucemia at admission a, elevated cardiac markers and st segment deviations. conclusions: acr was an independent predictor of adverse outcomes in nseacs. this simple and accesible marker should be considered for risk stratification in this high risk setting. aim of the work was to examine possible connection of methabolic syndrome with endothelium dysfunction in pre and postmenopausal women with and without ischemic heart disease (ihd). methods: hundred and eight-nine pre and postmenopausal women with ihd were examined and in same age without ihd. all women were measured arterial pressure using korotkov method (according to jnc- recommendations). vasa regulating function of endothelium examined with ultrasound in triplex scanning using reactive hyperemia probe (method by d. celermajer). willebrant factor determined in blood plasma. results: in group of women with ihd ( %) had arterial hypertension: among them ( %) in pre and ( %) postmenopausal. among women without ihd ( %) had hypertension: ( %) were pre-and ( %) postmenopausal. during reactive hyperemia probe diameter of radial artery was: women with ihd . ae . mm; speed of blood flow . ae . m/s, willebrant factor . ae . ; women without ihd corresponding . ae . mm (p < . ) and . ae . m/s (p < . ), willebrant factor . ae . (p < . ) where there significant difference was noted. findings allows us to suppose, that women with ihd have higher abundance of arterial hypertension, that in connection with other components of metabolic syndrome, specify development of endothelium dysfunction, in comparison with women without ihd, which have arterial hypertension, endothelium dysfunction infrequently. objective: recently, incretin-related drugs are widely used for improving blood glucose level in clinical practices. in this study, we tried to examine the efficacy and safety of these drugs of the japanese approved dose. we compared the efficacy and safety of the human glp- analogue liraglutide (the approved dose . mg) with the dipeptidyl peptidase- (dpp- ) inhibitor sitagliptin (the approved dose mg) once daily in the obese adults with type diabetes, over weeks. methods: japanese obese out-patients whose glycemic control was inadequately controlled with oral hypoglycemic agents received either maximum weeks of treatment with . mg lilaglutide (n = ) or mg sitagliptin (n = ) once daily within the period from march to october , at chubu-rosai hospital. the primary endpoint was change in body weight. other measurements were hba c, lipid profiles, body weight, body mass index, serum creatinine, estimated gfr, and adverse events before and at , , , weeks after liraglutide or sitagliptin administration. results: at the japanese approved dose, the greater reduction of mean body weight was achieved with liraglutide than with sitagliptin (À . kg, p < . , + . kg, p = n.s. vs. baseline). the degrees of lowering hba c (both . % at baseline) were À . % for liraglutide and À . % for sitagliptin (both p < . at baseline). the egfr of the sitagliptin group worsened from . to . ml/min/ . m (p < . at baseline). the most common adverse events were gastrointestinal symptoms ( ( %) patients on . mg liraglutide). conclusion: liraglutide provides greater body weight reduction over weeks even at the japanese approved dose of . mg. objective: to examine prevalence of cardiovascular risk factors in patients with type diabetes and stroke in primary care setting. methods: study was conducted at primary health center tuzla and included all patients with type diabetes and stroke who were registered in one family medicine team. we also calculated absolute cardiovascular risk according to the european guidelines on cardiovascular disease prevention in clinical practice. results: prevalence of stroke in diabetic patients was . %. significantly more women had stroke than men ( . % vs. . %; p = . ). mean age of patients was . ae . years. men were significantly older than women ( . ae . vs. . ae . ; p = . ). majority of participants belonged to age group > years ( . %). mean duration of diabetes was . ae . years. more than half of patients ( %) had diabetes - years, . % had diabetes - years, and . % patients had diabetes > years. family history for diabetes had . % patients. the most prevalent cardiovascular risk factors were hyperlipidemia ( . %) and hypertension ( . %). obesity was present in % patients, and . % patients had family history for premature cardiovascular disease. unhealthy diet had . % patients, . % were physically inactive, and % diabetic patients were smokers. mean absolute cardiovascular risk was . ae . %; . ae . % in men, . ae . % in women. men had significantly higher absolute cardiovascular risk than women (p = . ). conclusion: prevalence of cardiovascular risk factors in patients with type diabetes and stroke were very high. it indicates more effective strategies in primary care setting to reduce risk of macrovascular and microvascular complications. the prevalence of metabolic syndrome was determined as a crosssectional study among healthy saudi adults ( % males and % aged - years) attending national guard clinics using the definition proposed by ncep atpiii. the prevalence of metabolic syndrome was %. only one third of the participants had normal weight (bmi = . - . ). central obesity based on waist circumferences was noted in % of males and % of females. low hdl-c showed the highest prevalence ( %) followed by high tg ( %). about % of participants had impaired fasting blood glucose ( ! mg/dl). only % had high blood pressure ( ! / mmhg). more than three quarters ( . %) of the respondents had ! component of metabolic syndrome. in conclusion, metabolic syndrome needs to be addressed as an important health problem in the gulf region. background/aim: adequate treatment and monitoring of diabetes can significantly improve quality of life and extend life expectancy in diabetic subjects. aim of this study was to examine metabolic control in patients with type diabetes in primary care setting. methods: study was conducted at primary health center tuzla and included randomly selected patients with type diabetes, aged years and over, from one family medicine team. we evaluated parameters of metabolic control in patients with type diabetes according to the european guidelines on cardiovascular disease prevention in clinical practice. results: there were significantly more women than men ( . % vs. . %; p < . ). mean age of patients was . ae . years. mean duration of diabetes was . ae . years. only ( . %) patients had blood glucose < . mmol/l, and ( . %) patients had hba c < . %. controlled blood pressure / mmhg had ( . %) patients. only ( . %) patients had total cholesterol < . mmol/l, while ( . %) patients had triglycerides < . mmol/l. normal body mass index (bmi) < kg/m had ( . %) patients and recommended waist circumference ( . %) patients. mean blood glucose was . l ae . mmol/l, hba c . ae . %, systolic blood pressure . ae . mmhg, diastolic blood pressure . ae . mmhg, total cholesterol . ae . mmol/l, triglyceride . ae . mmol/l, bmi . ae . kg/m , waist circumference . ae . cm. conclusion: metabolic control of type diabetes in family medicine practice was inadequate which indicates more effective interventions in order to achieve appropriate metabolic control of diabetes and reduce risk of complications. aim: the aim of the study was to determine the metabolic responses to two different liquid milk protein diets in prediabetic and healthy volunteers. the diets were composed of . g whey or casein protein, g maltodextrin and g lactulose or . g maltodextrin and g lactulose (control). procedures: fifteen prediabetic and healthy volunteers consumed all liquid test diets with blood sampling over a h time period. blood glucose, incretin hormones, nefas, hydroxybutyric acid and plasma amino acids were analyzed. the feeling of hunger was determined using a visual analog scale. results: in both, prediabetic as well as healthy volunteers, postprandial blood glucose levels were significantly decreased and plasma insulin levels were significantly elevated with the protein diets compared to the control diet. gip and glp- levels also increased after the protein-contaning test-diets. in the prediabetic volunteers, changes in glucose, insulin, amino acids, non-esterified fatty acids and hydroxybutyric acid displayed time delayed changes. a reduced feeling of hunger was reported in the prediabetic compared to the control group. conclusion: both protein components elevate insulin secretion and cause reduced blood glucose auc and these effects are more pronounced in prediabetics. however, despite differences in the amino acid composition, casein and whey protein did not reveal significantly different effects. postprandial changes in plasma metabolites in prediabetics suggest more metabolic pertubations than just impaired glucose disposition. methods: ins- e cells or freshly isolated rat islets were incubated for h in the presence of either leptin or tnf-a at lower ( . nmol/l or ng/ml) or higher concentration ( nmol/l or ng/ml) individually or in combination. proinsulin mrna was detected by real time-pcr, insulin by radioimmunoassay kit, β cell proliferation were tested with mtt assay and β cell apoptosis was determined with annexin v-fitc/pi by fluorescent activated cell sorting. results: higher leptin ( nmol/l) or tnf-a ( ng/ml) significantly suppressed gsis (p < . ) and reduced the intracellular proinsulin mrna level and insulin content (p < . ) in ins- e cells and primary islets. whereas, lower leptin ( . nmol/l) or tnf-a ( ng/ml) did not show such effects. however, the inhibition effects were compromized when two factors were simultaneously administrated in either cultured ins- e cells or pancreatic islets. similarly, higher leptin or tnf-a was able to inhibit ins- e cell proliferation and promote cell apoptosis. again, these effects were alleviated in the presence of both factors. furthermore, western blotting showed that tnf-a inhibited leptin receptor (ob-rb) expression, decreased the phosphorylation of stat . conclusion: tnf-a exerts antagonistic effects on leptin actions in pancreatic β cells by interfering with ob-rb/jak/stat signaling pathway. increased tnf-a level may contribute to the pathogenesis of hyperinsulinemia and disturbed glucose metabolism in people with obesity. aims: identifying socioeconomic factors associated with the metabolic syndrome (mets) is useful to target preventive measures. our objective was to estimate, in france, the prevalence of metabolic syndrome (mets) and to investigate the association between socioeconomic position and mets. methods: the french national nutrition and health survey (enns) cross-sectional national multistage sampling was carried out from february to march . data included waist circumference and blood pressure measurements, blood sample and sociodemographic and medication information. the prevalence of mets was assessed using several definitions, including the most recent joint interim statement (jis). association with sociodemographic covariates was assessed using logistic regression models. results: among the participants - years of age, mets prevalence was found to vary from . % according to the national cholesterol education program definition to . % according to the jis definition, without difference between genders. after adjustment for other covariates, risk of mets increased with age in both men and women (for year: ora = . , p < À and ora = . , p < À ; respectively). in women, mets risk was inversely associated with education level; women with the lowest education level facing a six fold greater risk of mets (ora = . , p < À ). in men, risk of mets was higher in men born outside of france (ora = . , p = . ) than in french-born males. conclusions: mets prevalence is lower in france than in most industrialized countries. lifestyle modifications, targeted to migrants and persons living in low socioeconomic conditions, should contribute to further reducing mets. folate. patients were divided into two groups: group (homocysteine < lmol/l) and group (homocysteine ! lmol/l). results: the mean age was . ae . years. homocysteinemia was . ae . mmol/l. a significant correlation was found between homocysteine levels and the number of criteria for ms (p = . ). besides, a significant decrease of hyperhomocysteinemia (from . % to . %, p = . ), systolic blood pressure (from . ae . mmhg to . ae . mmhg, p = . ), uric acid (from . ae . lmol/l to . ae lmol/l; p < . ) and a significant improvement of hdl levels ( . ae . mmol/l to . ae . mmol/l, p < . ) were reported. a non significant improvement was observed for the other parameters. furthermore, a correlation was noted between the variation of homocysteine and hdl levels (p = . ). the association found between homocysteine and the severity of ms suggests a reflection on the cardiovascular risk caused by such association and on the importance of hyperhomocysteinemia screening in patients with ms. object of study and method: the patients with ms: of them presented with the recurrent form of af, had no arrhythmia. the groups were comparable in terms of age, concomitant disorders, arterial hypertension duration, arterial pressure, and severity of chronic heart failure. patients with permanent af, hemodynamically significant heart disease, myocardial infarction with wave q in the medical history, were excluded from the study. in a review of the diagnostic efficiency parameters showed statistically significant differences in the two groups, with the evaluation of their specificity (se), sensitivity (sp) and or (odds ratio). results: patients with ms having abdominal obesity and arterial hypertension over years (se . ; or . ( % . - . ); x = . ; p = . ); homa ir index more than . (se . ; or . ( % . - . ); x = . ; p < . ); reduced hdl cholesterol level below . mmol/l (se . ; or . ( % . - . ); x = . ; p < . ); left atrial dilation (se . ; or . ( % . - . ); x = . ; p = . ); albuminuria more than mg/day (sp . ; or . ( % . - . ); x = . ; p < . ); waist circumference more than cm (sp . ; or . ( % . - . ); x = . ; p = . ) were at high risk of af. the duration of abdominal obesity and hypertension for years, insulin resistance index > . , reduced hdl < . mmol/l, an increase in albuminuria > mg/day, an increase in waist circumference > cmrisk factors for af in ms. patients and methods: fifty-three patients with ms over , comparable in duration af, comorbidity and treatment. patients with permanent af, hemodynamically significant heart disease, myocardial infarction with wave q in the medical history, were excluded from the study. following a successful cardioversion all patients assigned amiodarone. group (n = ) in the adjuvant therapy prescribed metformin over - mg/day; group (n = ) metformin < mg/day, group (n = ) metformin is not assigned. the observation period is months. results: in group homairind decreased to . ae . (p < . compared with baseline), in the nd to . ae . (p > . ) and rd to . ae . (p > . ) (p - < . ), and improvement of lipid profile and increased gfr ( . ae . (p < . compared with baseline), . ae . and . ae . ml/min, in the st, nd and rd groups, p = . between groups); decreased volume of the left index atria ( . ae . (p < . compared with baseline), . ae . and . ae . ml, in the st, nd and rd); reduction in waist circumference ( . ae . (p < . compared with baseline), . ae . and . ae . cm, in the st, nd and rd). patients in group was maintained sr for much longer ( . ae . days) than in patients of the nd ( . ae . ) and the d group ( . ae . ) (p = . ; p - < . ; p - < . ). aims: metabolic syndrome (mets) is the serious health problem worldwide and is associated with increased risk of cardiovascular disease. mets has a significant genetic component which is estimated on - %. apolipoprotein a (apoa , omim acc. no ) gene and its variants have been associated with the plasma lipids, mainly triglycerides and its role in mets development is recently discussed. we have analyzed, if there is the association between the apoa gene haplotypes (based on the rs and rs variants) and mets in middle european -slavic population. methods: apoa haplotypes based on the presence of either common or at least one minor apoa allele (rs , c- and rs , g ) and the presence of mets were analysed in adults ( males and females, - years old) selected according the monica protocol and examined at / and / . the presence of mets was analysed according the ncep-atp iii criteria. results: in females with at least one minor apoa allele, the prevalence of mets was significantly higher both at / ( . % vs. . %, p < . ) and at / ( . % vs. . %, p < . ). in males, association between apoa gene and mets was not detected neither at / ( . % vs. . %, p = . ) nor at / ( . % vs. . %, p = . ). a. blazquez , o. garcia-sanchez , y. quiros , v. blanco-gozalo , m.j. montero , j.m. lopez-novoa , c. martinez-salgado , f.j. lopez-hernandez universidad de salamanca, ibsal, iecscyl-ibsal-university of salamanca, salamanca, spain diabetes commonly causes a type of chronic nephropathy, namely diabetic nephropathy (dn). diagnosis of dn is presently accomplished late in the course of disease. microalbuminuria anticipates progression towards dn only in a subset of patients. another subset of diabetic, microalbuminuric patients never develop dn. accordingly, new biomarkers are necessary to more accurately identify diabetic patients progressing towards dn. ngal has also been associated to progression to dn. on the other hand, hypertension is a well-known factor of co-morbidity in diabetic nephropathy. we decided to study the capacity of ngal to detect the additive effect of hypertension on progression to diabetic nephropathy. in the present work we aimed at unraveling the origin of the increased urinary ngal. spontaneously hypertensive rats (shr) or normotensive wistar rats were rendered hyperglycemic by a single administration of streptozotocin, or not (as controls). renal function was monitored and ngal was measured in urine, plasma and tissue samples. their kidneys were perfused in situ with krebsdextran solution (containing or not exogenous ngal), and urine was collected. plasma and renal tissue ngal was also measured by western blot, and renal ngal expression was determined by rt-pcr. our results suggest that the urinary ngal is increased by the coexistence of diabetes and hypertension, but not by each of these conditions. ngal excretion results from its altered tubular handling. this subtle and primary renal alteration might be studied further as an early marker of the increased risk of chronic renal disease posed by the co-morbidity of hypertension and diabetes. the increasing prevalence of obesity is a major public health concern. more than . billion adults, and older, were overweight, over million men and nearly million women of whom were obese in . large-scale studies have demonstrated that overweight and obesity increase the risk of developing several forms of cancer, including several that are not classically viewed as hormonedependent. in both men and women, increasing bmi is significantly associated with higher death rates from cancers of the oesophagus, colon and rectum, liver, gall bladder, pancreas and kidney, as well as non-hodgkin lymphoma and multiple myeloma. the associations between obesity and particular maignancies may be affected by body fat distribution, and may result from diverse factors including diet and abnormal levels of hormones and inflammatory cytokines. recently, there is more and more sufficient evidence that excess body weight is an avoidabl e cause of excess cancers including gastrointestinal, endometrial, esophageal adenocarcinoma, colorectal, postmenopausal breast, prostate, and renal cancers. the mechanism that obesity association with cancer is remains not well understood. there are some most studied hypothesized mechanisms such as, high levels of insulin and free levels of insulin-like growth factors (igfs), sex hormones, adipocytokines, inflammatory cytokines, c-myc oncogenic transcription factor, obesity-induced hypoxia and warburg effect, and so on. in the future, the potential mechanisms and conclusions in obesity associated with increased risk for developing cancer, and the underlying cellular and molecular mechanisms will be studied. results: among patients with ms (mean age: years; % male), ( %) had abdominal obesity, ( %) had a c > . %, ( %) had fpg > mg/dl and ( %) had homa > . . if we consider as ir indicators: . presence of prediabetes criteria (fpg > mg/dl and/or a c > . %); and/or . homa > . , patients ( %) met at least one marker of ir, but of them ( %) had homa < . [ ( %) of them were on therapy with metformin, an insulin-sensitivity drug]. in the multivariate analysis, presence of type diabetes (hr . ; p < . ) and presence of prediabetes criteria (hr . ; p < . ) were associated with homa > . discussion: although most of the patients with ms have clinical markers of ir (fpg > mg/dl, a c > . %), only a third part of them have homa levels associated with ir. these observations suggest that: of spilberger's test. from to women were followed for the incidence of ah. results: high level of anxiety (hla) in studied cohort revealed in . % of women. women with hla more often tried unsuccessfully to quit smoking compared to lower levels of anxiety ( . % and . %, respectively; x = . , p < . ). women with hla in twotimes less likely to follow the diet (x = . , p < . ) and assess their physical activity more passive (x = . , p < . ). relative risk (hr) of development of ah in women with hla during the first years of study was in . -fold higher ( . % ci: . - . ; p < . ), over years it was . ( . % ci: . - . ; p < . ) and hr was . ( . % ci: . - . ; p < . ) over years of follow-up compared to those with lower anxiety levels. depending on age groups the risk of ah incidence within years was highest in older group with hla aged - years (hr = . ; . % ci: . - . , p < . ). conclusions: there is high prevalence of hla in russian female population aged - . during years of follow-up women with hla have significantly higher risk of ah especially in older age groups. material and methods: under the third screening of the who "monica-psychosocial" (mopsy) program random representative sample of women aged - years (n = ) were surveyed in novosibirsk. d was measured at the baseline examination by means of test "mmpi". from to women were followed for years for the incidence of ah. results: the prevalence of d in women aged - years was . %. women with major d ( %) significantly extended negative behavioral habits: smoking and unsuccessful attempts to give it up, low physical activity, they were less likely to follow a diet. relative risk (hr) of ah in women with d during the first years of study was higher in . -time compared to women who had no d ( . % ci: . - . ; p < . ). with regard to age groups hr was significant in oldest age category - years (hr = . ; % ci: . - . ; p < . ). hr of incident ah in persons with d within years was . ( . % ci: . - . ; p < . ) and there were no significant differences in age groups. we did not have risk of ah over years of follow-up in women with d (p > . ). the prevalence of d in women aged - years is more than %. women with d had unfavorable lifestyle and higher relative risk of ah over the first - years of the study. purpose: study the association of high level of anxiety (hla) with vntr polymorphisms d and dat genes; determine the relative risk (hr) of arterial hypertension in men with hla. the who " monica-psychosocial" in monica-psychosocial" in , monica-psychosocial" in , surveyed a random representative sample of men aged - years ( men). to assess the level of anxiety was used spielberger's test. cox proportional regression was used for hr assessment. results: the hla in an open population of men aged - years was . %. since hla genotype was significantly associated / drd gene and genotype / gene dat. for years hla maximizes the hr of hypertension in the first years. conclusion: there is high prevalence of hla at male aged - in russian. hla were significantly associated with certain vntr polymorphisms of genes drd , dat; hla increases the hr of hypertension in the first years. inhibiting beta cell proliferation and promoting its apoptosis which concomitantly leads to decreased β cell mass. dermatology, faculty of medicine, cairo university, cairo, egypt background: psoriasis is a disorder with genetic and immunologic background. leptin can regulate the t-helper response. objective: our primary goal is to study the functional polymorphism (g- a) of the leptin (lep) gene in the genetic predisposition of psoriasis, and our secondary goal is to examine factors affecting plasma leptin levels in psoriasis, and to compare patients with and without metabolic syndrome (ms). methods: the study involved psoriatic patients and healthy controls. analysis of g- a polymorphism of the lep gene was made by the pcr and restriction fragment length polymorphism technique. the relationship between lep gene polymorphism and the clinical features of the patients was analyzed. plasma leptin levels and proportions of comorbidities in patients vs. controls were compared. results: in controls the ga, aa and gg frequencies were %, % and % respectively, while in patients the distribution of genotypes was . %, . % and . % respectively, with significant difference (p = . ) between patients and controls. in patients with ms the gg, ga and aa frequencies were . %, . % and . % respectively, while in patients without ms the distribution of genotypes was . %, % and . % respectively, with significant difference (p = . ) between both groups. plasma leptin showed a significant higher levels in the patients vs. the controls (p < . ), and among the different lep genotypes (p < . ) in the patients′ group. conclusion: lep g- a polymorphism could be a predictor for higher plasma leptin and increased risk of psoriasis and could be used as a marker for psoriasis-related comorbidity risk. introduction: contractile dysfunction, associated with disturbances in excitation-contraction coupling, has been widely demonstrated in diabetic heart. aims: the aim of this study was to investigate the pattern of mrna encoding cardiac muscle proteins that are involved in the process of excitation-contraction coupling in early onset type diabetic goto-kakizaki (gk) rat. methods: experiments were performed in gk and wistar control rats aged - weeks. gene expression was assessed in ventricular muscle with real-time rt-pcr, shortening and intracellular ca + were measured in ventricular myocytes with video edge detection and fluorescence photometry, respectively. results: expression of genes encoding some membrane pumps and exchange proteins were unaltered (atp a / , atp b , slc a ) whilst others were either upregulated (atp a ) or downregulated (slc a ) in gk ventricle compared to control. expression of genes encoding some calcium (cacna c/ g, cacna d / d , cacnb /b ), sodium (scn a) and potassium (kcna / , kcnj / / / / , kchip , kcnab , kcnb , kcnd / / , kcne / , kcnq , kcng , kcnh , kcnk , kcnn ) channel proteins were unaltered whilst others were either upregulated (cacna h, scn b, hcn ) or downregulated (hcn , kcna , kcna , kcnj ) in gk ventricle compared to control. the amplitude of ventricular myocyte shortening and intracellular ca + transients were unaltered however, the tpk shortening was prolonged and thalf decay of the ca + transient was shortened in gk myocytes compared to controls. conclusions: early changes in expression of genes encoding various cardiac muscle proteins are associated with disturbances in myocyte shortening and intracellular ca + transport. results: analysing level of tnf-alpha, we found that in group , there were significantly higher values than the control group by . times ( . ae . pg/ml: . ae . pg/ml, respectively), and significantly higher than patients without insulin resistance ( . ae . pg/ml). analyzing level of il- , the presence of ir, level of this cytokine increases by only a factor of ( . ae . pg/ml) relative to that of the control group ( . ae . pg/ml). in the second group, the level of il- ( . ae . pg/ml) was significantly higher than in group and exceeded the performance of control group by . times. analyzing the ratio of the level of tnf-alpha and il- , we have detected a significant increase in the coefficient tnf-alfa/il- in group ( . ae . ) compared with group patients ( . ae . ). that is, ir in chc patients gives a significant shift in balance of cytokines toward proinflammatory interleukins, which can be observed by increase of tnfalfa/il- over . (p < . by mann-whitney). conclusions: progression of ir in patients with chc is accompanied by an increase in ratio tnf-alfa/il- serum. beyond the value of . , chc patients will an require in-depth study for carbohydrate metabolism. cardiovascular medicine, international university of health and welfare sanno hospital, tokyo, japan background: hyperglycemia has been suggested as a significant factor in coronary microangiopathy in patients with type diabetes (t dm), but whether it can be reversed through treatment of hyperglycemia is unknown. aim: to clarify whether glycemic control can improve coronary microangiopathy in t dm. methods: subjects were t dm who underwent coronary angiography and age-matched controls. myocardial segments perfused by angiographically normal coronary arteries were studied. baseline myocardial blood flow (mbf, ml/min/ g) and mbf during dipyridamole administration ( . mg/kg/min) were measured using positron emission tomography (pet). myocardial flow reserve (mfr) was calculated by the ratio of mbf during dipyridamole administration to the baseline mbf. after the first pet study, patients were subdivided into an additional intensive therapy group (atg) and no-additional therapy (natg) group. second pet scan was performed - months later. results: baseline mbf was comparable among the atg ( . ae . ), natg ( . ae . ) and controls ( . ae . ). however, mbf during dipyridamole administration was significantly lower in both the atg ( ae . ) and natg ( ae . ) than in controls ( ae , p < . ) as was the mfr (atg, . ae . ; natg, . ae . ; controls, . ae . ; p < . respectively). mfr was significantly improved in the atg ( . ae . ; p < . ), but not in the natg ( . ae . ; p = ns). there was a significant inverse relationship between percent change in mfr and percent change in glycemic control. however, no significant relationships were seen between the percent change in mfr and percent change in plasma lipid fractions. conclusion: coronary microangiopathy in t dm can be reversed by intensive therapy for hyperglycemia. l. drimba, r. s ari, j. né meth, z. szilv assy, b. peitl background: our aim was to investigate the effect of "sui generis" hyperinsulinaemia on proarrhythmogenic electrophysiological changes and on cardiac arrhythmias. methods: euglycaemic hyperinsulinaemia was induced in chronicallyinstrumented conscious rabbits equipped with a right ventricular pacemaker electrode catheter. hyperinsulinaemia was induced by either or mu/kg/min insulin infusion and a variable rate of glucose infusion ensured the maintenance of euglycaemia ( . ae . mmol/l). the effect of hyperinsulinaemia on cardiac electrophysiological parameters and arrhythmia inducibility was studied by means of -lead surface ecg recording and by programmed right ventricular stimulation (prvs). the role of adrenergic activation was investigated by determination of plasma catecholamine level and by intravenous administration of beta adrenergic blocking agent, propranolol. results: both and mu/kg/min insulin infusion prolonged the pq and the tpeak-tend intervals and shortened the rverp, but no significant changes on other measures of ecg (hr, qt, qtc) were observed. the incidence of prvs-induced ventricular premature beats and non-sustained ventricular tachycardia was higher during euglycaemic hyperinsulinaemia than that of fasting state. we found that higher plasma level of insulin was occurred, the more inducibility of arrhythmias was seen. no change in plasma catecholamine level was observed, but the propranolol restored the prolonged tpeak-tend interval. our results indicate the "sui generis" proarrhythmic effect of hyperinsulinaemia due to reduction of the repolarization reserve in otherwise healthy rabbits. propranolol can be used safely for prevention of arrhythmia in patient with hyperinsulinaemia. euglycaemic hyperinsulinaemia is suitable method to induce acquired long qt syndrome in healthy rabbits. objective: this study investigated the prevalence of metabolic syndrome (mets) and its association with demographic, socioeconomic and behavioral factors in shift workers. a cross-sectional study was conducted on a sample of shift workers of both sexes in a poultry processing plant in southern brazil. the diagnosis of mets was determined according to the recommendations from "harmonizing the metabolic syndrome". the distribution of each of the components of mets was evaluated according to the demographic, socioeconomic and behavioral characteristics of the sample. the multivariate analysis followed a theoretical framework for determining mets on shift workers. the prevalence of mets on the sample was . % (ic % : . - . ). the most frequent altered component was waist circumference (rp . ; ic % . - . ). after adjustment, the prevalence of mets was positively associated with women (rp . ; ic % . - . ), workers of over years of age (rp . ; ic % : . - . ) and those who reported sleeping five or less hours per day (rp . ; ic % : . - . ). on the other hand, mets was negatively associated with higher educational level (rp . ; ic . - . ) and having more than three meals per day (rp . ic % . - . ). in addition, most of the altered components of mets were associated with sociodemographic characteristics, whereas only waist circumference and altered blood pressure were associated with behavioral characteristics. conclusion: sex, age, educational level, eating habits and duration of sleep appeared as independent risk factors for mets. arab world covers a vast geographic area, consists of countries with an approxiimate population of about million people. geographically, arab world is variable ranging from dry desert areas to heavily raining green land. this part of the globe is also unique for its wide cultural, social and ethnic variations. most of the countries are well-heeled with significant natural resources including oil, gas and are benefited from high income. the socio-economic progress has brought benefits in the region such as improved access to health care, education, and safe drinking water. this rapid economical change has also set the scene for the modern lifestyles activities, people are eating more and exercising less. these changes in the lifestyle cause variuos metabolic syndromes including obesity, diabetes mellitus. in spite of marvelous advancement in medical sciences, the most of the metabolic syndromes are still an incurable life-long disease and swiftly increasing in all over the world. presently, six countries including saudi arabia, bahrain, united arab emirates, kuwait, oman and egypt are among the world's highest for the prevalence of metabolic syndromes especially the diabetes mellitus. metabolic syndromes placed a great burden on the public health and clinical practice in the region. v. negrean , o. mislea , i. cheta , t. alexescu , i. chisalita internal medicine, umf iuliu hatieganu cluj-napoca, cluj-napoca, umf 'victor babes' timisoara, timisoara, romania introduction: it is known that type diabetes is a major cardiovascular risk factor, but the relationship between impaired fasting glucose (ifg) and the occurrence of cardiovascular events is still undefined. objectives: to determine whether the ifg is a risk factor for cardiovascular disease. results: twenty-four percent of the patients with ifg progressed to diabetes and % from the control group were diagnosed with this condition. twenty-one percent of the patients with ifg and % from the patients in the control group were diagnosed with hbp. sixty percent from the patients with ifg and % of the patients in the control group were obese, % from the subjects with ifg and % from the subjects in the control group show ischemic heart disease. fifty-five from the patients with ifg and % from the patients in the control group declared that they practice no physical activity. there was a significant correlation between the presence of ifg and the hbp (or = , p < . ), the absence of physical activity (or = , p < . ), obesity (or = , p < . ), ischemic heart disease (or = , p < . ). conclusions: our study shows that ifg is correlated with the cardiovascular risk: patients with ifg have three times higher risk to develop hbp, six times higher risk to be obese and three times higher risk to have ischemic heart diseses. introduction: : the most common investigated factors in chronic inflammation in type diabetes are increased c-reactive protein level, erythrocyte sedimentation rate. the matrix metalloproteinases are a family of proteolytic molecules which contribute to adipose tissue abnormalities. metalloproteinase (mmp- ) has a significant contribution to development of complications of diabetes. aim: : the assessment of the inflammation intensity in patients with type diabetes mellitus and the examination of mixed meal influence on mmp- plasma level. materials and methods: : twenty subjects were qualified to this study. all of them were diabetics on insulin treatment. concentrations of mmp- were estimated at fasting state and after mixed meal challenge (elisa). we also measured body mass, bmi, systolic and diastolic blood pressure and: esr, crp, daily average glucose, hba c. results: : mmp- concentration values were higher in fasting state in comparison to in postprandial state. mmp- correlates with esr, crp, bmi, average daily glucose level and body weight. however, there are no significant correlations between mmp- and hba c. conclusions: : there was a statistically significant positive correlation between serum metalloproteinase and exponents of inflammation, such as erythrocyte sedimentation rate, c-reactive protein. after the mixed meal we observed a significant decrease of metalloproteinase concentration in relation to its concentration in the fasting state. it was shown that the concentration of metalloproteinase depends on short-term metabolic control of type diabetes, not depending on long-term control of the disease. background: several studies suggest increased oxidative stress and reduced endothelial function in obstructive sleep apnoea syndrome (osas). we assessed the association between osas, endothelial dysfunction and oxidative stress. the effect of nasal continuous positive airway pressure (ncpap) on oxidative stress and arterial dysfunction was also evaluated. we studied consecutive patients with heavy snoring. patients underwent overnight home polysomnography. ten patients with severe osas were revaluated after months of ncpap therapy. oxidative stress was assessed by measuring urinary -iso-pgf a and serum levels of soluble nox -derived peptide (snox -dp). serum levels of nitrite/nitrate (nox) were also determined. flow-mediated brachial artery dilation (fmd) was measured to asses endothelial function. results: polysomnographic indices were correlated with the metabolic score, insulin levels and central obesity indices. severe osas had higher urinary -iso-pgf a (p < . ) and serum nox and lower nox. a negative association was observed between fmd and osa severity. apnea/hypopnea index was correlated with urinary isoprostanes (r = . , p < . ). metabolic syndrome (t = À . , p < . ) and urinary -isoprostanes (t = À . , p < . ) were the only independent predictors of fmd. after -months of ncpap treatment, a significant decrease of serum nox , (p < . ) and urinary -iso-pgf a (p < . ) was observed, while serum nox showed only a minor increase. a statistically significant increase of fmd was observed (from . % to . %). conclusions: our study indicates a strong association between osas and metabolic syndrome. patients with osas and cardiometabolic comorbidities have increased oxidative stress and arterial dysfunction that are partially reversed by ncpap treatment. pendyffryn medical group, prestatyn, diabetes centre, royal liverpool university hospital trust, liverpool, uk introduction: metabolic syndrome (mets) and low testosterone levels are independently associated with increased all-cause and cardiovascular mortality. low testosterone levels are associated with obesity, insulin resistance and an adverse lipid profiles in men and the metabolic syndrome and type diabetes have a high prevalence of testicular hypogonadism. the relationship and interaction between these conditions and the potential affect they have on each other is not fully understood. method: this study examined the correlation between testosterone and the criteria of the metabolic syndrome in subjects (age . years, ae . ,( - . ) (mean, sd (range)), total-testosterone . nmol/l, ae . ,( . - ), free-testosterone . nmol/l, ae . , ( . - . ), sex hormone-binding globulin level . nmol/l, ae . , ( - ). correlation and significance statistical testing used the pearson correlation coefficient. results: diabetes was present in . % and a further . %( / ) had the metabolic syndrome. total-testosterone, free-testosterone and shbg had significant and the strongest correlations with age (r = À . , À . . . respectively, p < . ). shbg had the strongest negative correlations with triglycerides (r = À . ), waist circumference (r = À . ) and hba c (r = À . ), (total-testosterone, triglycerides (r = À . ), wc (r = À . )), all significant p < . . there were positive correlations with hdl (r = . shbg, r = . tt, p < . ). there were no significant correlations with blood pressure and free-testosterone had no correlation with mets criteria. conclusion: lower testosterone levels have the greatest correlation with ageing but are also associated with detrimental changes in central adiposity and dyslipidaemia. shbg rises with age, however lower levels have a stronger association with cardiovascular risk. this study suggests that cardiovascular risk and androgen abnormalities might be methods: group (gr ) was composed of normal subjects (age = . ae . ; means ae sem). group (gr ) consisted of non-obese type ii dm pts with hypertriglyceridaemia (type iv hlp) and ath (age = . ae . ). group (gr ) consisted of nonobese type ii dm pts with mixed hyperlipidaemia (type iib hlp) and ath (age = . ae . ). following have been determined in serum, in fasting state: total cholesterol (ch), hdl-cholesterol (hdl-ch), atherogenicity coefficient (hac), triglycerides (tg), lipolytic activity (la), lipoprotein fractions, prostaglandins a and e , prostaglandins f alpha (pgf). following have been determined in plasma, during standard ogtt: glucose, insulin, insulin/glucose index (igi), glucagon, c-peptide, sth, somatostatin, acth, cortisol, aldosterone, beta-endorphin. results: both gr and gr pts, compared to gr , had higher body mass, ch, tg, hac, and lower hdl-ch, la, insulin (at ogtt hour ), igi, sth (hour ), basal aldosterone. gr pts, compared to gr , had lower sth (hours and ). gr pts, compared to gr , had higher glucagon (hour ), somatostatin (hours and ), cortisol (hours and ), pgf, and lowerc-peptide (hour ), sth (hours and ). conclusions: altered hormonal-metabolic patterns have been observed in non-obese type ii dm pts with ath and dyslipidaemias, including decreased sth and elevated cortisol. hyperlipidemia has been indicated as an important factor of contributing to diabetes progression. however, whether native ldl or modified ldl causes dysfunctional effect of insulin secretion in islet cells is still elusive. the present study aims to identify the mechanisms of electronegtive ldl (l ) and l (less electronegtive ldl) acting on the insulin secretion of pancreatic β-cells. rin-m f cells, were cultured in the complete medium with human native l , l , or oxldl. the intracellular concentration of reactive oxygen species (ros) measured by use of dcfhda was significantly increased after loading l ( lg/ml) or oxldl ( lg/ml), but not effected after loading l ( lg/ml). the cell viability assayed by prestoblue tm reagent was suppressed to % after loading l or oxldl; however, l did not inhibit the cell viability. the insulin release of rin-m f cells was determined by elisa kit. our results demonstrated that % decrease of secretion ratio in the phase of high glucose-induced response after the β-cells were exposed in l for h as comparison with in normal medium. we also found that phosphor-c-jun was activated after loading l or oxldl, but not after loading l . the activation of c-jun may modulate the gene expression or the process of insulin secretion. thus we suggest that l , not l , is the main subparticle which induces oxidative stress and then lead to dysfunction of insulin secretion responding to high glucose stimulation in β-cells. target group for diet and physical activity interventions due to their increased risk of post-natal weight gain, type diabetes and related health problems. postpartum weight gain and/or retention, particularly in the first months are commonly due to lack of nutrition knowledge, poor dietary habits and physical inactivity. mothers are also integral to the shaping of attitudes and eating and activity behaviours of their children. the proposed study will evaluate whether an individualized weight management program with nutrition and physical activity advice and support enhances weight loss compared with standard care in overweight and obese women and women with a history of gdm. it is hypothesized that, compared with individuals given standard diet and physical activity advice, overweight and obese women, and women with a history of gdm prescribed exercise energy expenditure targets and using heart rate (hr) and dietary intake monitoring with electronic reminders, are better able to achieve a target weight loss ( % reduction from prepregnancy weight for overweight or obese pregravid ( ! . kg/m ), for overweight women ( . - . kg/m ) to achieve a weight loss that places them in the healthy-weight range, and for women who were in the healthy-weight range pregravid to return to their prepregnancy weight) through changes in eating and activity behaviours. objective: diabetes is associated with moderate cognitive deficits and neurophysiological and structural changes in the brain, a condition that may be referred to as diabetic encephalopathy. we used high-fat and sugar diet and streptozotocin induced diabetic rats to observe the changes of proteins of insulin signaling which closely correlate with learning and memory. we try to illuminate the possible mechanisms of learning and memory decreased in t dm. methods: a total of rats were randomly divided into two groups: control group (c), diabetes mellitus group (dm). after weeks, morris water maze was used to perform training trial and probe trial in order to detect spatial learning and memory abilities. and we detected proteins of insulin signaling such as ir, irs- , akt, p-creb and bcl- in the hippocampus of the rats by western blot and immunohistochemistry staining. results: . water maze experiment: compared with the c group, the escape latency increased significantly in dm from the nd day. in the spatial probe experiment, the first time passing hidden platform prolonged significantly and the distance swimming in the quadrant of hidden platform decreased significantly in the dm. . immunohistochemistry staining: compared with the c group, the positive neurons of ir, irs- , akt, p-creb, bcl- increased in the dm group. . western blot: compared with the c group, the expression of ir, irs- , akt, p-creb, bcl- increased in the dm group. conclusions: the learning and memory ablities decreased, while the expression of ir, irs- , akt, p-creb, bcl- abnormal increased in t dm model rats. the results indicate that insulin signal transduction were impaired in t dm. objectives: niacin, a widely used lipid-modifying drug, is known to induce hyperglycemia during prolonged and high-dose treatments. however, its potential mechanism (s) whereby the islets are involved remains to be determined. we thus aim to investigate the potential role of niacin and its receptor gpr a involved in regulating islet beta-cell function and insulin resistance. methods: hfd-induced obese mice were employed to study the in vivo effects of niacin. blood glucose/serum insulin levels, oral glucose tolerance test (ogtt)/insulin tolerance test (itt), and homeostasis model of assessment-insulin resistance (homa-ir) were performed to assess glucose homeostasis. real-time pcr, western blot and immunefluorescent assays were used to study the expression of genes of interest. cyclic adenosine monophosphate (camp) and glucosestimulated insulin secretion (gsis) from isolated islets and ins- e beta cells were determined. knockdown of the gpr a in ins- e cells was also examined and compared. results: eight-week treatment with niacin increased blood glucose levels by % in hfd-induced obese mice while the areas under curve of ogtt and itt, and homa-ir index were consistently enhanced. in addition, niacin treatment significantly decreased gsis in isolated pancreatic islets. ex vivo and in vitro studies showed niacin decreased gsis, increased mrna expression of ucp and gpr a as well as inhibited intracellular camp accumulation in ins- e cells. in corroboration, the decrease in gsis and camp levels were abolished by the knockdown of gpr a. our data indicate that niacin treatments leads to hyperglycemia and impaired pancreatic islet function, which is probably via the activation of islet niacin receptor gpr a-induced pathway. a once daily glp- analogue, liraglutide, is emerging world-wide as a drug for the treatment of diabetes and also, potentially, obesity. this agent not only acts on glycemic control, but also exerts an effect on body weight control, because liraglutide inhibits gastric emptying, resulting in appetite reduction and lower energy intake. herein, we treated type diabetic obese subjects with . mg/day liraglutide and examined glycemic control and body weight changes over a month period. glycemic control was markedly improved (baseline hba c . ae . %, endpoint hba c . ae . %) with liraglutide. based on subgroup analysis, the good responders to liraglutide were ( ) bmi < . ( ) diabetes duration < years. ( ) postprandial cpr < . ng/ml. while liraglutide-induced gastric symptoms, specifically nausea, occurred in nearly all patients at baseline, it had disappeared in about half by the end of the study. unexpectedly, the hba c improvement was not associated with the presence of nausea. while acute body weight loss ( . ae . kg) was observed at month, there were no significant body weight changes at the end of the study. individual body weight change was associated with the presence or absence of nausea at the end of the study. in conclusion, the effects of liraglutide on body weight loss lasted only a short period and no chronic effects were observed. thus, the hba c lowering effect of liraglutide is not due to reduced energy intake, but rather, to recovery from defects in postprandial insulin secretion. background and aims: durability of good glycaemic control may delay development of diabetic complications. early initiation of combination treatment with oral anti-diabetic drugs (oads) having complementary mechanisms of action may increase durability of glycaemic control compared with stepwise addition of oads. dpp- inhibitors such as vildagliptin are good candidates for early use in combination with metformin as they are weight neutral with no additional risk of hypoglycaemia. materials and methods: about drug-na€ ıve patients with type diabetes mellitus (t dm) with hba c between . and . %, will be randomised in verify, a -year, multinational, double-blind, parallel group study. the study will test the hypothesis whether early combination therapy with vildagliptin/metformin will result in lower treatment failure rate or in lower rate of loss in glycaemic control over time than with metformin alone. other objectives include evaluation of rate of fasting plasma glucose progression, change in hba c over time, time to insulin initiation, development/progression of diabetic complications, changes in weight, changes in homa-β/ir, safety and tolerability. insulin secretion rate and insulin sensitivity will be assessed in annual standard meal-test. patients will also be evaluated for early changes in the vasculature, microalbuminuria and retinal microaneurysms. results and conclusions: verify is the first study to investigate the long-term clinical benefits of early combination treatment vs. the standard-of-care metformin followed by addition of oads. verify will provide valuable data on the durability of glycaemic control, βcell function, insulin resistance, safety and tolerability and explore early changes in the vasculature of patients with t dm. patients with metabolic syndrome are at high risk for developing atherosclerosis. recent studies have suggested glucagon-like peptide- (glp- ) signaling to exert anti-inflammatory effects on endothelial cells, although the precise underlying mechanism remains to be elucidated. on the other hand, pparc activation was demonstrated to inhibit the transcription of factors, such as nfjb, resulting in atherosclerosis prevention via suppression of the expressions of cytokines and adhesion molecules in endothelial cells. we investigated whether pparc activation is involved in the glp- -associated antiinflammatory action in endothelial cells. we constructed an adenovirus expressing the ppre (+)-luc reporter gene for use with the reporter assay system. when we treated huvec cells with . nmol/l exenatide, endogenous pparc translational activity was significantly elevated by % as compared with control cells. the maximum pparc activity enhancing effect of exenatide was observed h after the initiation of exenatide incubation and was approximately % of that induced by lmol/l pioglitazone. when incubated with exenatide and pioglitazone simultaneously, pparc activity was additively promoted, suggesting that these two agents synergistically stimulate pparc activity. as h , a pka inhibitor, abolished glp- induced pparc enhancement, the signaling downstream from glp- cross-talks with pparc activation. in conclusion, our results suggest that glp- has the potential to induce pparc activity, partially explaining the anti-inflammatory effects of glp- on endothelial cells. cross-talk between glp- signaling and pparc activation would confer major impacts on treatment of patients at high risk for cvd events. in the rat hypothalamus by adenovirus-mediated gene transfer and then examined phenotypes of the rats. dnlkb significantly inhibited the thr phosphorylation of ampk alpha subunits, while wtlkb did not alter phosphorylation, suggesting that hypothalamic ampk is activated in basal states and negatively regulated by dnlkb . dnlkb -overexpressing rats exhibited body weight gain and slight insulin resistance as compared with wtlkb -overecpressing or sham operation-rats. taking into consideration that food intakes did not differ among these rats, this effect was probably due to reduced energy expenditure. in fact, the adipose tissue in dnlkb -overexpressing rats produced smaller amounts of pgc alpha and ucp , resulting in increased adipose tissue weights, as compared with wtlkb overexpresing rats. neither hepatic fatty acid synthesis nor gluconeogenesis was significantly altered. the phenotypes observed in dnlkb -overexpressing rats appear to be like those of ampk alpha deficient pomc neuron mice. in conclusion, our findings demonstrated inhibition of hypothalamic lkb to lead to reduced energy expenditure and body weight gain, suggesting that central lkb is involved in bodyweight regulation probably via ampk modification. material and method: anthropometric variables and lipid related factors concentration were measured. pcr and rflp were performed. the distributions of a polymorphic site and its relationship with mentioned factors were examined. result: in normal subjects there wasn't any relationship between these three polymorphism and studied profile, but in females with mets, presence of g allele in rs significantly increase diastolic blood pressure, low density lipoprotein and apolipoprotein a (apo a ) level and the c allele in rs , increase waist circumference, triglyceride and apo a level. while previous studies in adults demonstrated that snps in apoa , have primarily been associated with plasma lipoprotein levels and associated downstream consequences, such as weight gain and heart disease risk, in present study we find that there are some relation between this variation and lipid profile in female with metabolic syndrome and this relationship is sex dependent. tryglicerides mean value was mg/dl and cholesterol mg/dl; the mean value was slightly elevated but inside the lot of the patients the variations were wide probably due to liver inssuficiency (low values) and alcooholic etiology of underlying liver disease (higher values). serum uric acid had a mean value of . mg/dl. no large variations inside the lot. medium level of serum creatinine . mg/dl; higher values in child c cirrhosis and hcc. conclusions: most of the metabolic disturbancies in hcc are correlated with the underlying liver disease. in a few cases of small lesions but mostly in large and complicated hcc these are significant and require specific treatment. background: a significant inter-individual variability in statin treatment efficacy is likely to have a strong genetic background. gene for slco b belongs to the candidates with potential to influence the statin treatment efficacy. slco b codes for solute carrier organic anion transporter, which has been shown to regulate the hepatic uptake of statins and some other drugs. materials and methods: slco b rs (t>c) polymorphism was successfully analysed in the group of patients with dyslipidemia (treated with simvastin or atorvastatin, or mg per day) and healthy normolipidemic controls. the polymorphism was analysed using nested pcr-rflp. lipid values (total-, ldl-and hdl-cholesterol, triglycerides) were analysed before and after - weeks of treatment. results: after treatment, as expected, there was a significant decrease both in total ( . self-care management), were applied to all patients at baseline and month follow-up. t-test and chi-square test were used to analyze the data. after months, (out of ) and (out of ) patients remained in the study. main findings revealed, a significant difference in a c level between the groups (p < . ). the self-care management score increased in both groups, but the increase was significantly higher in the intervention group (p < . methods: after the treatment decision was final, patients were assigned to either vildagliptin or other oads (sulphonylurea, thiazolidinedione, glinide, a-glucosidase inhibitor or metformin except dipeptidyl peptidase- inhibitor or glucagon-like peptide- mimetic/ analogue). demographic data and patient history, especially risk factors and macro-and microvascular complications, were collected and reported by the investigators. results: in total, , patients were enrolled in countries across the world. baseline characteristics are presented in the table. hba c was better controlled in east asia and europe than in india, latin america or middle east. patients in europe had higher bmi and longer duration of diabetes than patients in east asia and india. prevalence of risk factors such as hypertension and lipid disorders was high overall, but particularly higher in europe. macro-and microvascular complications were reported in . % and . % of the overall study population, respectively, and their prevalence was higher in europe. conclusions: data from edge study show that the hba c goal of % as recommended by international guidelines is not achieved worldwide and metabolic control varies remarkably between regions. in addition to the high prevalence of concomitant risk factors, complications were reported already after years of diabetes in a substantial proportion of patients. aim: sudomotor dysfunction due to small fiber neuropathy can be observed very early in pre-diabetes. the aim of this study was to assess the predictive power of ezscan, a non invasive, quick and simple measurement of sudomotor function to identify glucose impairment. research design and methods: the study was performed in german subjects at risk of diabetes. glucose metabolism was assessed by using, oral glucose tolerance test (ogtt) at baseline and after year follow-up. sudomotor function was evaluated by measuring hand and foot electrochemical sweat conductances to calculate a risk score. results: at baseline, patients had normal glucose tolerance (ngt), had pre-diabetes (impaired fasting glucose, ifg and/or impaired glucose tolerance, igt) and four had newly diagnosed type diabetes. the auc values for fpg, h-ogtt glucose, h-ogtt glucose, hba c and ezscan score to predict pre-diabetes were . , . , . , . and . respectively. subjects having a moderate or high ezscan score (> ) at baseline had a substantially increased risk for having ifg and/or igt at follow-up visit presented by an odds ratio of . [ . - . ], the or for having h-ogtt ! . mmol/l at follow-up was . [ . - . ] and for having hba c ! . % was . [ . - . ] compared to subjects with low ezscan risk. conclusions: this preliminary study, which must be confirmed in a larger population, shows that ezscan measurement is associated with diabetes progression which may have implications for prevention and disease management. methods: two groups are involved to the studies -the group of patients with metabolic syndrome (ms) and control group (c)- healthy, age matched volunteers. volunteers were expose to -h ogtt (according to who) and -h oltt (contained g of fat: % saturated, % monounsaturated and % pufa). during both tests the blood glp- , gip, glucose, insulin and free fatty acids (ffa) levels were assessed. results: fasting level of incretins do not statistically differ between ms vs. c participants. only ffas were elevated during whole oltt, when the glucose concentrations decreased in early postprandial period. secretion of gip was activated by ogtt as well as by oltt, however concentration of gip in oltt was higher. output of glp- during whole ogtt was significantly lower in patients with ms. in patients with ms amount of gip released during oltt was lower compared to control patients. conclusion: low level of incretins during oxidative stress connected with fat food intake, may not provide the protective effect for metabolically stressed pancreatic beta-cells. background: who estimates that . million deaths worldwide are due to hypertension, approximately . % of all deaths. this is an important risk factor forcardiovascular disease. argane oil is an integral part of the moroccan diet. several studies showed that an argane oil supplemented diet decreased systolic and diastolic blood pressure measurments in animals and suggested that consumption of argan oil may have a beneficial effect in preventing cardiovascular disease. objective: to study the effect of a regular consumption of argane oil on hypertension in healthy postmenopausal women. methods: seventy-seven postmenopausal women ( . ae . years) were assigned to consume ml of argane oil during weeks of nutritional intervention. anthropometric (weight, height and bmi) and clinical profile (blood pressure) have been determined at and weeks. results: showed that systolic blood pressure was significantly reduced ( . ae . to . ae . mmhg) after weeks (p = . ). diastolic blood pressure underwent a slight decrease ( . ae . to . ae . mmhg) but not significantly (p = . ). conclusion and perspective: these results suggest that consumption of argane oil can be relevant to prevent cardiovascular disease into postmenopausal women and help to decrease cardiovascular risk. the positive impact on blood pressure recorded by a significant decrease in sbp and hypertension is a significant result, however, the mechanisms involved in obtaining this result need to be defined more accurately, focusing mainly on the effects of certain constituents of argane oil as gamma-tocopherol on the mechanisms regulating blood pressure. the epidemic of obesity is associated with multiplication of prediabetic patients. recognition of them is essential as this state is considered to be the last chance to prevent the manifestation of diabetes. our aim was to determine metabolic alterations in healthy men with (dr: n = ) or without (h: n = ) first degree dm relatives. volunteers were adjusted according to age and bmi, insulin resistance was determined with hyperinsulinaemic-normoglycemic clamps and ßsejt function by iv glucose tolerance test. fasting glucose, insulin and ffa values were not different among the groups, but at the and of ivgtt, glucose levels were higher (h: . ae . , vs. dr: . ae . mmol/l, p < . ), injected glucose did not suppressed ffa levels (h: . ae . vs. dr: . ae . mmol/l, p < . ) and first phase insulin secretion was decreased in dr group (h: ae vs. dr: ae ; p < . ). there were no differences among the groups in total body-, muscle and fat tissue glucose disposal, leptin and resistin levels, but the adiponectin levels were significantly lower in dr group (h: . ae . vs. gd: . ae . mg/ml, p < . ) and the ffa/adiponectin ratios were higher (h: . ae . vs. gd: . ae . , p < . ). in conclusion the impairment of insulin secretion and fatty acid metabolism are the earliest sign of diabetes risk in men with first degree dm relatives. the measurement of ffa/ adiponectin ratio could be a simple parameter to screen adult male relatives of diabetic patients for identification of genetic risk of diabetes. the original reaven′s definition from , which has been revised in , missed the abdominal obesity. the definition accepted by who in was not applied due to difficult evidence of the insulin resistance. a new definition of the ms formulated by idf and ead was published in . in this case, the abdominal obesity was the necessary condition of the ms diagnosis. in order to unify the criteria, five essential parameters of the ms were put on the same level by the international medical organizations in . it is not easy to define the ms. it cannot be identified as a single disease, as it consists of a complex of problems. that is why the definitions of the ms were rearranged several times during past years and the used parameters are much stricter. we can assume that in the future this process will proceed. aims: the metabolic syndrome (ms) represents an obesity-related severe health problem, and its prevalence is world-wide increasing in parallel with the growing obesity epidemiology. gwa studies have shown that many single nucleotide polymorphisms (snps) in several genes are involved in common obesity. the aim of this study was to look for associations between snps in the mc r (rs , rs , rs ), sirt (rs , rs , rs , rs , rs ) and fto (rs , rs , rs , rs ) genes and obesity and/or ms in a southern italy population. methods: one-thousand unrelated non diabetic severely obese patients (mean bmi . kg/m , mean age . years) and controls (mean bmi . kg/m , mean age . years) entered the study. mc r, sirt and fto were genotyped by real time taqman assay. anthropometric, clinical and biochemical data were collected for all enrolled subjects. ms was diagnosed according to the american heart association criteria. results: metabolic syndrome was diagnosed in . % of our patients. the four fto snps were significantly associated with the obese phenotype ( . < p < . ). at binomial logistic regression analysis, only snp rs was significantly associated to obesity after correction for sex and age (or/ %ci: . / . - . and . / . - . , for the heterozygous and the homozygous mutated genotypes, respectively) and to ms presence (or/ %ci: . / . - . ) . conclusions: this study confirms that fto is a susceptible gene for obesity risk, and patients bearing the polymorphic allele in the rs snp could be at high risk of ms insurgence, possibly to be addressed toward preventive programs. results: number of patients who achieved hba c goals according age and presence of cvd are shown in table . conclusion: t d patient of middle age reached hba c goals in lowest percentage of cases. among different treatment groups percentage of patients reached hba c goals were the lowest in group treated by insulin with oad. the prevalence of diseases arising mainly due to the bad lifestyle is increasing. it is necessary to find optimal tools to lower the prevalence of the metabolic syndrome (ms). there is no network of institutions that systematically cooperate in the field of education and treatment of the ms. for students and academics the possibility of establishing ( ) and deepening the cooperation in this scientific field is therefore limited. the role of the project is to strengthen relations between the institutions in the form of cooperating network, which will meet the essentials principles of the primary, secondary and tertiary prevention of the metabolic syndrome. the key role of the project is to open an professional discussion and deepen the communication and professional relationship across the cooperating institutions which are realized primarily through internships of students (bachelor and doctoral degree), academic staff, roundtable discussions with experts and partners from the collaborating institutions, organizing workshops and doctoral and scientific conferences. czech society of sports medicine ( cstl) is a professional guarantor of creating a network of cooperating institutions in terms of the objectives and scientific credibility. background and aims: tissue ages accumulation is thought to be a specific marker of long-term glycaemic control, oxidative stress and cardiovascular risk. prediabetes -impaired fasting glucose (ifg) and impaired glucose tolerance (igt), are considered as risk categories for the development of both type diabetes and cardiovascular disease. the aim of the present study was to assess advanced glycation end products (ages) in prediabetes and their relation to anthropometric and glycaemic control parameters. material and methods: subjects (mean age . ae . years, mean bmi . ae . kg/m ) were enrolled. according to glucose tolerance they were divided into two age-matched groups - subjects with ngt and with prediabetes (ifg and igt). glucose tolerance was studied during ogtt applying who criteria. plasma glucose was measured by a hexokinase method, hba c was assessed immuno-turbidimetricaly. tissue ages accumulation was assessed non-invasively measuring the skin fluorescence of ultraviolet light on the ventral side of the lower arm (age-reader-diagnopticstm). antropomethric measurements -weight, height, waist circumference, were performed. visceral fat area was estimated by bioimpedance method (inbody ). results: no significant difference in ages accumulation was found between the groups with prediabetes and ngt. significant positive correlation was observed between ages accumulation, age (r = . ) and visceral fat area (r = . ). the non-invasive assessment of tissue ages accumulation probably is not a sensitive enough method for identifying subjects with prediabetes and increased cardiovascular risk. at the early stages of glucose homeostasis impairment ages accumulation appears to be related to age and visceral obesity rather than to glucose tolerance. this study is an observation study for mild diabetic males with bmi of or higher with subsequent month-follow-up based on single administration of exenatide and dietary and exercise intervention. method: subjects were cases of male patients (age: . ae . , bmi ae . ) with apnea hypopnea index (ahi)≧ /hr and . >hba c> . %. based on polysomnography and measurements of ct abdominal visceral fat area and various biomarkers before and and months after exenatide administration, the observation study was conducted for months. results: decrease in bodyweight was observed by . ae . kg on average during the months with no cases to gain in bodyweight and bmi. ahi was significantly improved from . ae . /h to . ae . /h. improvement was observed in hba c, -ohdg, pro-bnp, high molecular weight adiponectin and visceral fat areas but not in hs-crp and subcutaneous fat area. conclusion: not only diabetes but also sleep apnea syndrome was improved by exenatide administration in japanese mild diabetes patient. weight reduction may have played the primary role. effect of weight reduction provided by the pharmacological property of exenatide is useful to improve sleep apnea syndrome. currently, changes in individual calorie intake and nutrient composition during the study period have been analyzed. [ . - . ], p = . in igt group. no significant association was found between baseline fasting insulin level and progression from either ifg or igt to type diabetes. conclusions: individuals with ifg or igt identified through high-risk strategies in a bulgarian population, have a rather high risk of developing diabetes within year. baseline proinsulin and proinsulin: insulin ratio, known to reflect beta-cell dysfunction, appear to be independent predictors for progression to diabetes in both ifg and igt. introduction: the insulin receptor substrate (irs- ) seems to be an important factor involved in the modulation of insulin signalling in adipose tissue. in this study we want to check the expression of irs- in visceral and subcutaneous adipose tissue, its relationship with insulin resistance and with the metabolic syndrome. material and methods: we measured irs- expression in visceral and subcutaneous adipose tissue from morbidly obese patients. we have determined the level of insulin resistance with the homa-ir index. patients were classified into two groups based on whether or not to have metabolic syndrome (according to the idf criteria) results: irs- expression in subcutaneous adipose tissue is significantly higher than in visceral adipose tissue (p = . ). homa-ir was significantly correlated with the irs- expression in subcutaneous adipose tissue (r = À . , p = . ), but not in visceral adipose tissue (p = . , p = . ). the morbidly obese patients with metabolic syndrome have significantly lower irs- expression levels in subcutaneous adipose tissue than those without metabolic syndrome (p = . ). in visceral adipose tissue, the levels of irs- are lower but not significant (p = . ) in the morbidly obese patients with metabolic syndrome. the presence of metabolic syndrome in morbidly obese patients is associated with a lower irs- expression level in subcutaneous adipose tissue. in the general population and in hiv+ subjects the hypertension is the major risk factor worldwide for cardiovascular morbidity and mortality. this condition has been accompanied by several complication, including dyslipidemia and impaired glucose metabolism. for all these reasons identification of hypertension is of pivotal importance in hiv infected patients. aim of this study was to evaluate the incidence of hypertension and comorbidity in male hiv+ patients. we enrolled only male patients attending two clinics of the infectious diseases in center of italy (chieti and ancona). three hundred and four patients accepted to participate at the study. viroimmunological, lipid and metabolic parameters, including triglycerides, cholesterol, hcv/hbv co-infection, tabacco use were measured at the time of enrollment. the study has shown an incidence of hypertension (esh guidelines) % ( / patients), dyslipidemia % ( / ), diabetes % ( / ), hcv or hbv co-infection % ( / ) and tobacco use % ( / ). patients with hypertension showed dyslipidemia in % of cases ( / )and diabetes in % ( / ). remarkable that only % of patients with hypertension were treated for hypertension. in addition, the average age of the patients in the study was . ae . years. the study has shown a high incidence of hypertension in hiv+ men, even considering the young age of the patients. furthermore, hypertension is associated with a high incidence of co-mobility. hypertension is associated with evidence of under treatment, it showing a poor perception of the problem in this context. method: this study was a -weeks', prospective trial in subjects with metabolic syndrome. metabolic syndrome was defined as the presence of at least three out of five risk factors according to the ncep-atp iii with the asian criteria of abdominal obesity (abdominal circumference; > cm in men, > cm in women). all participants received individualized education by skilled personnel with information about tlc. blood chemistry including lipoprotein profiles and anthropometric data were collected before and after weeks' tlc. result: eighty-six subjects were screened, and subjects with metabolic syndrome were enrolled. body weight was not significantly changed after tlc. fasting blood glucose levels were not significantly changed (from . ae . to . ae . mg/dl, p = ns). therapeutic lifestyle change did not result in significant changes in total cholesterol (from . ae . to . ae . mg/dl, p = ns) and triglyceride (from . ae . to . ae . mg/dl, p = ns). but, weeks' tlc resulted in significant reduction in ldl-cholesterol levels (from . ae . to . ae . mg/dl, p < . ), increase of hdl cholesterol levels (from . ae . to . ae . mg/dl, p = . ). conclusion: four weeks' therapeutic lifestyle change improved lipoprotein profile (especially ldl-c and hdl-c) in metabolic syndrome. our findings indicate that the importance of tlc with education should be emphasized for the control of metabolic syndrome. nutrition, hasanuddin university, school of medicine, makassar, indonesia obesity in major public health and economic problem of global significance. the prevalence of obesity in children has increased significantly, although less rapidly in indonesia. from the public health view, it is disconcerting that the prevalence of adolescent obesity has increased by nearly % in the past two decade. case and control study design was done in makassar, the participant is senior high school students. the study aim to identify the risk factors of adolescent obesity to premetabolic syndrome by measuring body mass index, waist circumference, lipid profile (cholesterol, trigliceride, hdl, ldl and apo b) and fasting oral glucose. data was analyzed using spss program, the relationship among variables was calculated with pearson correlation and regression test. the indicators for obesity using waist circumferences and bmi, energy intake using h food recall and was analysed using wfood . the study showed, a positive correlation between waist circumference and small density ldl, apo b, cholesterol (p < . , p < . , p < . ). student with abnormal waist circumference tend to have abnormal biochemical markers (or . , . , and . ) as a risk premetabolic factors conclusion: nutrition education and food balance diet should be given to adolescent obesity to prevent metabolic syndrome in later of life. l. mundbjerg , g.f. thomsen , r. holst , c. juhl department of endocrinology, department of occupational medicine, hospital of south western denmark, esbjerg, institute of regional health research, region of south denmark, odense, denmark introduction: severe obesity is associated with reduced worker productivity and chronic absence from work. gastric bypass surgery is the most effective treatment of severe obesity. the objective of this study was to measure employment status in danish gastric bypass patients before and after surgery. methods: the study is a nation-wide retrospective case-control register study. data were extracted from three sources: cases were identified in the danish national patient register according to the operational code for laparoscopic gastric bypass surgery and matched on a : basis with respect to age, gender and residence municipality with control subjects. the employment status was calculated from the danish national labour market authority's databasedatabase (dream) which includes information on all public transfer incomes. by linking the databases we achieved a valid measure of the amount of working days. results: the amount of working days was significantly lower in cases compared to controls. there was a significant decline in employment status during the observational period in both groups. this decline corresponded with the timing of the financial crisis (employment data collected over the period january st to december st ). there was no significant difference in the decrease of employment status between groups. conclusion: gastric bypass surgery patients are affected by the economic recession in a similar degree as the general population. thus, the patients do not seem to benefit from the operation nor do they appear particularly vulnerable in periods of recession. excessive accumulation of fatty tissue in obesity associated with fat and glucose metabolism. fish oil contains n- pufas epa and dha had been demonstrated in several studies had effects on the expression of genes ppar-a and srebp- c, the pathomechanism still controversial. this study aims to determine the effect of fish oil on insulin resistance in mice obesity. clinical trials using c bl/ j mice was conducted in animal laboratory medical faculty of hasanuddin university. the mice was giving a normal diet (nd) or high fat diet (hfd) for weeks. mice was divided by four groups; normal diet (nd), high-fat diet (hfd), hfd + g/ g fish oil (hfd-fo), hfd + metformin g/kg diet (hfd-met) as a positive control for weeks. gene expression of ppar-a and srebp- c from the liver were measured by rt-pcr. the study showed, hfd mice had significantly higher body weight compared to nd. hfd-fo have higher blood glucose levels than other groups. ppar-a expression in liver was lower in hfd than nd, but increased in the hfd-fo and hfd-met compared with hfd alone. srebp- c expression decreased in hfd-fo and hfd-met, glucose metabolism of hfd_fo tended to decrease, while the hfd-met is likely to increase. we conclude, fish oil improved insulin resistance, decreased expression of srebp- c and increased expression of ppar-a in the liver tissue through decreasing lipogenesis and increased fat oxidation in the liver. methods: total subjects were divided into two groups having whr > . as obese and whr < . as non-obese. circulating il- and resistin level, fasting blood glucose, insulin and lipid profile were estimated. insulin resistance was calculated by the homeostasis model assessment (homa) index. the genotype and allele frequency of il -g c gene polymorphism was determined by pcr-rflp method in obese and non-obese adult women from north india. results: the genotype distribution of il -g c gene polymorphism was statistically significant in obese women (p = < . ; or = . ; % ci = . - . ) compared to non-obese women. the circulating level of serum resistin was highly significant in obese women ( . ae . vs. . ae . , p = < . ) compared to nonobese. significant association was found with cc + gc genotype of il -g c promoter gene polymorphism in case of waist circumstance, serum triglyceride, homa index and serum resistin level (p = . ; or = . , % ci = . - . ). conclusion: serum resistin is associated with the disorder of metabolism of glucose and lipid in metabolic syndrome. the relationship between this hormone with cc + gc genotype of il -g c promoter gene polymorphism suggests that they may take part in the development of metabolic syndrome in north indian adult women. the comorbidities associated with excessive weight are major causes of morbidity and mortality, thus causing further reduction in quality of life. the dysfunction of excessive fat and its peculiar distribution plays a decisive role in the development of metabolic disorders. the aim of the study was to estimate the prevalence and the correlates of obesity and dysglycemia in a rural community. overweight and obesity were defined according to world health organization criteria, considering both the value of body mass index (bmi) and waist circumference (wc). dysglycemia (impaired fasting glucose -ifg and diabetes) was established based on ada recommendations. the study included people, . % men and . % women, with the mean age of . ae . years. more than half of them ( %) had an excessive weight: . % were overweight and . % were obese. the crude prevalence of overweight and obesity was . % and . % respectively for men, and % and . % respectively for women. the prevalence of diabetes was . % and for ifg of %. the prevalence of dysglycemia increased with the bmi value, with the highest frequency in the grade iii obesity group ( . % prevalence of diabetes, ifg . %). large wc was identified in . % of the studied population ( . % in men, . % women). the individuals with diabetes had a significant higher mean wc ( . cm vs. . cm, p < . ). these results show that excessive weight and abdominal obesity could become a public health problem in romania, thus requiring national screening and educational programs. objective: hyperuricemia is associated with obesity; however, few studies reported the effects of surgery types on uric acid metabolism for severe obesity. the current study was aimed to explore the effects of gene and bariatric surgery on uric acid reduction and to identify the potential pathways. subjects: all participants were han chinese, aged from to years old. a total of severely obese patients with at least body mass index (bmi) of were recruited in the beginning of the study, where cases received laparoscopic adjustable gastric banding (lagb) and cases received laparoscopic mini-gastric bypass (lmgb). a -month follow-up was ensued after surgery to identify the effects of bariatric surgery and estrogen receptor-a (esr ) gene on serum uric acid reduction. results: a tagsnp (rs ) of esr could influence serum uric acid reduction. bariatric surgery effect on serum uric acid reduction was greater in lmgb as compared with lagb at the th month of post-surgery (À . ae . mg/dl vs. À . ae . mg/dl, p = . ). obese patients carrying risk genotype (tt) on rs and exhibiting better glycemic control had a greater serum uric acid reduction at the th month of post-surgery. synergic effect of rs and lmgb exhibited the highest serum uric acid reduction at the th month of post-surgery (À . ae . mg/dl). conclusion: for severely obese han chinese, bariatric surgery appears to reduce serum uric acid levels by mediating different factors, including esr gene and gender, ameliorating glycemic control, and changing dietary patterns. remained significantly lower. compared to mgc, mgr but not mgrc male offspring had higher body fat % and visceral adiposity at months of age. results: the average age of patients was . years, more dominant were females with . %. patients with ms characterizes increased values of bmi ( . kg/m²), which is statistically significantly more that in the control group, where is average value of bmi . kg/m², waist . cm in the study group, and . cm within control group (p < . ), blood pressure . / . mmhg, homa index . , average value of insulinemia . (lu/ml), (within control group homa index was . ), the average value of insulimenia . (lu/ml), average values of: total cholesterol . mmol/l, hdl cholesterol . mmol/l, ldl cholesterol . mmol/l, triglycerides . mmol/l, relation between ldl/hdl . . arterial hypertension was present in . %, hypercholesterolemia in . %, reduced hdl in . %, increased ldl in . %, trigliceridemia in . %. conclusion: abdominal obesity is characterized by manifested insulin resistance and distinct hyperinsulinemia. arterial hypertension as one of the components of metabolic syndrome represents significant cardiovascular risk factor, increased level of triglycerides represents significant risk factor which favors atherosclerosis, in our study the presence of this parameter was . %. introduction: diabetes is the most feared disease because it leads to a variety of complications including end-stage vascular disease, cardiovascular damage and retinal abnormalities. the increased risk of atherosclerotic disease in diabetic subjects may be due to enhanced foam cell formation following an increased susceptibility of low density lipoprotein to oxidative modification. cardiovascular disease (cvd) is the most prevalent complication of diabetes mellitus. methods: the aim of this study was to assess the ldl susceptibility to lipid peroxidation (ldl ox) in two study groups of elderly patients (aged ae years): a group of patients with cardiovascular disease and a group of patient with cardiovascular disease associated with type diabetes mellitus. the ldl susceptibility to in vitro induced lipid peroxidation was evaluated following its incubation with a prooxidant system. : results obtained showed the susceptibility of ldl to in vitro oxidation was increase in diabetic group ( . %) compared with a cardiovascular disease group. conclusion: this study indicates that low-density lipoprotein from diabetic subjects is more susceptible to oxidation. patients with diabetes have a greatly increased relative risk of developing cardiovascular disease when compared with patients without diabetes. much of this risk is related to insulin resistance and is associated with both traditional and nontraditional cardiovascular risk factors. therefore, measurement of ldlox may be helpful for identifying high-risk patients with type diabetes and cvd. janus kinase (jak) and signal transducer and activator of transcription- (stat ) in several cell lines. objective: we sought to determine the role of hypothalamic s pr in the control of jak /stat signaling and food intake in vivo. materials and methods: western blot, immunohistochemistry, gas analyzer, dissection of the hypothalamic nuclei and intrecerebroventricular (icv) infusion of s p ( ng), leptin ( À ) and cucurbitacin ( lmol/l) were combined to evaluate the role of s pr on leptin signaling and on food intake in lean and obese wistar rats and in ob/ob mice. results: high expression of s pr was found in the hypothalamus when compared to other peripheral tissues. s pr is mainly expressed the arcuate nucleus of the hypothalamus, in the same neurons that possess stat . icv infusion of s pr activator, s p, increased jak and stat phosphorylation and the energy expenditure and reduced the food intake in lean rats. in addition, s p potentiated the effects of leptin in the reduction of food intake. conversely, the pharmacological inhibition of stat , blocked the anorectic effect of s p. interestingly, low expression of s pr was observed in the hypothalamus of ob/ob mice and wistar rats fed on high fat diet, whereas, s p infusion reduced the food consumption and increased leptin signaling and action in obese rats. these results indicate that hypothalamic s pr has a key role in the control of leptin signaling and on food intake. aim: the adifit program is an intensive -week multidisciplinary treatment program which promotes weight reduction among obese. during the first weeks behavior change, physical exercise, and nutritional counseling is offered three times a half a day per week, thereafter once a week half a day. the aim was to evaluate efficacy of the adifit program in weight reduction, and its effect on eating behavior, and body image. methods: patients were evaluated at baseline (t ) and after month (t ). bmi was assessed. psychometric instruments such as the german versions of the eating behavior questionnaire (fev), and the body image questionnaire were used at both time points. paired-sample t-test and wilcoxon signed rank test were used for statistical analyses. results: fifty patients participated, % were female. bmi was significantly reduced from t to t (mean ae sd: . ae . vs. . ae . ; t = . , p < . ). results discerned significant improvements from t to t in fkb scale (negative attitudes towards one′s own body) ( . ae . vs. . ae . ; t = À . , p < . ), and scale (restricted body dynamics) ( . ae . vs. . ae . ; t = À . , p < . ). on the other hand, fev scale (cognitive restraint of eating) improved significantly from t to t ( vs. , z = À . , r = À . , p < . ). fev scale (disinhibition) was significantly lower at t ( vs. , z = À . , r = À . , p < . ) as was fev scale (hunger) ( vs. ; z = À . , r = À . , p < . ). after weeks patients showed significant reduction in weight, improvements in body image and eating behavior. metabolic peptides in serum and plasma samples contain status information for diabetes. previously, we have demonstrated that intrinsic protease activity caused instability of plasma and serum peptides. other reports have described that metabolic peptides, including glp- , gip, glucagon, and oxytomodulin, are subject to instability caused by proteolytic and other enzymatic degradation intrinsic to plasma. the variability may result in inaccurate quantitative measurements of the peptides creating challenges when interpreting pharmacokinetic and pharmacodynamic data. using both mass spectrometry and elisa based detection methods; we investigated the instability of metabolic peptides in whole blood, serum, and plasma under a variety of routine clinic conditions. first, the same subjects blood was drawn into different blood collection devices including serum and edta, citrate, heparin, and an edta tube containing enzyme inhibitors. the metabolic peptides of interest were spiked into plasma for time incubation at different temperatures. samples were quenched and processed for both maldi-tof ms and elisa analyses. quantitative analysis of each marker was used to characterize the kinetics of the peptide digestion ie stability (halflife). further a blood collection tube was developed to minimize degradation using enzymatic inhibitors specifically for the stabilization of glp- , gip, glucagon, and oxytomodulin. the addition of specific enzyme inhibitors for stabilization of each peptide reveals more insight regarding enzymatic degradation and stabilization of the peptide biomarkers. our data clearly demonstrates the need of enzymatic inhibitors for peptide stabilization, especially in a clinical setting. ( . ae . mg/dl) . subjects underwent a standardized meal test: g of bread, a boiled egg, g of apple, in the morning after h fasting. venous blood glucose samples:before meal test (sample ), h (sample )and h (sample ) after ingestion of standardized meal. neuropathy (p = . ). women had higher prevalence of neuropathy (p = . ). people with sensory neuropathy had lower weight and bmi than those with autonomic neuropathy and those without neuropathy (p = . ). fasting blood glucose was higher in subjects with neuropathy (p = . ). value of sample was increased in people with neuropathy (p = . ). other parameters cardiometabolic risk factors were not associated with diabetic neuropathy at onset of t d. conclusions: diabetic neuropathy is a frequent complication at diagnosis of t d. people with higher fasting or postprandial glycemia may associate more frequently diabetic neuropathy at onset. m. metalla , m. carcani , g. qirjako , e. demiraj durre regional hospital, endocrinology, durre regional hospital, durres, statistical, mother teresa university hospital center, tirana, internist, durre regional hospital, durres, albania background: metabolic syndrome is a risk factor for cardiovascular diseases and is associated with abnormal cardiac structure and function. the aim of the study: to evaluate the left ventricular structure and function in patients with metabolic syndrome, without installation of diabetes mellitus or arterial hypertension. material and methods: it was analyzed a total of consecutive adults ( -{ %} males and -{ %} females) with metabolic syndrome and healthy ( -males and females) without metabolic syndrome. metabolic syndrome was defined using the atp lll criteria. assessment is done with classic echocardiography, pulsed wave doppler and tissue doppler. results: there was difference in two groups in bmi, in waist circumference, in systolic and diastolic arterial presure in total colesterol, in level of triglicerid and hdl colesterol p < . . there was no diference in age, fasting serum glucose level, lvedd, sw, pw, lvm, lvmi, lav, lvef, early trans mitral inflow (e), late trans mitral inflow (a) and in the rate e/a (p = . ). echokardiografic measurements by tdi in peak mitral anular velocity in early diastole ea were . ae . vs. . ae . cm/sec (p < . ) in the metabolic syndrome and controll grups respectively. average values of sa were significantly lower in the ms than in controll group, . ae . vs. . ae . (p < . ). the ratee/ea mitral was . ae . vs. . ae . (p < . ) in metabolic syndrome and controll group respectivly. the early identification of isolated syndrome in non diabetic, non hypertensive adults may be an indication of an aggressive preventive measure. the fasting glycaemia altered and hyperinsulinemia are strong predicting factors of type dm (dm ) and sedentary habits can lead to this disease, mainly associated with obesity. objectives: verify the influence of physical activity, vo max and anthropometric measurements on glycaemia and insulin fasting in active military over the age of of the brazilian army (ba) serving in rio de janeiro. methods: two hundred and fifty subjects (aged . ae . years), in active duty in the ba, volunteered to participate in the study. the insulin and glycemic levels were measured as well as body mass, stature and waist circumference. body fat (bf) was measured by hydrostatic weighing, when body density was obtained. vo max was measured by maximal cardiopulmonary treadmill exercise test (cpet) using an individualized ramp protocol. oxygen consumption and carbon dioxide production were measured using a cpx-d metabolic cart. results: the prevalence of type dm found was . % and afg was . %. vo max showed an inverse correlation (p < . ) with insulin levels, homa-ir and fasting glycaemia and also with anthropometric measures and %bf. the bmi and %bf presented direct correlation (p < . ) with insulin, homa-ir and fasting glycaemia. subjects in the highest quartiles of vo max and in the lowest quartiles of wc and of %gc also presented lower levels of fasting glycaemia and insulin and homa-ir. the data suggest that vo max was an inverse and nutritional state a direct relationship between glycaemia and fasting insulin. subjects with an active lifestyle have less prevalence of alterations in glycaemia and fasting insulin levels. the increase in prevalence of cardiovascular conditions, and metabolic syndrome (ms) observed in the last decades was accompanied by increase in dietary fructose (fr) consumption (also as sucrose). the aim was to assess the prevalence of fructosemia in cardiovascular patients with or without ms and to investigate the possibility of treatment of hyperfructosemia and other components of ms with oral acarbose. material and methods: fasting serum fr concentration in cardiovascular patients with metabolic syndrome (group ) and in cardiovascular patients without ms (group ) was measured by colorimetric method with commercially available biovision set. patients of the first group were treated with acarbose (glucobay, bayer) increasing the dose from to mg per day to normalize the glucose metabolism. fasting and post oral sucrose load ( g) serum levels of glucose, fr, insulin, nefas and uric acid (ua) were measured at baseline and in days. results: fasting serum fructose concentration varied widely and among patients in both groups, and was significantly higher in group ( . ae . vs. . ae . lmol/l). the data after days and weeks of acarbose use is presented in the conclusions: dyslipidaemia is found to be the risk factor for ischemic stroke in diabetic subjects, with statistically significant differences compared to nondiabetics. hdl-cholesterol was found as a protective factor for haemorhagic stroke in nondiabetic subjects. agave tequilana weber variety azul is an economically important in mexican people because it is the sole plant allowed for tequila production but because it is a potential source of prebiotics, the inulin-type agave are nondigestible/fermentable carbohydrates which are able through the modification of the gut microbiota, the pos content of agave inulin differs from inulin extracted from chicory root. the aim was to assess the efficacy and safety of inulin type agave on lipid profile in dyslipidemic obese subjects. a clinical trial, open was carried out in obese, hypertrygliceridemic and hypercholesterolemic subjects between and years old. all the subjects received g/day of inulin in the morning, during days. biochemical and metabolic profiles before and after pharmacological intervention were performed. after inulin administration, there was a significant reduction of the trygliceride concentrations ( . ae . and . ae . mg/dl; p = . ). glucose serum ( . ae . and . ae . mg/dl; p = . ), and hba c ( . ae . and . ae . % p = . ). there was not a significant reduction of total cholesterol, low density lipoprotein and very low density lipoprotein. anthropometric parameters did not change in the group and soluble fiber intake did not produce any gastrointestinal adverse effect. the increase of fiber intake (inulin type agave) are efficacy and safety to reduced trygliceride concentrations levels in dyslipidemic obese patients. stress and strain have long been associated with the work people do. we aimed to investigate occupational stress index and influence of several different work stressors on cardiometabolic risk factors: diabetes, lipid levels in hypertensive workers in south serbia methods: we studied persons (professional drivers, construction workers, production line workers and bankers): composed group with hypertension ( - years of age, majority males), were age and sex matched controls without hypertension. clinical examination was performed and blood was sampled. we analyzed work stressors by using questioners with different factors and occupational stress index (osi) was calculated with permission of dr belkic. comparison was made regarding total burden and the nature stress burden (underload, high demand, strictness, extrinsic time pressure, aversive/noxious exposures, threat-avoidant vigilance/disaster potential, conflict/uncertainty) results: diabetes was highly present in bankers ( %) and glucose levels were significantly higher in this subgroup. the incidence of diabetes in construction workers was %. total cholesterol, ldl, triglycerides were higher and hdl lower in bankers and contraction workers (p < . ) and linearly correlated with osi (p < . ). previous myocardial infarction suffered . % of bankers. total osi was significantly higher in diabetic hypertensive bankers and construction workers (p < . ), as well as high demand, strictness and extrinsic time pressure (p < . ). conclusion: hypertension appearance in working population is related to high osi, especially when other cardiometabolic risk factors added. further steps are needed to reduce the level of work stressor and provide a better quality of live in individuals. background and aim: plasma levels of adipocytokines in healthy individuals or diabetes mellitus patients have been previously reported as well as salivary levels of many adipocytokines. nevertheless, salivary levels of some adipocytokines in patients with metabolic syndrome have not been investigated. the aim of this study was to evaluate salivary and plasma levels of leptin and adiponectin in patients with metabolic syndrome. results: compared with healthy individuals, leptin levels in patients with metabolic syndrome were significantly increased, both in plasma ( . ae . vs. . ae . ng/ml, p < . ) and in saliva ( . ae . vs. . ae . pg/ml, p = . ). whereas plasma adiponectin levels were decreased significantly in patients with metabolic syndrome ( . ae . vs. . ae . lg/ml, p = . ), salivary adiponectin levels were inversely increased ( . ae . vs. . ae . ng/ml, p = . ). conclusion: this study showed that, similarly to plasma, there was an elevated change in salivary leptin levels in patients with metabolic syndrome compared to healthy individuals. however, for salivary adiponectin levels, the opposite result to plasma adiponectin levels was revealed. replacing saliva to plasma for detecting altered leptin and adiponectin should be concerned in patients with metabolic syndrome. objective: to examine dietary intake in family members with diabetes type (dt ) to identify contributing factors to glycemic control and development dt . design: descriptive and prospective study involving members of families who provided food intake from days, weeks days and weekend day. inclusion criteria were proband member diagnosed with dm with ! siblings and living parents. methods: data were collected at the participants' homes or at the university clinic. the biometric measures were glucose and hemoglobin glucose (hba c). data was entered into nutritional data system to research, the "gold standard" for nutritional analysis. also, the data entry into spss v was done. : of , ( % women, mean age . ae . ; , mean blood glucose . mg/dl ae . ; - and mean (hba c) . % ae . ; . preliminary data indicate intake total fat was higher than the recommendations % of participants, while carbohydrate intake was higher in %. method: this was a retrospective, observational study of consecutive cardiac bypass patients that underwent surgery at sultan qaboos univesity hospital in muscat, oman, between and . analyses were performed using descriptive statistics. the study included a total of cardiac bypass surgery patients with an overall mean age of ae years and % ( / ) were males. mean body mass index was kg/m ranging from to kg/m . twenty-seven percent of the patients were either past or current smokers while % ( / ) had a family history of coronary artery disease. all but of the patients ( %) were on statins pre-op. the most prominent co-morbidities were hypertension ( %), angina ( %), diabetes mellitus ( %), myocardial infarction ( %), and congestive heart failure ( %). the mean average pre-op total cholesterol, low-density lipoprotein cholesterol (ldl-c), high-density lipoprotein cholesterol (hdl-c), triglycerides, apolipoprotein a (apo a ), and apolipoprotein b (apo b) were . ae . mmol/l, . ae . mmol/l, . ae . mmol/l, . ae . mmol/l, . ae . g/l, and . ae . g/l, respectively. eighty-one percent, %, and % of the patients had or or diseased heart vessels, respectively. there was a total of %, %, and % of the patients that had on-pump, off-pump, and on-pump beating coronary artery bypass surgeries, respectively. mortality was recorded in two patients ( %) in an approximately -year period. conclusions: patients undergoing cardiac bypass surgery were observed with a high prevalence of cardio-metabolic risk factors. aim: to evaluate the association between osteocalcin and phenotypic characteristics of metabolic syndrome. material and methods: data of children and adolescents participants of the project "health worker cohort study" was analyzed. to each participant we determined: insulin, glucose, triglycerides, hdl, waist circumference and blood pressure. glucose and insulin were evaluated by glucose-oxidase method and homa. total osteocalcin concentration was determined by chemiluminescence. body mass index (bmi) was evaluated according to cdc chart′s for children and adolescents according to age and sex. using multiple lineal regression and logistic regression we evaluated the association between osteocalcin values and components of metabolic syndrome. results: the proportion of male in the study population was . %. the prevalence of overweigh and obesity was . % and abdominal obesity was . %. the proportion of elevated glucose, hypertriglyceridemia, low levels of hdl, hypertension and metabolic syndrome were . %, . %, . %, . % and . % respectively. difference of medians according to ages groups, was observed for glucose, insulin, homa and osteocalcin (p < . ). the study showed a negative correlation between bmi, fat percentage, waist circumference, glucose levels and crp with ostelcalcin levels (p < . ). conclusions: serum osteocalcin levels were associated with some phenotypic characteristics of metabolic syndrome and measures of adiposity. background: previous studies show that hyperuricemia precede the development of the metabolic syndrome and can be a risk factor to diabetes type , cardiovascular disease and heart failure, independently of obesity. aim: to identify the association between hyperuricemia and cardiovascular risk factors (crf). the study population included adolescents, all of them participants from the "cohort study of health workers". crf were evaluated according to idf pediatrics criteria. the cut-off points for hyperuricemia was levels of uric acid > mg/dl, for hyperinsulinemia > mu/l, insulin resistant (ir) have homa > . . a multivariate regression analyses was used to evaluate the association between hyperuricemia and crf. resultados: the proportion of female in the study population was %. mean age was ae . years, prevalence of bmi >p was %, abdominal obesity ( . %), hypertension ( . %), hyperuricemia ( . %), glucose ! ( . %), hypertrigliceridemia ( %), low levels of hdl ( %), hyperinsulinemia ( %), ir ( %), crp ( . %) and ms ( . %). proportion of hyperuricemia was six times higher in men, ( vs. . , p < . ). the study show association between hyperuricemia and age (or: . ;ic % . - . ), hypertrigliceridemia (or: . ;ic % . - . ) hyperglucemia (or: . ;ic % . - . ), hyperinsulinemia (or: . ;ic % . - . ), ir (or: . ;ic % . - . ), abdominal obesity (or: . ;ic % . - . ) and ms (or: . ;ic % . - . ). conclusions: hyperuricemia is associated to crf. hyperuricemia is not considered for adolescent health diagnostic. however early diagnostic is important for avoid the presence of several crf. method: pancreas of fetuses and offspring from diabetic and nondiabetic sprague-dawley rats were obtained and processed for histological and morphometric studies and for inmunohistochemical analysis of pdx. , insulin and glut . results: fetuses of diabetic mothers, showed a significant delay in the morphogenesis of the islets, with a significant reduction of the diameter, area and beta cell mass and expression of pdx , insulin and glut . these fetal alterations had an impact on postnatal life and offspring of diabetic rats had significantly higher glucose levels. in offspring of days, the alterations persisted and the expression of insulin and glut was significantly lower. at days the islets were mature but the size, beta cell mass and expression of insulin, glut and pdx. were still significantly lower. at days the structure of the islets was normal, but the reduction in size, beta cell mass and expression of glut persisted, but with no significant reduction in the expression of insulin and pdx. conclusions: in utero hyperglycemia induced a delay on the differentiation of beta cells and morphogenesis of islets, a reduction of the beta cell mass and in the expression of insulin, glut and pdx. . these alterations persisted up to adulthood causing hyperglycemia to offspring. g. yoshino , t. an , s. nakano , k. kuboki center for diabetes, shinsuma general hospital, kobe, division of diabetes, metabolism and endocrinology, department of internal medicine, toho university, tokyo, japan background and aim: it has been a matter of debate whether the intervention is necessary even for elderly metabolic syndrome subjects. present study is therefore conducted to explore whether the elderly subjects with metabolic syndrome show increased cad risk measuring plasma small, dense ldl-cholesterol, hs-crp and plaque score of the carotid artery. methods: a total of subjects including male ranging from to years-old, were recruited for this study. they are divided into four groups according to their age (below and above years-old) and an association of metabolic syndrome. blood sampling was done after overnight fast. small, dense ldl-cholesterol was measured employing direct assay method. results: in the non-elderly subjects, plasma triglyceride, small, dense ldl-c, hs-crp and plaque score of carotid artery were all increased in the metabolic syndrome group compared to that of non-metabolic group, while there was no significant difference in either hs-crp or the plaque score between the two groups within elderly subjects. within the elderly metabolic syndrome group, subgroup with type diabetes had higher fasting blood glucose, hs-crp, small, dense ldl-c and plaque score than the subgroup without type diabetes. conclusion: metabolic syndrome is an important factor for progression of subclinical atherosclerosis in the non-elderly subjects, but it cannot be a significant determinant of subclinical atherosclerosis if the subjects are limited within elderly group without type diabetes. thus, intervention for metabolic syndrome may not be obligatory for elderly metabolic syndrome subjects if they are not diabetic. methods: a retrospective cross-sectional study of randomly selected patients on antihypertensive drugs at the outpatient clinic at sultan qaboos university hospital, muscat, oman. the recorded variables included age, gender, history of diabetis mellitus, weight, fasting blood glucose, creatinine level, systolic blood pressures (sbp), diastolic blood pressure (dbp), and type of medication. all parameters were collected of the last two visits from (january and december ) for each patient who had been labeled with persistent hypertension using the hospital information system (his). analyses were conducted using descriptive statistics. results: overall mean age of the cohort was ae years, % were male, % were diabetic, mean sbp ae , dbp ae , weight ae , and fbg . ae . on visit , % were on b-blockers, % patients were on calcium channel blocker, % on angiotensinconverting enzyme inhibitor and % were on diuretics either as a monotherapy or in combination. target bp was attained in . % patients with diabetes mellitus compared to . % in non diabetics after the second visit. the mean body weight in patients with controlled hypertension was . kg compared to . kg in patients with uncontrolled hypertension. the study showed that diabetes mellitus, increased body weight and high fasting blood glucose reduces the attainment of blood pressure goal in patient on antihypertensive therapy. purpose: comparable evaluation of lipid profile and inflammatory markers between patients with stable angina (sa) and patients with sa and diabetes mellitus of type (dm). material and methods: a total of patients with sa (mean age . ae . years) with coronary stenosis < % were examined. group i included patients with sa and dm; group ii - patients with sa without dm. lipid profile parameters; inflammatory markers (hs-crp, tnf-alpha, homocysteine, interleukine β, , ; scd l, mmp- , timp- ); endothelial dysfunction markers (endothelin- , nitrites) were measured initially and in year. results: there were high levels of hs-crp, tnf-alpha, lipoprotein (a), mmp- , triglycerides, and endothelin- in both groups. the level of timp- reduced in both groups. patients in group had significantly elevated levels of total cholesterol, ldl cholesterol, homocysteine, apo-b, apo-b/apo a- ratio, il- β. in group the following positive correlations were found: between glycohemoglobin and apo-b, apo-b/apo a- ratio, homocysteine; il- and hs-crp; homocysteine and ldl cholesterol, mmp- , duration of coronary artery disease; endothelin- and scd l, tnf-alpha. reliable increasing homocysteine, tnf-alpha mmp- , ldl cholesterol were revealed in both groups. conclusions: prospective study showed that both groups had similar blood biochemical abnormalities. however in patients with dm there was an increase in the levels of atherogenic lipid fractions as well as homocysteine, tnf-alpha and mmp- which may indicate a higher risk of developing coronary events even in the absence of significant coronary stenosis. objectives: il- is a pleotropic cytokine and is reported to be involved in various inflammatory and immune-mediated disorders. previous data in apo e-/-mice demonstrated that il- accelerates atherosclerosis via ifn-c and cxcl expression and the effect was independent of t-cells. we therefore investigated whether il- is involved in cholesterol efflux and plaque stability. methods: two groups of chow-diet-fed, male apolipoprotein e-/mice, aged weeks (n = /group) were fed a normal diet and injected intraperitoneally for days with either recombinant il- ( ng/g/ day) or with phosphate buffer saline (pbs). mrna expression of il- , scavenger receptor cd , mmp- and lxr-a genes was determined by real-time pcr. immunohistochemistry was also performed for expression of above genes. results: il- administration led to a significant increase in serum cholesterol and lipoproteins except hdl-c which was decreased. in heart and aortic tissues, expression of il- , scavenger receptor cd and mmp- genes increased . , and fold respectively, whereas expression of lxr-a gene was reduced by . fold. atherosclerotic lesion size was quantified in the ascending aorta and the aortic arch. exogenous il- administration significantly increased frequency of atherosclerotic lesions and lesion area in il- treated mice vs. control animals ( . ae . % vs. . ae . % (p < . ; pbs vs. il- group). the observed data strongly implicates il- as a proatherogenic and proinflammatory molecule which not only enhances inflammation but augments cd and mmp- expression which may lead to enhanced foam cell formation and plaque instability and thereby aggravate atherosclerosis. objective: the present study was attempted to found the association between tnf-a promoter gene g- a polymorphism with metabolic syndrome and insulin resistance. the g- a tnf-a polymorphism has been studied in subject with metabolic syndrome according to ncep atp iii criteria (age . ae . ; bmi . ae . ) and healthy control without metabolic syndrome (age . ae . ; bmi . ae . ). the g- a variant was detected by pcr amplification and nco- digestion. furthermore insulin resistance, serum leptin and tnf-alpha levels were also measured in both the groups. polymorphism was significantly less frequently observed in the control population as compared to study group. furthermore, on dividing the subjects into two groups according to the absence (homozygous for the wild type g allele) (tnf- allele) or presence of the mutant a (tnf- ) allele, significantly high levels of tnf-a (p = . , or = . , % ci = . - . ) and leptin (p = . , or = . , %ci = . - . ) were observed in tnf- group as compared to tnf- group. whereas, there was a non-significant tendency toward insulin resistance in the tnf- group. conclusions: our results suggest that the g- a mutation of the tnf-a gene is likely to play an important role in the development of metabolic syndrome and metabolic abnormalities. metabolic syndrome is associated with residential-area crime rates for men and perceived crime for women: gender differences in social vulnerability to metabolic syndrome introduction: crime rates and perception of crime within neighbourhoods have been linked to residents' cardiometabolic outcomes. men and women vary in their perception of crime but share exposures to residential-area crime. it is unclear whether gender differences exist in the nature of crime-related vulnerability to metabolic syndrome. aim: to assess gender-specific associations between perceived and reported crime, and metabolic syndrome (mets) methods: cross-sectional data from a biomedical cohort study of adults randomly selected from the north-west region of adelaide, south australia, were analysed (n = . ) (mean age = . , standard deviation = . ). clinically measured mets was defined using international diabetes federation criteria. perceived crime was expressed as a standardised factor score reflecting six items related to neighbourhood safety and crime. reported crime rates were obtained from police data, aggregated at the statistical local area level (n = ) and standardised. associations were evaluated using multilevel regression models accounting for area-level clustering and covariates including area-level income and participant sociodemographic factors. results: the prevalence of mets was, for men (n = ), . % ( % ci = . - . ), and for women (n = ), . % ( %ci = . - . ). for men, mets was associated with rates of violent crime (or = . , %ci = . - . ) and total crime (or = . , % ci = . - . ), but not perceived crime. for women, mets was associated with perceived crime (or = . , %ci = . - . ), but not reported crime. conclusions: crime is an adverse social exposure. mets is associated with perceived crime in women and reported crime rates in men. these differentials suggest gender-specific causal pathways by which awareness and perception of adverse social exposures relate to mets independent of socioeconomic factors. background: epidemiological studies suggest that the resting heart rate (rhr) is an independent predictor of cardiovascular and all cause mortality. however, the power of the rhr to predict cardiovascular events in patients with the metabolic syndrome (mets) is not known. methods: we prospectively investigated the relationship between rhr and cardiovascular events in consecutive patients undergoing coronary angiography for the evaluation of coronary artery disease (cad) over a follow-up period of . ae . years. the mets was defined according to ncep-atpiii criteria. results: in the total study population, both all cause and cardiovascular mortality were increased with an increasing rhr (standardised adjusted hrs . [ . - . ]; p = . and . [ . - . ]; p = . , respectively). from our patients, ( . %) had the mets and did not have the mets. among patients without the mets, a higher baseline rhr indicated a significantly higher risk of total mortality (h = . [ - . ], p = . ) and cardiovascular mortality (hr = . [ . - . ], p = . ) after multivariate adjustment. however, the rhr did not significantly affect total mortality (p = . ) or cardiovascular mortality (p = . ) in patients with the mets. interaction terms rhrxmets were significant for both total and cardiovascular mortality (p = . and p = . , respectively), indicating that the respective risks conferred by a high rhr were significantly higher in patients without the mets than in patients with mets. conclusion: we conclude that among angiographically characterized coronary patients, the metabolic syndrome status significantly affects the association of the rhr with total and cardiovascular mortality: rhr is a strong predictor of both total and cardiovascular mortality among subjects without the mets, but not among mets patients. aim: to estimate influence of diet therapy, physiotherapeutic treatment to body mass reduction and prevention of cardiovascular and metabolic risks. patients and methods: were surveyed patients with a metabolic syndrome aged of - years: women ( %) and men ( %): ( %) pts were overweight, ( %) pts had bmi . ae . kg/sq.m, pts ( %) -bmi . ae . kg/sq.m. % pts had hypercholesterolemia, % -glucose intolerance, % -high arterial blood pressure. all patients were undergone by the assessment of nutrition status, biochemical researches. there was executed food allowance correction and added complex of physiotherapeutic treatment. control examination was carried out in weeks by body structure definition by bioimpedance analysis and biochemical blood tests. results: there were noted that level of cholesterol decreased from . ae . mmol/l to . ae . mmol/l (p . ), level of blood glucosefrom . ae . mmol/l to . ae . mmol/l. there was registered decreasing systolic arterial pressure of % of patients to . ae . mmhg (p . ) and diastolic at % pts -to . ae . mmhg (p . ). there were fined reduction of a fatty component on . ae . by kg, with preservation of active cellular weight - . ae . in kg (p < . ) in patients. conclusions: physical exercises, physiotherapeutic procedures jointly balanced food allowance promote more considerable decrease in weight of body and decrease in cardiovascular and metabolic risks. results: after adjustment for sociodemographic and lifestyle factors, the relative risk (rr) of pd comparing subjects with metabolic syndrome to those without it was . and the % confidence interval ( % ci) . - . . this association was especially due to high serum triglyceride levels ( ! . vs. < . mmol/l, rr . , % ci . - . ), and high plasma glucose levels ( ! . vs. < . mmol/l, rr . , % ci . - . ). the results remained after excluding the first years of the follow-up. after this exclusion and further adjustment for other components of the metabolic syndrome, the suggestive association between pd and bmi was strengthened ( ! kg/m vs. < kg/m , rr . , % ci . - . ). conclusions: high serum triglycerides and plasma glucose levels predicted low pd incidence, even after excluding the presumable preclinical disease phase. also, the suggestively increased pd risk in subjects with high bmi varied according to the follow-up time, proposing that an adequate time period should be considered to account for the preclinical disease phase in pd. pancreatic intrinsic nervous system (pins) maturation goes on postnatally and is involved in the control of pulsatility and amplitude of insulin secretion (is), both altered in obese and diabetic patients. the aim of our study was to determine the impact of obesity in infancy on pins maturation and control of is. c bl/ j mice aged weeks received a normal (nd) or a western diet (wd) for weeks. weeks old mice were used as initial controls (t ). after sacrifice, pancreases were placed in organ incubators for h. the impact of pins upon is was studied by adding to the culture the nicotinic receptors agonist dmpp in presence or absence of l-name (inhibitor of nos) or snp (no donor). insulin was assayed in culture supernatants. pins density and phenotype were determined by ihc. pins density was less in nd compared to t mice, whereas there was no difference between wd and t mice. cholinergic innervation significantly increased with age in both wd and nd mice whereas nitrergic innervation increased in nd mice and decreased in wd. pins stimulation by dmpp induced a time-dependent increase in is, significantly larger in nd compared to wd mice. is profile was identical in wd and t mice. addition of l-name inhibited dmppinduced is in nd mice while snp tended to reduce it. neither l-name nor snp altered is in wd mice. our study suggests that wd induces neuroplastic changes in the pins that could be involved in pancreatic dysfunctions observed during obesity. purpose: inflammation drives the progression from central obesity to insulin resistance, metabolic syndrome and hypertension. whether inflammation caused by allergic diseases such as allergic rhinitis can predispose to hypertension is controversial. therefore, we studied the association between hay fever and hypertension in the united states national health and nutrition examination survey (nhanes). we analyzed data on men and women in nhanes nhanes - . we included participants aged years or older who had valid data on hay fever and hypertension. results: . % of the participants had a previous diagnosis of hay fever and . % of them had hypertension. there were ethnic differences in the prevalence of previous hay fever diagnosis (p < . ) and hypertension (p < . ). overall, there was no significant association between previous hay fever diagnosis and hypertension. in women aged - , there was an association between previous hay fever diagnosis and hypertension (or = . , % ci = . - . , p = . ). this association was not diminished after adjustment for age, race and body mass index (or = . , % ci = . - . , p = . ). after further adjustment for physical activity, alcohol consumption, smoking, liver enzymes, c-reactive protein and ige level, the association remained significant (or = . , %ci = . - . , p = . ). conclusions: in this nationally representative population-based survey, previous hay fever diagnosis is not significantly associated with hypertension in adults, except for women aged - . further work is needed to confirm that this is a true association. the university of hong kong, hong kong, hong kong s.a.r. objective: beta- microglobulin (b m) is the light chain of the major histocompatibility complex class molecule. glycation of b m renders it toxic. serum b m level predicts mortality in chronic kidney disease and some malignancies such as multiple myeloma. we hypothesized that it also predicts mortality in people with diabetes. research design and methods: participants of the third national health and nutrition examination survey aged or above who had diabetes or were on medication for diabetes were included in the analysis. results: during a median follow-up of . years (range . - . years) and . person-years, ( . %) and ( . %) participants died from diabetes-related causes and all causes, respectively. tertile of b m was significantly associated with allcause (hazard ratio (hr) = . , % ci: . - . ) and diabetesrelated mortality (hr = . , % ci: . - . ). the association was independent of cardiometabolic risk factors, cancer, microalbuminuria and impaired glomerular filtration rate. conclusions: serum b m level is a novel independent predictor of diabetes and all-cause mortality in people with diabetes. an elevated level is associated with a substantially increased risk of death. metabolic syndrome (ms) refers to a constellation of factors that increase risk of cardiovascular diseases (cvd) and diabetes. insulin resistance and associated abnormalities is considered to be a link between obesity and cvd. our ongoing study investigates relationship of anthropometric, metabolic and cardiovascular parameters in young patients with incipient ms (young lean subjects with essential hypertension; ht) and obese otherwise healthy subjects (ob) in comparison to healthy lean controls (c) similar for age and sex. methods: all subjects underwent the oral glucose tolerance test. the insulin sensitivity index according matsuda (isimat) and ir homa were calculated. fasting serum concentration of total cholesterol (tchol), hdl cholesterol, triglycerides (tg), and uric acid as well as fasting and post load plasma glucose and insulin concentrations were measured. results: young lean ht patients had comparable bmi but higher body fat percentage (p = . ), higher fasting plasma insulin (p = . ), slightly higher uric acid (p = . ), and higher t-chol (p = . ) than c. despite ngt, ht patients had lower isimat (p = . ) and higher ir homa (p = . ) than controls., but these parameters were comparable to the ob group. / of young lean ht patients similarly to ob otherwise healthy subjects exhibited three and or more features of ms. conclusions: young lean patients with hypertension displayed signs of insulin resistance comparable to obese subjects and metabolic abnormalities typical for metabolic syndrome. early life style interventions might prevent theto development of complete ms in these young ht and ob subjects. increased prevalence of overweight in male patients, whereas women had increased prevalence of obesity (grade ii and iii). hypertensive diabetic subjects with other metabolic risk factors are more prone to microvascular and macrovascular complications. methods: eighty-six patients were divided into two groups. the group included subjects (mean age . ae . years) with ah and ao (mass body index (mbi) . ae . kg/m ) and the group - subjects (mean age . ae . years) without metabolic disorders. the parameters of -hour bp monitoring; microalbuminuria and mdrd; total cholesterol, low-density lipoprotein cholesterol, highdensity lipoprotein cholesterol, triglyceride, diene conjugates (dc), malonic dialdehyde (md), catataze and inflammatory markershomocysteine, high-sensitivity c-reactive protein (hs-crp) and fibrinogen were estimated. results: in group there was registered increase in mean -h and daytime systolic bp, time and square indices, in night time systolic and diastolic bp variability. in renal function factors there was registered increase mdrd. in biochemical parameters there was detected increase in total cholesterol, triglyceride level, md and dc level, fibrinogen and hs-crp level; and decrease of catalase level; high density lipoprotein cholesterol compared to group . besides in group positive correlation between lipid and inflammatory markers against each other and with parameters of -h bp monitoring, microalbuminuria, mdrd and mbi was found. conclusion: we revealed relationship between blood pressure profile parameters, renal function parameters, atherogenic lipid profile parameters, inflammatory markers and mbi, that is indicative of development of cardiovascular and cardiorenal risk in patient with ah and ao. there is considerable interindividual variation in therapeutic response to metformin in women with pcos and obesity. genetic factors may play an important role in therapeutic response to metformin and tcf l gene could be one of such factors. tcf l marker is one of the strongest risk factors known for predicting increased likelihood of conversion from prediabetes to t d. tcf l belongs to a subfamily of tcf -like hmg box-containing transcription factors. tcf l is a component of the wnt-signaling pathway and determine the glucoseinduced insulin secretion and regulates the maturation of β-cells of the pancreas from pluripotent stem cells. in addition, this gene plays an important role in adipogenesis and differentiation of adipose tissue. the aim of our study was to evaluate the efficacy of using metformin in patients with pcos and obesity in relation to their rs polymorphism of the tcf l gene. patients with pcos and obesity receiving therapy with metformin were examined. comparative analysis revealed a significant increase in the frequency of genotype c/t (v = . ; p < . ; or = . ; % ci = . - . ) and t/t (v = . ; p < . ; or = . ; % ci = . - . ) in the group of patients with positive dynamics of treatment with metformin compared with the group without positive dynamics of treatment. thus, patients with pcos and obesity who possess the genotype c/t and t/t of the tcf l gene are more likely to have positive therapeutic response to metformin. objective: to investigate the relationship between resistin gene polymorphism with its circulating level, metabolic risk factor and insulin resistance in adult women. design: total healthy subjects were enrolled for the study, (age . ae . years) were with metabolic syndrome and were age matched control (age . ae . years) without metabolic syndrome. circulatory resistin, insulin, plasma glucose and lipid profiles fasting level were estimated along with insulin resistance. resistin-c g promoter region polymorphism were done by rflp method digested with bbsi restriction enzyme. results: homozygous mutant genotype (cc) (cc v/s cg + gg) (p = < . : or = . : % ci = . - . ) of the c/g resistin gene polymorphism was significantly less frequently observed in the control population. on dividing the subjects further in to two groups according to the abscence (resistin- ) and presence (resistin- ) of the mutant g allele, significantly high levels of resistin (p = . , or = . , % ci = . - . ), triglyceride (tg) (p = . ), plasma glucose (p = . ), systolic blood pressure (sbp) (p = . ), diastolic blood pressure (dbp) (p = . ), whr (p = < . ) were observed in resistin- group . conclusion: our results conclude that the c/g mutation of the resistin gene is likely to play an important role in metabolic syndrome and metabolic abnormalities. background: in both obesity and allergy, inflammation occurs. therefore, we examined the association between body mass index (bmi), a measure of general obesity, and serum ige level, a measure of allergy. excluded from this study. using the complex sampling function of spss, the unstandardized regression coefficient, b, for the relationship between bmi and the natural logarithm of ige level was calculated. results: there was a sex difference in ige level (p < . ). before adjustment, ige was associated with bmi in women (b = . , p = . ) and in the overall population (b = . , p = . ). after adjusting for race/ethnicity, age and sex except in sex-specific analysis, the association in women (b = . , p = . ) and the overall population (b = . , p = . ) remained significant. after further adjustments for physical activity, alcohol consumption and smoking, the association was still significant in women (b = . , p = . ) and the overall population (b = . , p = . ). the association was attenuated but remained significant in women (b = . , p = . ) and the overall population (b = . , p = . ) after further adjustment for levels of liver enzymes and c-reactive protein. conclusions: in this nationally representative population-based survey, ige level is associated with bmi. the attenuation in the association after controlling for liver enzymes and c-reactive protein suggests that hepatic inflammation accounts for some of the association. background: janus kinase (jak) is involved in cytokine receptormediated intracellular signal transduction. inhibition of jak protects beta-cells from cytokine toxicity and has been shown to delay the onset of diabetes in the mouse model. the influence of jak single nucleotide polymorphisms (snps) on diabetes risk or on diabetesrelated metabolic traits is unknown. methods: we therefore investigated the association of jak tagging snp rs (c>t) with metabolic phenotypes and type diabetes (t dm) in a cohort of coronary patients including non-diabetic subjects and patients with t dm, totally comprising individuals. results: among non-diabetic subjects snp rs was significantly associated with hba c (cc: . ae . , ct: . ae . , tt: . ae . %; p = . ), fasting glucose (cc: . ae . , ct: . ae . , tt: . ae . mmol/l; p = . ), and hdl-cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ), as well as with total cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ) and ldl-cholesterol (cc: ae , ct: ae , tt: ae mg/dl; p = . ). in patients with t dm, the jak variant was significantly associated with fasting glucose (cc: . ae . , ct: . ae . , tt: . ae . mmol/l; p = . ). the association between snp rs and t dm did not reach statistical significance (allelic odds ratio = . [ . - . ]; p = . ). we conclude that jak tagging snp rs is significantly associated with phenotypes conferring an increased cardiometabolic risk, at least in non-diabetic coronary patients. the association between rs and the risk of t dm warrants further investigation. l. garrido-s anchez , x. escoté , l. coín-aragü ez , j.c. fren andez-garcía , r. el bekay , j. background: munc c is associated to glucose metabolism and could play a relevant role in the insulin resistance. however, little is known on the regulation of munc c expression. we analyze munc c gene expression in human visceral (vat) and subcutaneous adipose tissue (sat) and their relationship with obesity and insulin. we evaluated subjects distributed in non-obese lean subjects, overweight subjects, obese subjects and nondiabetic morbidly obese patients ( with low insulin resistance and with high insulin resistance). results: the lean, overweight and obese persons had a greater munc c expression in adipose tissue than the morbidly obese patients (p < . ). vat and sat munc c correlated negatively with weight (p = . , p = . ) and bmi (p = . , p = . ). vat munc c correlated negatively with glucose (p = . ). sat munc c correlated negatively with insulin (p = . ) and homa-ir (p = . ), and was the main determinant of the improvement in homa-ir index at days after bariatric surgery (b = À . , p = . ). sat explants cultures show that insulin produced a significant down-regulation of munc c expression (p = . ). this decrease is also obtained when explants are incubated with a liver x receptors alpha (lxra agonist, either without (p = . ) or with insulin (p = . ). however, munc c expression is not affected when explants are incubated with insulin plus a sterol regulatory element-binding proteins- c (srebp- c) inhibitor (p = . ). conclusions: munc c gene expression in human adipose tissue is down-regulated in obesity and is inversely associated with insulin resistance. insulin may have an effect on the munc c expression, probably through lxra and srebp- c. lab., faculty of medical technology, endocrin, tripoli-university of medical sciences, biochemstry, cdc, biotechnology, research centre, tripoli, a protective factor for obesity, type- diabetes mellitus (t dm), polycystic ovary (pcos), and lacunars infarction. objectives: the objective of this study was to investigate the association between this polymorphism and t dm, gestational diabetes (gdm), and obesity. methods: genotyping was achieved by pcr-relp in individuals chosen randomly from the out patient's clinics of al-jala maternity hospital of tripoli and gharian hospital, including: t dm patients, gdm patients, obese, healthy control individuals from libyan pregnant women population (north-west region). the results revealed that this polymorphism has no association with t dm, gdm, and obesity in comparison with the control sample. conclusion: t a polymorphism of sorbs gene is not associated with the pathological conditions studied. r. parhimovich, n. konovalova, r. tishenina, n. mylov moscow regional research clinical institute named after m.f. vladimirskiy, moscow, russia area ( . ) of bmi ! . kg/m (bmi ) had significant larger areas than those of wcm ( . ). wci and bmi had good sensitivity ( . % and . %). wci and wci had good specificity ( . % and . %) and classification ( . % and . %). the proposed cutoff values were wci . further cohort study is needed to confirm these values. for national reference, we recommend measuring at umbilical due to its feasibility. servicio de endocrinologia y nutricion, hospital regional universitario carlos haya, ciberdem, servicio de cirugía, hospital regional universitario carlos haya, m alaga, spain introduction: the fndc gene encodes a membrane protein which is proteolytically cleaved, glycosylated and secreted into the blood as irisin. it has been described that causes a significant increase in total body energy expenditure, reduces body weight and improves dietinduced insulin resistance in mice. however, little is known in human. the aim of this study was to analyze the irisin levels in morbidly obese subjects undergoing bariatric surgery at baseline and months after surgery. material and methods: we measured serum irisin levels in morbidly obese subjects undergoing roux-en-y gastric bypass and in healthy controls. we have analyzed anthropometric variables and the level of insulin resistance with the homa-ir index. results: morbidly obese patients have a lower serum irisin levels that control subjects ( . ae . vs. . ae . ng/ml, p = . ). serum irisin levels were similar before and after bariatric surgery in morbidly obese subjects ( . ae . vs. . ae . ng/ml; p = . ). there were no significant differences between morbidly obese subjects according to the homa-ir levels, neither before nor after surgery. irisin levels correlated negatively before surgery with glucose (p = . ), triglycerides (p = . ), cholesterol (p = . ), homa-ir (p = . ) and waist to hip ratio (p = . ). in a multiple lineal regression model, irisin levels were associated with waist to hip ratio (p = . ) after adjusting for fasting glucose, cholesterol, triglycerides, homa-ir and age. no significant correlations were found at months after surgery. conclusions: irisin levels in decreased in morbidly obese subjects and is mainly related to waist to hip ratio. results: the level of uric acid increased with age in women and had a significant difference in women of - years (r = . , p < . ). in men, the maximal level of uric acid was in the group - years. incidence of hyperuricemia among women was %, in men - %. we determined that the highest level of triglyceride, cholesterol, systolic and diastolic pressure was among women and men with hyperuricemia. the higher level of uric acid was found in patients with maximal body mass index (bmi > ). incidence of hyperuricemia among women in the i group was . %, in ii - . %; in iii - . %, in iv - . %. conclusions: it was determined that the level of uric acid was increasing with age and the highest level of some components of metabolic syndrome (triglyceride, cholesterol, systolic and diastolic pressure) was among patients with hyperuricemia. introduction: cushing's disease (cd) is the most common reason of endogenous hypercortisolaemia. the cortisol excess leads to serious metabolic and cardiovascular complications which significantly increase the morbidity and mortality in cd. objective: to assess the prevalence of preoperative glucose homeostasis alterations in cd and their influence on the effectiveness of surgical treatment. material and methods: a prospective study that included patients ( women; six men) with cd. the prevalence of prediabetes (impaired fasting glucose, impaired glucose tolerance) and overt diabetes was assessed. the relationship was evaluated between duration of cd symptoms and the presence of glucose homeostasis alterations as well as their impact on the efficacy of surgical treatment for cd. the proportion in the study group of overt diabetes was . %, whereas the prevalence of prediabetes was . %. . % of patients were obese (bmi ! ) and additional . % were overweight (bmi ! ). there was confirmed the association between duration of cd symptoms and occurrence of diabetes (p < . ) and any type of glucose homeostasis alterations (p = . ). there was no relationship confirmed between the presence of glucose homeostasis alterations and efficacy of transsphenoidal surgery for cushing's disease. conclusion: a longer duration of cd symptoms was associated with greater risk of metabolic complications such as: prediabetes and secondary diabetes. the efficacy of surgical treatment for corticotroph adenoma does not depend directly on the presence of preoperative glucose homeostasis alterations. objective: the study objective was to identify factors associated with depressive symptoms in elderly with metabolic syndrome. material and methods: it was a case-control study to check sociodemographic and lifestyle influencing depressive symptoms in elderly patients with metabolic syndrome. the cases were attended in program family health strategy, classified as having metabolic syndrome and depressive symptoms and the control group consisted of individuals with metabolic syndrome who didn′t have depressive symptoms. it was used as a measure of association, odds ratio (or) with confidence interval of % and p-value, obtained by conditional logistic regression model. conclusions: in the population studied showed that depression was associated with individuals at higher stress levels, those who had shown the mourning, elderly older than years, those with cognitive deficits and negative perception of health. the results reinforce the need to train health professionals so that they can identify and intervene in this population, to improve the quality of life for seniors. introduction: vascular endothelial growth factor (vegf) is said to play key role in pathogenesis of diabetic nephropathy by upregulating the expression of endothelial nitric oxide synthase (enos). human vegf gene, located on chromosome and is highly polymorphic. insertion/deletion (i/d) polymorphism of the bp fragment at position of the promoter region of vegf gene has been implicated in many diseases of angiogenic origin. aim of the study: to investigate i/d polymorphism of vegf gene in patients with type diabetes mellitus and to assess their possible role in diabetic nephropathy. materials and method: fifty subjects with diabetic nephropathy, subjects with diabetes mellitus without nephropathy and normal controls were evaluated for i/d polymorphism of the bp fragment at position of the promoter region of vegf gene by polymerase chain reaction. the frequency of vegf alleles and genotype distribution were compared in diabetic subjects, diabetic nephropathy subject and control groups. results: distribution of vegf genotype was found to be significantly (p < . ) different amongst diabetic nephropathy subjects, diabetic subjects and controls by fisher's exact test and chi square test. statistically significant association (p < . ) of d allele was also found with diabetic nephropathy. conclusion: our study shows that i/d polymorphism of the bp fragment at position of the promoter region of vegf gene is associated with diabetic nephropathy. university of delhi, new delhi, india between bai, bmi and percent body fat (pbf) in an endogamous population of india. design: data was collected on adults with respect to bodyweight, height, skinfolds, hip and waist circumference, and blood pressure. pearson correlations was calculated for bai and bmi with pbf. differences in correlation for baivsbmi were examined using fisher z-tests. receiver operating characteristic (roc) analysis was used to compare the predictive validity, and to determine optimal cut-off values. ors were calculated to assess the risk of having hypertension using the proposed cut-off points. results: the correlation of pbf with bmi (men: r = . ; women: r = . ) were stronger than those with bai (men; r = . ; women: r = . ). the regression model for bai explained . % of the variance in pbf in men and . % in women whereas the corresponding regression model for bmi explained . % variance in men and . % in women. in men, the sensitivity and specificity of bai to predict hypertension was higher than wc, whr and whtr but lower than bmi. in women, the sensitivity of bai was higher than bmi and wc. in men, odds of hypertension on bai were lower than other anthropometric markers while in women, it was higher for other anthropometric markers. conclusions: bai can be used as an additional marker for screening population, however its validity needs to be demonstrated on other populations too. obesity is a multifactorial syndrome characterized by a chronic state of positive energetic balance. the experimental model of treating neonatal rats with monosodium l-glutamate (msg) was used. amino acids, which also participate in the formation of proteins, are precursors of signaling molecules as local hormones and mediators; indeed, glycine can induce catecholamine secretion of adrenal medulla. catecholamines of the adrenal medulla have an important role in the regulation of the metabolism, affecting the mobilization of fats. therefore, abnormalities in catecholamines secretion can contribute for obesity development. thus, the purpose of our work was verify if glycine administration has an inhibitory effect on hypothalamic obesity development. animals were treated with tap water added to glycine ( . g/kg). catecholamine content and secretion from adrenal medulla were measured using the trihydroxyindole fluorescence method. msg treatment induced . % enhancement of perigonadal fat pad when compared to control animals (p < . ). however, glycine treatment caused a reduction of almost % on perigonadal pad in obese group (p < . ); control-glycine group presented a decrease of . % in perigonadal fat pad related to control (p < . ). msg treatment reduced . % basal catecholamine secretion (p < . ). obese animals that received glycine presented an increase in basal catecholamine secretion ( . %, p < . ). in conclusion, we showed that glycine treatment did not inhibit obesity development, but the decrease in adiposity observed in obese and control rats treated with glycine may be consequence, at least in part, of the enhacement in basal catecholamine secretion due to stimulatory effect of the glycine. background: increased high sensitivity c-reactive protein (hscrp) and c-glutamyl transferase (ggt) have been reported to be associated with metabolic syndrome (mets) and its components. the aim of this study is to determine whether these two biomarkers independently predict new occurrences of mets in koreans. methods: on-going prospective cohort study, korea health examinee study (koex), has recruited . individuals since . among them, repeated survey was done in approximately years for individuals. only newly occurring mets cases during follow-up was included in this study. odds ratios (or) and % confidence intervals (ci) for the risk of mets were estimated using multivariate logistic regression analysis. results: three hundred seventy-six newly occurring mets cases were ascertained in the follow-up survey. two years' cumulative incidence of mets was . % and was higher among men than women ( . % vs. . %). after adjustment for potential covariates, an increased risks for newly occurring mets were observed among those with higher hscrp measured at baseline examination in men (or = . , % ci . - . ; ! . (mg/l) vs. < . (mg/l)) and in women (or = . , % ci . - . ; ! . (mg/l) vs. < . (mg/l)). also higher risk was observed in those with higher ggt in women (or = . , % ci . - . ; ! (iu/l) vs. < (iu/l)) and in men (or = . , % ci . - . ; ! (iu/l) vs. < (iu/l)). conclusions: metabolic markers such as hscrp and ggt are clearly predicted new occurrence of mets. clinical usefulness of these markers needs to be more investigated in the extended follow-up study. objective: thyroid dysfunctions are supposed to be implicated in metabolic risk. we assessed the effects of hyper-, hypo-and euthyroidism on patients′ lipid metabolism and oxidative stress from a month follow-up clinical pilot study. methods: a study cohort of probands was grouped into hyper-(n = ), hypo-(n = ) and euthyroid (n = ) patients and healthy controls (n = ). patients received their individual medication and underwent a month follow-up. routine thyroid parameters, inflammatory status, lipid metabolism and oxidative stress were analyzed in patients before and after months of medication and in healthy controls. additionally, we measured the body weight, length, waist and hip circumference, bmi as well as blood pressure (bp). results: analyses of routine thyroid parameters confirmed patient's status. anthropometric baseline characteristics were comparable between groups. bp was significantly higher in all baseline patient groups compared to controls. baseline vs. follow-up analyses revealed that euthyroid follow-ups had a significant increased bmi, waist circumference and waist-to-length ratio. further, euthyroid and hypothyroid follow-ups had a significantly lower bp. observations on lipid metabolism revealed that hypothyroid and euthyroid follow-ups showed declined hdl levels and significant higher hld-ldl ratios compared to their pre-treated state. cholesterin, ldl, tg, oxldl levels and inflammatory markers were comparable in baseline and follow-ups. concerning oxidative stress we found significantly declined asymmetric dimethylarginine (adma) levels in all three follow-up groups. results: in the elderly group without metabolic syndrome, autonomy was associated with increasing age, sedentary behavior, and depressive symptomatology. in the presence of metabolic syndrome, in addition to these factors, the lowest level of education, being insufficiently active in physical activities, and have at least one chronic disease is not transmissible, also correlated with worse autonomy. the strong association between obesity and cardiovascular disease stresses the necessity of elucidation the underlying molecular mechanisms linking these pathologies. adrenergic over-activation can promote cardiac hypertrophy and progression to heart failure. our aim was to evaluate a novel sensor for camp namely epac (exchange protein directly activated by camp) and downstream signalling pathways in the development of cardiac hypertrophy and susceptibility to ischaemia/reperfusion injury in a rat model of obesity-induced insulin resistance. methods: wistar rats on a hyperphagia-inducing diet, hid (supplementing normal rat chow with sucrose and condensed milk) for and weeks were compared to age matched controls. isolated working hearts were subjected to min global ischaemia and functional recovery was measured after min reperfusion. hearts were also freeze-clamped at different time points during ischaemia and reperfusion. epac activation was determined by rap activation kit. nfat, p mapk, erk / , pkb and creb were determined by western blotting using appropriate antibodies. results: the heart weight increased significantly after weeks on hid along with an increase in the hypertrophic marker, nuclear nfat. the weeks hid hearts recovered significantly after ischaemia compared to controls, along with a significant increase in phospho-pkb after min reperfusion, compared to week hid hearts. however, results on epac activation showed variable responses. type diabetes mellitus (t dm) and hypertension (htn), both illnesses share pathogenic mechanisms that predispose to micro/ macrovascular complications. it is well known the role of hyperglycemia and insulin resistance of diabetes in vascular endothelial dysfunction. several studies have shown the association of serum concentrations of osteocalcin (oc) in the metabolism of glucose. oc a marker of bone formation by osteoblasts and produced hormone that regulates energy metabolism, was found recently in arteries with atherosclerosis, suggesting their direct association with vascular disease. we analyzed the relationship between serum oc concentrations and cardiovascular risk factors. a cross-sectional analytical study was carried out in patients with t dm plus htn and healthy subjects (hs). oc serum levels were measured and also statistically correlated with cardiovascular risk parameters. total osteocalcin serum levels in t dm + htn subjects were significantly higher than those in hs (p < . ), whereas the uncarboxylated oc concentrations were lower in t dm + htn subjects than in hs (p < . ). body mass index, waist circumference, fat percentage, fasting plasma glucose, high-density lipoprotein cholesterol, fasting serum insulin, homeostasis model assessment-insulin resistance and high sensitivity-c reactive protein were negatively correlated with uncarboxylated osteocalcin (p < . ). in addition, carboxylated oc was also positively correlated with systolic and diastolic blood pressure (p < . ) and homeostasis model assessment-insulin resistance (p < . ). oc serum concentrations are associated with cardiovascular risk factors in patients with t dm + htn. the oc forms (uncarboxylated/carboxylated) might play different roles in cardiovascular and endocrine physiology and hence be of different value as cardiovascular risk markers. aim: to evaluate the prevalence of ms in a group of medical students from bucharest and their habits related to nutrition and physical activity. cross-sectional study: ms was defined according to international diabetes federation criteria. medical students from bucharest were included in the survey, based on their informed consent. they were examined clinically (weight, height, waist, blood pressure), provided a blood sample (glycaemia, lipids, triglycerides, cholesterol, high and low-density lipoproteins) and answered to block adult questionnaire for food and physical activity. results: students enrolled, . % females. . % of subjects were free of signs of ms, . %, . % and . % met one, two and three criteria for ms diagnosis. the highest prevalence of abnormality was found in waist (above the limit in . % cases), followed by hdl (decreased in . % cases). significant differences among genders were found in waist. food habits: boys were found to eat significantly more calories, fats, carbohydrates and proteins compared to girls. no differences for fibres, transfats, free sugar, fruits and vegetables. physical activity: boys consumed significantly more energy through physical activity, recreational activities and vigorous physical activity compared to girls. only in % of cases the energetic consume was higher than the ingestion (no difference by gender). conclusion: high prevalence of unhealthy habits related to nutrition and physical activity in a particular highly educated young group are concerning for the occurrence of ms in the future. triphala an age old commonly used powered preparation of three medicinal dried plant fruits amla (emblica officinalis), harad (terminalia bellirica) and bahera (terminalia chebula) in equal proportionsis used in indian systems of medicine. present work evaluated the anti-hyperglycemic, anti-hyperlipidemic, and antioxidant potentials of 'triphala' formulation viz., (emblica officinalis: terminalia bellirica: terminalia chebula:: : : ) in subjects with igt and tiidm. the therapeutic effect of 'triphala' administration ( gm bd) in tiidm, igt and healthy individuals was assessed by monitoring blood glucose at days intervals, hba c, lipid profile, oxidative stress markers, and liver & kidney function markers at days intervals. dna damage was assessed by comet assay, flow cytometry and hoechst nuclear stain. molecular markers were determined in the beginning and at the end of therapy. results: 'triphala' ( : : ) administration for year significantly brought down blood glucose levels with a marked improvement in lipid profile in all the groups, this was further supported by increased protein expression of ampk and adiponectin. triphala provided resistance to oxidative stress generated not only by the increasing the antioxidant enzymes activity, but also by shortening comet tail length and number of cells in g phase of cell cycle. our results indicated that diabetes is strongly associated with elevated levels of ar, tnf-a, il- and il- , but triphala down regulated the same, proving its anti-inflammatory potential. conclusion: these observations raise the prospects of using triphala formulation for treatment of diseases associated with oxidative stress and imbalanced cytokine production. introduction: glucoregulation disorders are a state of pre-diabetes increasingly diagnosed in the general population. its association with hypertension, increases the risk of cardiovascular morbimortality objective: identify the blood pressure profile in patients with disorders of carbohydrate. patients and methods: this monocentric study has permitted the prospective recruitment of patients. all had an oral glucose tolerance test (ogtt) with a mesure of plasma glucose level immediately before and h after taking g of glucose. clinical examination with taking blood pressure to two arms and a cardiovascular evaluation were performed. results: the glucoregulation disorders were concerned with patients ( %) with an average age of . years ( - years). sexratio: . . ifg was found in patients. ogtt revealed diabetes, igt. only patients with glucoregulation disorders have normal blood pressure. seventy-two patients have been followed for high blood pressure and five patients are newly diagnosed. more than a half of these hypertensive patients has an igt and a third is diabetic. in the family, the high blood pressure is reported in %, the early cardiovascular events are dominated by myocardial infarction and stroke. in high blood pressure group, patient/ is dyslipidemic and metabolic syndrom, as defined by idf , is concerned with patients/ . as for as cardiovascular events, they are reported in patients/ . (t dm) is an ongoing concern and adequate treatment remains an important issue. thiazolidinediones (tzds) are a class of drugs that initially showed great promise as unique receptor-mediated oral therapy for t dm. the tzds, rosiglitazone (rosi) and pioglitazone (pio) were widely used as hypoglycemic drugs in patients with t dm, but a host of serious side effects, primarily cardiovascular, have limited their use. aim: in the present study we have used a systems biology approach to assess specific gene expression profiles underlying the pathological processes in the heart of pre-diabetic mice treated with rosiglitazone or pioglitazone. results: our data demonstrate that both rosi and pio efficiently decreased high fat diet-induced plasma glucose and insulin levels. analysis of the heart demonstrated that rosi, but not pio, led to an increase in atherosclerotic plaque formation and an increase in heart weight to body weight ratio. a combined transcriptomics and bioinformatics approach revealed specific regulatory pathways that may explain the adverse heart effects associated with rosiglitazone but not pioglitazone treatment. conclusion: our data provide new insights into the mechanisms underlying rosiglitazone and pioglitazone action within the cardiovascular system, including drug efficacy and cardiotoxicity. a. vlassopoulos , m. lean , e. combet human nutrition, school of medicine, university of glasgow, glasgow, uk introduction: the new hba c criteria for diagnosis of pre-diabetes have been criticised for overdiagnosis, because many more people are diagnosed than with the old ogtt criteria. it is possible that some elevation of hba c is not driven by hyperglycaemia. aims: this study assesses associations of hba c, commonly assumed to relate solely to glucose concentration, with, . smoking, a major source of reactive oxygen species (ros) and . fruit & vegetables consumption associated with improved redox status. methods: one-way anova, chi-squared and multivariate linear regressions, adjusted for all known confounders were used to explore associations of hba c with self-reported smoking status and fruit & vegetables consumptions in the scottish health surveys - , among individuals without known diabetes and hba c < Á %. results: compared to non-smokers (n = ), smokers (n = ) were younger, consumed less fruit & vegetables, had lower physical activity levels, lower bmi, higher hba c and crp (p < Á ). hba c was higher in smokers (p < Á ) by two sds ( Á %), and . sds higher ( Á %) in heavy smokers (> cigarettes/day) than nonsmokers. smokers were twice as likely to have hba c in the 'prediabetic' range ( . - . %). pre-diabetes and low grade inflammation did not affect the associations. for every extra g vegetable portion consumed, hba c was . sds ( . %) lower (p = . ), but fruit consumption did not impact on hba c, within the low range of consumptions in this population. conclusion: this study adds evidence for a neglected link between oxidative stress and protein glycation, with implications for individuals exposed to ros and for epidemiological interpretation of hba c. v. aursulesei, i.c. roca, l. mihalache objective: to assess the relation between the traits of metabolic syndrome (ms) and the parameters with independent prognostic significance for cardiovascular risk. material and methods: hundred and forty-three patients were included according to the number of traits of ms ( . % arterial hypertension, . % abdominal obesity, . % low hdl-cholesterol, . % high tryglicerides, . % abnormal oral glucose tolerance). the markers of cardiovascular damage were assessed: pulse wave velocity (pwv -complior method), carotidian intima media thickness (imt), left ventricular hypertrophy (index of mass -lvmi and geometric patterns), flow mediated vasodilation (fmd), microalbuminuria (absent/present), ankle-brachial index (abi). results: in our study the cardiovascular damage is present in . %. pwv values increase with number of traits of ms (t-test) after adjusting for confounders/other cardiovascular risk factors (ancova). decreased abi is related with each of ms traits; the power of correlation depends on criteria association. pwv and abi are both related with postprandial hyperglicaemia and systolic blood pressure (p < . ), while imt is strongly related with hdlcholesterol (r = . , p = . ). lvmi and concentric hypertrophy pattern are also related with systolic blood pressure (r = . , p < . ), while eccentric pattern relates to waist circumference (r = . , p < . ). we cannot establish a relation between traits of ms and fmd or microalbuminuria. conclusions: hyperglicaemia and systolic blood pressure are best related with parameters of cardiovascular risk, but the clustering of ms components may interact to synergistically affect the extent of cardiovascular damage. pwv, abi and left ventricular hypertrophy should be systematically used for defining cardiovascular risk in ms. interleukin- (il- ) is pleiotropic cytokine with a key impact on immunoregulation and nonimmune events. sudies have investigated the role of action/lack of action of il- in the pathogeneses obesity, insulin resistance, type diabetes. aim of the study: to evaluate il- activity in hypertensive patients depend on prediabetes presence. materials and methods: hypertensive patients were examined. common clinical investigations were provided. il- plasma levels were detected using elisa. data is represented as me (q -q ). median test were used, p < . . results: prediabetes was observed in . % of hypertensive patients in % insulin resistance in hypertensive patients with prediabetes vs. % insulin resistance in hypertensive patients were detected. hypertensive patients with prediabetes ( . ( . - . ) %) characterized by significantly higher glycated haemoglobin levels as compared hypertensive patients ( . ( . - . ) %, p < . ). hypertensive patients were characterized by increased il- activity ( . ( . - . ) pg/ml). in hypertensive patients with prediabetes decrease il- activity ( . ( . - . ) pg/ml) were found. conclusion: hypertensive patients were characterized by increased il- adipose tissue is now recognized as a complex organ with a crucial role in energy metabolism and in the development of obesity and metabolic syndrome. modified response and metabolism of hormones has been observed in the visceral adiposity during obesity, specifically related to cortisone. the aim of this study was to assess the response to different concentrations of cortisone in adipocyte cell line t l . the expressions of β-hsd , enzyme responsible for the reduction of cortisone to cortisol, and aqp , involved in glycerol transport, were quantified after treating differentiated cells with cortisone at doses of , . , , and lmol/l during , , , , min, and h. total rna and cdna were obtained from the samples to develop a real time pcr using mnsod as housekeeping gene. results suggest time and dose dependent response of β-hsd and aqp ; increases in the expression were observed during the first min of treatment ( and fold, respectively), followed by expression decrease for both in a min period (p < . ). for the treatment with lmol/l cortisone, both proteins expressions showed quadratic tendencies, β-hsd tendency is described by the equation y = . + . x À . x while aqp tendency is described by y = . À . x + . x . it can be concluded that long term effects of cortisone over adipocyte metabolism may be modulated by the induction or repression of proteins like aqp and should be explored in obese individuals. objective: to present a series of cases of metabolic syndrome patients suffering sleep disorders in which the most relevant metabolic marker is serum tryglicerides levels. it has been considered that the key meatbolic alteration underlying metabolic syndrome is a resitance to insulin action. however, there could be other metabolic abnormalities that may lead to the devleopment of the clinical feautres of this diseasea. materials and methods: patients undergoing a medical check up at medica sur hospital were included. each patient was assesed in order to determine both matabolic syndrome and a current sleep disorder. anthropometric measures were taken, body rates were calculated and blood samples were taken for laboratory tests (serum glucose, tryglicerides and cholesterol levels determination). results were analysed with the spss software. results: fifteen patients meeting the world health organization metabolic syndrome were included, and who referred snoring, difficulties on getting asleep or frequent waking up while sleeping. anthropic measures, and lab results were. discussion: yet, the majority of these patients do not have serum glucose abnormalities, but mainly their weights correspond to overweight and to a phenotype of central adipose tissue distribution. the most significant metabolic alteration, in this set of patients, was hypertigliceridemia. this results suggests that there may be other metabolic pathways leading to the development of this disease. introduction: prediabetes, a condition leading to diabetes and cardiovascular diseases (cvd). in cameroon, few studies have been done about this health indicator. aims: to determine the prevalence of prediabetes and diabetes in cameroon cohort, and to compare metabolic risk factors between normoglyceamia and prediabetes individuals. patients and methods: a sample of cameroonian men and women ( - years) participated in a health survey. statistical analysis of data compared risk factors between three subgroups: normoglyceamia (ng), prediabetes (pd) and diabetes (dt). prediabetes was defined as a glyceamia of - mg/dl. metabolic syndrome (mets) was diagnosed using the national cholesterol education program (ncep) definition. results: the distribution of ng, pd and dt prevalence in the overall sample was . %, . % and . % respectively. the prevalence of mets in those with pd ( . %) was significantly higher than in those with ng ( %). many significant differences between ng and pd subjects were also noticed. conclusion: in this study, approximately % of the population who were found to be diabetic and prediabetic is at risk of cardiovascular diseases. our findings also show that prediabetes individuals are different from those with normal glycaemia in a great number of metabolic abnormalities including a higher prevalence of mets. prevention and control measures should be set urgently. research design and methods: prospective study of the thai comprehensive cirs was further evaluated by multiple logistic regressions. in determine the ability of the thai comprehensive cirs scores in predicting each outcome, the adjusted odds ratio was calculated, and backward stepwise selection was used in the statistical modeling. results: there were also prospective correlations between the baseline thai comprehensive cirs instrument and -month outcomes). total score at baseline emerged as significant predictors of -month qol (r = . - . , p < . ). every subscale of the thai comprehensive cirs was significantly related to patient satisfaction (r = . - . ), with only the neighborhood subscale as a significant predictor for adl (r = . ). the other outcomes (self management behavior, cost of care, and dbp) were not significant concurrent baseline predictors. method: we collected laboratory results of body mass index (bmi), blood pressure, fasting glucose, lipid profiles (total cholesterol, triglycerides, ldl-and hdl-cholesterol level) and visceral fat amount of cancer survivors who visited health promotion center at seoul national university hospital. an age and sex-matched control was selected randomly for each cancer survivor from visitors of this center. we compared blood pressure, fasting glucose, lipid profiles and visceral fat amount between cancer survivors and controls using multiple regression analysis after adjustment for bmi. results: one hundred fifty five cancer survivors and controls were included in statistical analyses. cancer survivors tended to have lower bmi compared to controls ( . ae . kg/m vs. . ae . kg/ m , p = . ) after adjustment for bmi, cancer survivors showed lower fasting glucose level ( . ae . mg/dl vs. . ae . mg/ dl, p = . ). however there were no significant differences of blood pressure, lipid profiles or visceral fat amount. background: both insulin deficiency and resistance are reported in patients with β-thalassemia major (btm). we assessed the ogtt and -h continuous glucose concentration by the continuous glucose monitoring system (cgms) and calculated homeostatic model assessment (homa), and quicki in adolescents with btm on regular blood transfusions and iron-chelation therapy. results: in adolescents with btm (age: . ae years), ogtt, ( %) showed impaired fasting blood (plasma) glucose concentration (bg) (> . mmol/l). two-hour after the glucose load, one of them had bg = . mmol/l (diabetic) and two had igt (bg > . and < . mmol/l). monitoring the maximum (postprandial) bg using cgms, adolescents had diabetes ( %) (bg > . mmol/l) and nine had igt ( %). homa and quicki revealed levels < . ( . ae . ) and > . ( . ae . ), respectively, ruling out significant insulin resistance in these adolescents. neither fasting serum insulin nor c-peptide concentrations were correlated with fasting bg or ferritin levels. the average and maximum blood glucose levels during cgm were significantly correlated with the fasting bg (r = . and . , respectively, with p < . ) and with the bg at -h after oral glucose intake (r = . and . respectively, with p < . ). ferritin concentrations were correlated with the fasting bg and the h blood glucose levels in the ogtt (r = . , and r = . , respectively, p < . ) as well as with the average bg recorded by cgm (r = . , p < . ). conclusion: cgm has proven to be superior to ogtt for the diagnosis of glycemic abnormalities in adolescents with btm. background: in obese children pancreatic beta-cells may not be able to cope with insulin resistance leading to hyperglycemia and type diabetes (t dm). objectives: to assess oral glucose tolerance, -h continuous blood glucose concentrations (cgm) and calculate homeostatic model assessment (homa), and the quantitative insulin sensitivity check index (quicki) in children and adolescents with simple obesity (bmisds = ae . ). results: ogtt performed in obese adolescents ( . ae years) revealed three cases ( %) with ifg (> . mmol/l), four cases ( %) with igt (> . < . mmol/l), and none with diabetes. using the cgms, ift was detected in four cases, the maximum bg ( h or more after meal) was > . and < . mmol/l (igt) in nine children ( %) and > . mmol/l (diabetes) in one case ( . %). five cases had a minimum bg recorded of < . mmol/l (hypoglycemia). no glycemic abnormality was detected using hba c ( . ae . %). / patients had homa values > . and quicki values < . denoting insulin resistance. beta cell mass percent (b %) = ae . % and insulin sensitivity (is) = . ae . % denoting insulin resistance with hyperinsulinaemia and preserved beta cell mass. in obese children and adolescents; cgms is superior to ogtt and hba c in detection of the glycemic abnormalities, which appears to be secondary to insulin resistance. introduction: the aim of this study is to evaluate the effect of vitamin e supplementation on glycemic control, lipid profile, inflammation markers and malondialdehyde level of type diabetic patients. material and method: thirty type diabetic patients were participated in this randomized single blind placebo controlled clinical trial study. fasting blood glucose, serum triglyceride, total cholesterol, ldl, and hdl-cholesterol concentration, malondialdehyde (mda), hs-crp, il- , and insulin level were measured. each subject then given a breakfast that was contained g fat. subjects' post-prandial biochemical measurement was measured as well. patients' then randomly divided in two groups. treatment group received vitamin e ( iu/per day) and control group received placebo for weeks. at the end of weeks baseline procedure was repeated and fasting, and -h postprandial biochemical markers were measured. statistical analysis: data analyzed using mann-whitney u test to compare the mean differences between both groups. basic data expressed as mean ae standard deviation, fasting and postprandial biochemical parameters before and after intervention expressed as median. results: no significant differences were found in fasting and postprandial lipid profile, glucose, insulin and homa-ir after weeks of intervention between two groups. significant decreases in fasting and postprandial serum mda levels in treatment group were recorded. no significant differences were shown in fasting and postprandial inflammatory markers except fasting il- . the result of this study shows that short term supplementation of vitamin e is safe and effective in decrease oxidative stress in type diabetic patients. objective: there is evidence that patients with normal weight and central adiposity (elevated waist circumference and waist-hip index) present a higher cardiovascular and metabolic risk. it has been proven that central adiposity is a risk factor for elevated systolic and diastolic pressure amounts, low hdl cholesterol and altered glucose while fasting. materials and methods: patients treated at the integral diagnosis and treament center of medica sur hosptial were inclued. anthropometric measurments were taken and metabolic (glucose and profile of lipids with ultrasensitive reactive c protein) parameters were analyzed. results: nine hundred and forty patients were included. women with a normal body mass index but with a waist > cm, had metabolic alterations on serum lipids which have a statistical significance when compared with those women with a waist circumference lesser ran cm. an elevated waist circumference diameter, regardless of the bmi, increases the metabolic risk. the measurement of the circumference of the waist and the hip must take place by routine in any medical evaluation. aim of the study: to study the prevalence of prediabetes in elderly age group ( years and above) and to study cardiovascular risk factors in prediabetic group. methodology: study was conducted on patients of age years and above. they were screened for prediabetes as per ada guidelines . such prediabetic study group ( cases) was investigated for cardiovascular risk factors (obesity, hypertension, microalbuminuria, crp, retinopathy, dyslipidemia) along with age matched controls. standard statistical tests were applied for analyzing data. hypertension and retinopathy with the prediabetic state. risk factors are more associated with igt as compared to ifg. conclusion: prediabetes is widely prevalent in the elderly population. it has strong association with metabolic syndrome. prevalence of igt is higher as compared to ifg. similarly, cardiovascular risk factors are widely prevalent in the prediabetic population. dyslipidemia, obesity, microalbuminuria, hypertension and retinopathy share the significant association as risk factors. early identification, of prediabetic state followed by primordial and primary prevention of cardiovascular disease should be the focus of intervention. background: despite commonly using body mass index (bmi) in diagnosing obesity, the accuracy of bmi in detecting adiposity is unknown in korean. we assessed accuracy of bmi in detecting body fat percentage (bf%) defined obesity. methods: this study is a cross-sectional design of subjects (age - . years, men . %) who conducted korean national health and nutrition examination survey (knhanes iv- ) in korea from january to december . we assessed the diagnostic performance of bmi using the who reference standard for obesity of bf% ! % in men and ! % in women, which were measured by dual energy x-ray absorptiometry. we tested the correlation between bmi and bf% by sex and age groups. we defined the bmi cutoff for bf%-defined obesity using roc analysis. results: bmi-defined obesity was present in . % of men and . % of women. according to age and sex, a sensitivity and a specificity of bmi ( ! kg/m²) showed difference. the bmi cutoff value for bf %-defined obesity is . kg/m² (sensitivity %, specificity %). difference between bmi cutoff value of korean and that of american to detecting bf% is about À . kg/m². in korean, bmi showed a limited accuracy to detecting adiposity by age and sex. the difference between bmi cutoff-value of korean and that of american to detecting bf% obesity is smaller than the difference of bmi cutoff-value between the asia-pacific and who criteria. background: the healthkick intervention was developed as part of a study that aimed to address diabetes risk factors in primary schools within low-resource settings in the western cape, south africa. the intervention focused on grade - learners, their parents and the educators. aim: to ascertain the risk of developing diabetes and other noncommunicable diseases among educators. method: educators (n = ) from urban and rural schools, participated in a health check in . measurements included random blood glucose and cholesterol testing, and height, weight, waist circumference and blood pressure (bp) measurements. cut-off values for bp levels in adults years and older of the nhlbi were used for categorising hypertension. results: educators participating in this study were mainly females, with most of them ( %) falling in the age range between and years, and % being older than years. only % of educators had bps in the normal range. half of those on treatment for hypertension had levels above / mmhg, while % with bps above these levels were not on medication. about % of those who said they had diabetes (n = ) knew what treatment they were on. cholesterol levels above mmol/l were seen in %. only % said they smoked cigarettes, whereas % were previous smokers. preliminary results show that most participants had a body mass index > kg/m . conclusions: many of the educators who participated in the healthkick study are possibly at risk for developing cardiovascular and other related non-communicable diseases, such as diabetes. s.k. kota , s. ugale , n. gupta , k.d. modi endocrinology, medwin hospital, laparoscopic surgery, kirolskar hospital, hyderabad, india objective: the objective of the present study was to prospectively evaluate the results of laparoscopic ileal interposition (ii) with diverted sleeve gastrectomy (dsg) for control of type diabetes mellitus (t dm) and related metabolic abnormalities. methods: all patients underwent ii +dsg. they had t dm ! years with poor glycemic control despite adequate dosage of oral hypoglycemic agents (ohas) ae insulin. the primary outcome was remission of diabetes (hba c < . % without ohas/insulin) and secondary outcomes were reduction in antidiabetic agent requirement and components of metabolic syndrome. we report the preliminary postoperative follow-up data of . ae . months (range: - months). there were patients (m: f = : ) with mean age of . ae . (range: - years), duration of diabetes of . ae . years (range: - years), and preoperative body mass index of . ae . kg/m (range: . - . kg/m ). sixteen patients ( %) had hypertension, while dyslipidemia and microalbuminuria was present in patients ( %) each. twenty two patients ( . %) had diabetes remission. fifteen/sixteen ( %) patients had remission in hypertension. all participants had weight loss ranging between % and %. postoperatively statistically significant decline was observed in the glycemic and lipid parameters, microalbuminuria at all intervals (p < . ). patients with postoperative duration > months had better improvement in terms of reduction in glycemic, lipid parameters and microalbuminuria. three patients had vitamin b deficiency year after surgery. conclusion: ileal interposition combined with dsg addresses both foregut and hindgut theories and brings about remissions in t dm patients. background and objective: the objective of this study was to evaluate the screening potential of various anthropometric indices, namely body mass index (bmi), waist circumference (wc), waist-to-hip ratio (whr) and waist-to-height ratio (whtr) in the early detection of dysglycemia among the omani adult population. methods: our study included omani adults ( males and females) who participated in a cross-sectional, community-based study. we defined glycemic status based on american diabetes association (ada) thresholds: < . mmol/l as normal, . - . mmol/l as impaired fasting glucose (ifg) and ! . mmol/l as diabetes mellitus (dm). the cut-off values for the anthropometric indices namely, bmi, wc, whr and whtr were based on the standard definitions. the age adjusted analysis showed that out of the four anthropometric indices, among the males the whtr at the cut-point of . gave relatively higher value of odds ratio with or = . ( % ci: . , . ) and among the females whr at the cut-point of . showed maximum odds ratio with or = . ( % ci: . . . ). the areas under the roc curves, at the cut-point of ifg ! . mmol/l, was more for whtr in case of males and whr in case of females. conclusion: this study shows that out of the four anthropometric indices, there are differences in the predictive values of dysglycemia among the omani males and females. in case of males, the whtr ! . appears to be a better indicator for detecting dysglycemia whereas among the females the whr ( ! . ) is a better indicator. introduction: increased serum ferritin and iron stores are involved in the pathogenesis of insulin-resistance. polycystic ovary syndrome (pcos) is diagnosed by oligomenorrhea and hyperandrogenism. pcos and obesity were associated with elevated serum ferritin levels. the link between obesity and altered iron metabolism was proposed. object: to evaluate the association between serum ferritin levels and insulin resistance and metabolic syndrome in obese and non-obese women. methods: retrospective study. five hundred thirty-nine women, of whom had pcos and of whom did not have pcos, were included in the study. results: serum ferritin correlated with menstrual cycle length, sex hormone-binding globulin, total testosterone, androstenedione, triglyceride, and total cholesterol both in obese and non-obese women. obese women (bmi > ) with high ferritin (ferritin ! . ng/ml, n = ) levels had higher insulin resistance, impaired glucose tolerance, and liver enzymes than obese women with low ferritin levels (ferritin < . ng/ml, n = ). however, among non-obese women, insulin resistance and metabolic disturbances were not significantly different between high and low ferritin groups. women with high ferritin levels had a greater risk of pcos and hyperandrogenism than women with low ferritin levels. independent of obesity, hypertriglyceridemia was the major metabolic disturbance in women with elevated serum ferritin levels. conclusions: the pathogenesis of increased iron stores correlated with insulin resistance and metabolic syndrome among obese and nonobese premenopausal women was different. the hypertriglyceridemia in women with pcos might be associated with iron metabolism. nutrition rehabilitation, unite de dietetique, pegomas, france and yogic counseling for stress management. all subjects underwent a residential program for weeks followed by therapy at home for weeks. results were analyzed using paired 't' test. conclusion: in remote areas organization of screening on base of diabetes bus helps to detect t d and early glucose metabolism disorders in more than % of people with increased risk. findrisk scale is useful screening tool to detect these people. however, in older age groups, percentage of screen-detected t d decreases, which may indicate lower efficiency of findrisk questionnaire at age ! . background and aims: changes in the cellular oxidative status are involved in the pathogenesis of obesity-associated hepatic steatosis. the possibility of gender difference in this process was examined in an experimental model of obesity induced by a western high-fat and highcarbohydrate cafeteria diet. methods: four groups of six swiss cd mice ( day old) received either cafeteria diet (male and female) or balanced diet (male and female) for weeks. hepatic hydrogen peroxide (h o ), thiobarbituric acid reactive substances (tbars), reduced glutathione (gsh) and the activity and/or gene expression of catalase (cat), glutathione peroxidase (gpx), superoxide dismutase (sod), hypoxia inducible factor (hif- -alfa) and nuclear factor (erythroid-derived )like (nrf ) were measured. results: higher levels of tbars and mitochondrial h o were found in livers from cafeteria-fed animals of both genders, with higher levels in females. the level of gsh was lower in cafeteria-fed mice of both gender; females showed higher levels than males (cafeteria or balanced diet). cat and gpx activities were reduced in cafeteria-fed mice of both sexes; the activities in females being lower than those of males. sod activity and the gene expression of cat, gpx and sod were not significantly altered when compared by gender or dietary treatment, but the expression of hif- -alfa and nrf was increased in female cafeteria-fed mice. the female animals exhibited a higher susceptibility to cellular oxidative stress in cafeteria diet-induced obesity in comparison to males. the molecular mechanisms seem to be, in part at least, posttranscriptional. acknowledgements: capes, cnpq, fundac ßa˜o arauc aria. objectives: to investigate the relationship between body fat percentage and body mass index (bmi) among young adults aged - years. methods: young adults aged - years were recruited for study when they took health examination in september in taiwan. all subjects underwent bioelectrical impedance analysis (tanita bc- ) to estimate their body fat percentage. basic demographic data, height, and weight were collected, and bmi was calculated from height and weight. overweight and obesity were identified according to bmi. the correlation between body fat percentage and bmi was analyzed using sas software . . results: a total of male and female participants were enrolled. the mean age was . ae . years old. the mean body mass index was . ae . for men and . ae . for women. the mean body fat percentage was . ae . for men and . ae . for women. categorized by bmi, the mean body fat percentage was . ae . for men and . ae . for women in bmi < . group, . ae . for men and . ae . for women in bmi . - group, and . ae . for men and . ae . for women in bmi - group and . ae . for men and . ae . for women in bmi > group (p < . ). the prevalence of too high or obese body fat percentage among young adults aged - years in taiwan was . % in male and . % in female according to the who and nih recommendations. the cutoff values of healthy body fat percentage for young adults in chinese population ought to be modified. it is estimated that - % of women of reproductive age have polycystic ovarian syndrome (pcos). this article summarizes the recent development and findings in the cardiometabolic abnormalities in patients with pcos. patients with pcos have the clinical features of oligomenorrhoea, hirsutism and infertility; however, they also exhibit hyperinsulinemia, obesity, hypertension, dyslipidemia, and an increased pro-thrombotic state. they have an increased risk of type diabetes and impaired glucose tolerance, and sleep apnea is also found more commonly in this population. however, despite the presence of cardiovascular risk factors and increased surrogate markers of cardiovascular disease it is unclear if they have accelerated atherosclerosis. end point studies are currently lacking and the available evidence are conflicting. this article will address the current evidence for the adverse cardiovascular risk in pcos and the other factors that may be implicated. finally the therapeutic options for treatment will be discussed. conclusion: results suggest that in the fasted condition, when fatty acids levels are elevated, the gluconeogenic flux is higher in cafeteriafed rats, a finding consistent with the higher glycogen levels. the lower production of co indicates a deviation of the citric acid cycle intermediates into the cytosol, a change which may favour the synthesis of fatty acids and triacylglycerols. these liver metabolic disturbances probably contribute to fatty liver diseases, hyperglycemia and dyslipidemia in cafeteria diet-induced obesity. certain cancers. this study aims to evaluate the association between obesity and colorectal cancer risk and also if the association varies with the blood type, age of obesity or cancer subsites. the study was carried out on hospital patients, different ages, diagnosed with colorectal cancer. we determined the blood type, cancer subsites and age of symptoms. we evaluated their family history and their lifestyle in terms of physical activity, smoking and alcohol consumption. results: out of the patients, % had the bmi ! kg/m and all of them showed abdominal obesity. the age of obesity was up to years to % of the subjects and over years for % of them. symptoms were detected over months before diagnosis for % of the individuals and between and months for % of them. in what respects the cancer subsites, % of the cases were located on the descending colon, rectum and sigma. % of the patients had a family history of different types of cancer (colorectal, pulmonary, gastric or breast neoplasia). sixty-five percent of them were smokers, % were alcohol consumers and % carry light or no physical activity. forty-nine percent were blood group a individuals. the study shows that obesity is a statistically significant risk factor for colorectal cancer and the association is stronger for the patients with a higher age of obesity, descending colon and rectum localisation of the neoplasia and blood group a individuals. technical university munich, munich, ikfe institute, mainz, germany purpose: the angiotensin ii receptor antagonist telmisartan (t) has demonstrated bifunctional effects on the hemodynamic, vascular and metabolic features of patients with metabolic syndrome (ms). accordingly, we tested the hypothesis, that antihypertensive therapy with t vs. amlodipine (a) improves diastolic myocardial function, vascular function and metabolic characteristics in ms. methods: this randomised cross-over study investigated ms patients (bmi ae kg/m ) with mild-moderate hypertension before and after months therapy with t vs. a. laboratory and ultrasound data were taken in the fasting state and h after a test meal ( g carbohydrates). cardiac function was assessed by tissue doppler as systolic (s') and diastolic myocardial velocity (e') and vascular function at the common carotid artery as elasticity modulus and pulse wave velocity. results: after months with t, fasting systolic blood pressure was reduced by ae mmhg (p < . ) and postmeal by ae mmhg (p < . ) vs. a ( ae mmhg (p < . ) fasting and insignificant ae mmhg (p < . vs. t) postmeal). with t but not with a, diastolic pressure dropped by ae (p < . ) fasting and postmeal (p < . ). with t but not a, e' increased fasting and postprandially by . ae . (p = . ) and . ae . cm/s (p = . ) and so did s' (p < . and . ), whereas vascular function improved postprandially alone (p < . and p < . ). conclusion: in ms patients, mild to moderate hypertension and without cardiac disease, monotherapy with telmisartan improved diastolic and systolic cardiac function in particular postprandially whereas amlodipine did not. introduction: the metabolic disorders at the tunisian military pilots are more and more frequent affecting more and more young subjects. the expert doctor is in front of a big problem to know the evaluation as well as the control of the evolutionary genius of these disorders to be able to minimize their complications materials and methods: it is about a retrospective study which was interested in the files of the tunisian military pilots followed regularly in the center of expertise of aeronautical medicine since . on these files, we found the various types of metabolic anomalies by referring to the age and the anthropometric characters during their appearance, as well as the evolutionary follow-up of these anomalies with or without treatment results: the metabolic disorders were found at % of the military pilots. these disorders are represented in the order by dyslipide´mies, then disorders of the hepatic metabolism, the hyper urice´mie and finally the not insulin-dependent diabetes. the therapeutic care ways begins with the hygie´no-dietary rules before the passage in the medicinal treatment. the metabolic disorders make the bed of the cardiovascular diseases; their complications particularly at the military navigators are very grave. the correction of these anomalies is imperative to avoid the vascular accidents which can be responsible for a sudden incapacity during flight. comparison to wt controls, and the epididymal fat weighs significantly less in the ko (p = . ; normalized to body weight). the irx ko mice showed increased feed and water intake relative to their body weight compared to wt littermates. moreover, qpcr and western blot analysis indicates differential expression of irx during adipogenesis in t -l cells. our data suggest that irx plays a role in the development of adipose tissue. method: forty-six obese participants (both sexes, age range from to years) group mean ae sd, . ae . years were selected for the study based on a bmi ! kg/m *. the participants were randomized as two groups. all participants were assessed for bmi and lipid profile at the beginning and end of days of the intervention. twenty six participants ( from each group) were assessed for leptin and adiponectin. the yoga group practiced yoga for min two times in a day for days. at the same time of the day the walking group practiced min of walking for two times in day. each day participants were given non calorie restricted diet regulated as kcal/day. data recorded at the beginning and at the end of the intervention were compared by repeated measures analysis of variance using spss version . , followed by post-hoc analysis. results: both groups showed a significant decrease in bmi (p < . ) and in total cholesterol (p < . ). only yoga group showed significant reduction in ldl cholesterol (p < . ) and significant increase in leptin (p < . ). the walking group alone showed a significant reduction in triglycerides (p < . ) and in adiponectin (p < . ). objective: human urotensin ii is the most potent vasoconstrictor identified to data. however, association between urotensin ii and hypertension and whether the association is independent of endothelial function has been controversial. here, we studied the association under adjustment for serum nitric oxide in a case-control study. methods: hundred and ninety-seven hypertensives and age-and sex-matched normotensive controls were studied. plasma urotensin ii, serum nitric oxide and other traditional biomarkers were examined. association between urotensin ii and hypertension was evaluated by multivariate conditional logistic regression analysis. results: hypertensives had higher levels of urotensin ii [median (interquartile rang): . ( . - . ) ng/ml vs. . ( . - . ) ng/ ml] and lower nitric oxide [ . ( . - . ) lmol/l vs. . ( . - . ) lmol/l] than normotensive controls. urotensin ii positively correlated with sbp (r = . , p < . ), dbp (r = . , p = . ) but negatively correlated with nitric oxide (r = À . , p = . ). in multivariate regression analysis, subjects in the highest th percentile of urotensin ii concentration ( ! . ng/ ml) had . times the risk of hypertension than did individuals in the lowest quartile (< . ng/ml) (p = . ). both univariate and multivariate analysis in pairs of serum nitric oxide level-matched cases and controls showed that risk of hypertension significantly and positively increased with levels of urotensin ii (all p < . ). conclusions: urotensin ii was markedly associated with hypertension and the association was independent of endothelial function. this study suggested that urotensin ii may have an etiological role in hypertension. objective: dilated cardiomyopathy (dcm) is the third most common cause of hf. the implication of transcription factors (tfs) in molecular pathways that guide heart development and cardio-specific gene expression has recently been established. however, the role of cardiac specific tfs; myocardin and tbx in the failing heart is unknown. the present study was designed with the aim to determine the expression profile and regulation of these tfs in failing hearts. methods: myocardin and tbx mrna levels were estimated by quantitative rt-pcr (qrt-pcr) in human ventricular biopsies and pbmcs of dcm patients (n = ) and controls (subjects with ventricular septal defect) (n = ). copy number variations in myocardin and tbx were determined by qrt-pcr in dcm patients (n = ) and control (n = ). myocardin and tbx promoter methylation patterns were studied in pbmcs of dcm patients (n = ) and controls (n = ) by methylation specific pcr (msp). results: myocardin and tbx mrna levels were found to be significantly six fold (p . ) and seven fold (p . ) increased in the failing human myocardium as compared to control samples respectively. promoter hypermethylation of myocardin was observed only in patients and none of controls were found to carry methylated alleles for myocardin. we did not observe any significant difference in promoter methylation status of tbx . there was no significant difference observed in the copy number of both the transcription factors; myocardin and tbx between patients and controls. conclusion: our results suggest that epigenetically regulated expression of cardiac specific tfs; myocardin and tbx may contribute to pathophysiology of dcm. introduction: mir- is among the most abundantly expressed and consistently dysregulated mirnas in heart failure and has been implicated in cardiac fibrosis. however, its role in diabetic cardiomyopathy is not known. abstracts of the th international congress on prediabetes and metabolic syndrome normalisation of the majority of indicators of lipid and carbohydrate metabolism. a.g. kistauri , g. devidze , m. jibladze , a.a. kistauri internal medicine, tbilisi state medical university, tbilisi, surgery, kutaisi ortodox christian hospital, kutaisi, georgia, lund university, lund, sweden aims: diabetic foot syndrome is a complex of purulent-necrotic and/ or ostheoarthropatic changes of the foot. in case of purulent-necrotic complications, lethality reaches - %. objectives: optimisation of infected diabetic foot treatment. methods: eight-four patients, suffering from infected diabetic foot. following was used as a material for antibioticogram: soft tissue scraping from the bottom of the injury, purulent discharge, bone biopsy. results: degree of bacterial contamination was high: between and - : anaerobic flora - . %, aerobic flora À . %. bacterial flora in purulent zone (decreased- . % to . %): staphylococcus aureus, saprophyticus, epidermidis, ps. aeruginosa, enterococcus, e. coli. the highest sensibility was shown to the following drugs (decreased- . % to . %): tienam, meronem, amoxiklav, vankomicin, cefepim, ceftriaxon, ciprofloxacin, likacin, klindamicin. less sensitivity was detected to the following drugs ( . - . %): ampicilin, doxaciclin, cefazolin, erythromycin. based on the above, the most appropriate combinations are: ftorchinolines + i-iii generation aminoglycozides (combination i) and/or iii generation cefalosporines + lincosynamides (combination ii). using the first drug combination, infection was stopped in . % and in . % of cases using the second. high amputations were performed in two cases, six more than half of foot. in cases process was stopped and amputation was avoided. conclusions: cause of tissue necrosis during neuropathic form of diabetic foot is infection, during neuroischemiccritical ischemy and infection. neuroischemic infected injury is characterised with much faster course than infected neuropathic ulcer. the most appropriate treatment combination of diabetic foot is fluorcholines + i-iii generation aminoglycozyed and iii generation cefalosporines + lincosomydes. background: continuous glucose-monitoring system (cgms) is a tool for assessment of glycemic excursions. glucose variability is a risk factor independent of glycosylated hemoglobin (hba c) for diabetic complications. aim: to evaluate the prevalence and extent of glycemic excursions & unrecognized hypoglycemia in type diabetic patients. setting and design: the study was carried out in type diabetes patients on oral agents. material and methods: patients underwent continuous glucosemonitoring by cgms for days. number and duration of glycemic excursions, unrecognized hypoglycemia, correlation coefficient (%) between cgms and self-monitoring blood glucose (smbg), mean absolute difference (%mad were analyzed. results: the mean age of patients was . ae . years. the mean hba c was . ae . %. the mean number of glycemic readings was . ae . times. the correlation coefficient was . and the mad was . ae . %, which were considerable. twenty three ( %) patients experienced hypoglycemic events. twenty seven ( %) patients had hyperglycemic events. the hypoglycemic events were found to have significant correlation with the duration of diabetes and inverse correlation with hba c, whereas age was significantly correlated with females diabetics (p < . ). conclusion: this study demonstrated that type diabetic patients have a considerable number of hypoglycemic and hyperglycemia events that may be missed by smbg. internal medicine department, zagazig university, faculty of medicine, university hospital, medical biochemistry, zagazig university, faculty of medicine, zagazig, egypt impaired fibrinolysis increase the risk of cvd in diabetics, it has been found also in igt associating metabolic syndrome but there is no data concerning fibrinolysis in subjects with normal gt that may convert to diabetes. therefore, the aim of work was to study the fibrinolytic activity, as measured by tpa activity and t-pai- antigen as markers of endothelial dysfunction in normal and igt offspring of type diabetes compared to subjects without family history of diabetes. we measured fibrinolytic activity (tpa activity and tpai- antigen) in subjects, healthy volunteers and offspring of type ( normal gt and igt), we measured fasting plasma insulin, lipid profile and insulin resistance. we found that tpa activity was significantly reduced and tpai- was significantly raised in igt group as compared to normal gt. surprisingly tpa activity was also significantly reduced and tpai- was significantly raised in normal gt. also, we found that igt increases the (tpai- antigen and decrease tpa activity in igt by . fold and . respectively than normal gt offspring. we can concluded hypofibrinolysis may aggravate insulin resistance and promote progression of atherosclerosis in those offspring in the future. this may explain the increased prevalence of cardiovascular diseases in early discovered diabetics. moreover, changes of these parameters can be used as a predictor for early detection of prediabetic state even before occurrence of glucose intolerance and the proper correction of this hypofibrinolysis may delay the development of atherosclerosis in diabetic stage. introduction: type diabetes in children is the most common juvenile endocrinopathy. decreased bone mass has been shown to be a common complication of type diabetes. the aim of our study was to evaluate the characteristics of bone mineral density (bmd) in diabetic children and their relationship with the age of diabetes, glycemic control and the biological markers of bone remodeling. with an assay of biological markers of bone turnover were performed for each child. results: sex ratio was . in the diabetic group and . in the control group. the average age of diabetics was . years and that of controls was . years. the two groups were comparable concerning the age, sex, anthropometric parameters and pubertal stage. the only difference found between the two groups concerning calcium intake that was lower in the controls. bone mineral density did not differ significantly between the two study groups. a significant difference was found comparing averages of bone markers (osteocalcin and ctx). the seniority of diabetes was correlated to the bone mineral density only in the diabetic daughter. the glycemic control represented by hba c was inversely correlated to the bone mineral density. conclusion: the prevention of bone damage in the diabetic child must go through adequate calcium intake, a proper sports activity and especially a good control of the disease. background and aims: the aim of the present study was to investigate all-cause mortality in relation to physical inactivity and diabetic status among patients surviving an acute myocardial infarction (ami). we hypothesised that physically inactive patients had a higher mortality risk compared to those who were physically active, regardless of diabetic status. methods: we enrolled n = patients with ami admitted to the coronary care unit of the central hospital in va¨stera˚s, sweden between november and may . all-cause mortality was followed-up until may . the relation between self-reported leisure time physical inactivity during the last year, diabetic status and allcause mortality was analysed univariately using kaplan-meier curves and multivariately using cox regression adjusted for the confounders bmi, prior angina pectoris, prior stroke, smoking, age, sex, education level and immigration status. p-values< . were considered statistically significant. results: a total of n = ( . %) of the ami patients had valid values for diabetics status and leisure time physical inactivity. of these, n = ( . %) died during follow-up. the mortality was significantly different (log-rank test p < . ) between physically active and inactive patients with or without known diabetes (see figure) . notably, physically inactive patients had a higher mortality regardless of diabetic status. after adjusting for confounders, the hazard rate was . (p = . ) for having diabetes and . (p < . ) for being physically inactive. conclusions: physically inactive patients had a higher mortality risk compared to those who were physically active, regardless of diabetic status. medical pharmacology, akdeniz university, antalya, turkey aims: we investigated functional effects of glp- ( - ), glp- ( - ), exendin- ( - ), exendin ( - ) and role (s) of reactive oxygen species (ros) and endothelium-derived hyperpolarizing factor (edhf) in the effects of these agents in small resistance arteries from control and diabetic rats. methods: mesenteric arterial rings were suspended in wire myograph and responses to glp- ( - ) and its analogues were recorded in the absence and presence of ros scavengers; superoxide dismutase (sod, u/ml) and catalase (cat, u/ml). role of edhf in glp- induced responses was investigated in kcl ( mmol/l)-contracted rings following incubation with no synthase inhibitor l-name ( À mol/l) and cyclooxygenase inhibitor indomethacin ( À mol/l). results: glp- ( - ) and glp- ( - ), but not exendin- ( - ) or exendin ( - ) produced concentration-dependent relaxations in mesenteric arteries from control and diabetic rats that were significantly higher in control compared to diabetic rats and in endothelium-intact compared to denuded preparations. incubation of control and diabetic rat mesenteric arteries with cat did not affect responses to glp- ( - ) and glp- ( - ) while, sod caused a significant increase in relaxant responses only in diabetic rats. glp- ( - ) and glp- ( - ) induced relaxations were significantly and similarly blunted by l-name plus indomethacin in control and diabetic rats. we provided evidence about relaxant effect of glp- ( - ) and glp- ( - ) in rat resistance arteries and about the reduced vasorelaxant effect of glp- in diabetic rats. our findings suggested that edhf played a role in glp- -induced relaxations and that increment in certain ros and/or reduction in sod function might play a role in reduced vazorelaxant responses to glp- in diabetic rats. results: significant differences for systolic blood pressure, lipids levels and kidney function between the groups are depicted in table . homa-ir was elevated in both groups, but significantly higher in the diabetic group ( . ae . vs. . ae . ; p < . ). diastolic blood pressure, crp and total cholesterol were not significantly different between the two groups. in the longitudinal group hba c levels decreased dramatically in the diabetes group ( . ae . % vs. . ae . %; p < . ), but less in the normal glucose tolerance test group ( . ae . % vs. . ae . %; p < . ). conclusion: diabetic patients with morbid obesity have a much higher cv risk profile compared with nondiabetic subjects despite presenting with the same bmi and should therefore be the preferred candidates for metabolic surgery since capacities are very limited. objective: morbid obesity (mo) has been shown to be associated with hypothyroid disorders in some patients. we therefore investigated the relationship between thyroid function parameters, bmi and insulin resistance in patients with morbid obesity before and after bariatric surgery. in patients ( . % women) with mo ( ae years; bmi . ae . kg/m ), parameters of thyroid function (tsh, ft , ft ) and homa-ir were determined before and years after bariatric surgery (weight loss À . ae . kg; p < . ). due to the lack of normal distribution, thyroid function parameters were logarithmized for statistical evaluation. results: of the patients, presented with hypothyroidism (tshrange: . - . lu/ml) before surgery, six of them with overt hypotheroidism (ft -range: . - . ng/dl). in the euthyroid patients, tsh decreased from . ae . to . ae . lu/ml (logtsh . ae . vs. . ae . ; p < . ). in the hypothyroid patients, tsh declined from . ae . to . ae . liu/ml (logtsh . ae . vs. . ae . ; p < . ). in the latter, the decline in tsh was more pronounced than in euthyroid patients (p < . ). concordantly, ft concentrations increased by . % (p = . ) and by . % (p < . ) in euthyroid and hypothyroid patients. homa-ir declined from . ae . to . ae . (p < . ) in euthyroid patients and from . ae . to . ae . in hypothyroid patients (p < . ), but did not correlate with the decline in tsh. the improvement of thyroid function after bariatric surgery is not associated with the reduction in insulin resistance. therefore the improvement of thyroid function could independently contribute to the positive long-term effects of this intervention. introduction: some years ago chronic diseases were considered to be a problem of the rich and elderly population. today we know that within high-income countries, poor as well as young and middle-aged people are affected by chronic conditions. for chronic disease, there are a small number of risk factors common to many diseases. the major biological risk factors identified in the world health report are: overweight and obesity, raised blood pressure, raised blood glucose and abnormal blood lipids and its subset raised total cholesterol. objective: was to carry out an epidemiological survey on prevalence of raised fasting blood glucose in kosova. material and methods: according to the who steps methodology the fasting blood glucose in blood sample from finger was measure with accutrend plus on sample of randomly selected participants aged - years. results: according who criteria raised fasting blood glucose is if capillary glucose is more than . mmol/l or more than mg/dl. in kosova, females are in higher risk for diabetes than males (females . % vs. males . %), total . %. prevalence of raised fasting glucose was increased with age. at the age - year the prevalence of raised fasting blood glucose was . %, at age - year . %, at age group - year %, at age group - year was . % and at the age group - year was . %. conclusion: effective preventive interventions are needed, and health systems should prepare to detect and manage diabetes and its sequel. objectives: hypertension and hyperglycemia are features of the metabolic syndrome and diabetes. methylglyoxal (mg), a reactive glucose metabolite, is elevated in diabetic patients. we investigated whether mg induces hypertension and its molecular mechanisms. methods: male week old sprague-dawley rats were treated with mg ( mg/day by continuous infusion with a minipump) for weeks. aortic rings were used for vascular contractility, and other tissues alongwith cultured vascular smooth muscle cells (vsmcs) for molecular studies. hplc, western blotting and q-pcr were used to measure mg, proteins and mrna, respectively. sirna for angiotensinogen and the receptor for advanced glycation endproducts (rage) were used to study mechanisms. results: mg treated rats developed a significant increase in blood pressure, plasma aldosterone, renin, angiotensin (includes precursor and products), norepinephrine, epinephrine and dopamine levels. the aorta showed increased contractility to the a agonist phenylephrine. mg level and protein and mrna for angiotensin, at receptor, a d receptor and renin were significantly increased in the aorta and/or kidney of mg treated rats. treatment of cultured vsmcs with mg or high glucose ( mmol/l) significantly increased cellular mg, and protein and mrna for nf-jb, angiotensin, at and a d receptors, which were prevented by inhibition of nf-jb. silencing of mrna for rage prevented the increase in nf-kb induced by mg. silencing of mrna for angiotensinogen prevented the increase in protein for nf-jb, angiotensin, at and a d receptors. conclusions: mg activates nf-jb through rage and thereby increases activity of the renin angiotensin aldosterone system to cause increased vascular contractility and hypertension. background: guidelines state obesity as an indication for diabetes screening. abdominal obesity is valuable to manifest metabolic risk as much as and may be even more than body mass index (bmi). in this study the answer to "which is a better indicator for diabetes screening; bmi or waist circumference?" has been questioned. method: three hundred people attended to the invitation of diabetes screening in istanbul medeniyet university goztepe research and training hospital outpatient clinics. their demographic characteristics, bmi, waist circumference, fasting blood glucose (fbg), diabetes history and if diagnosed drug regimen were recorded. results: a total of individuals ( women, men) were enrolled. one hundred forty three of ( %) individuals had a bmi ! . among those people ( %) had fbg ! and < mg/dl and (% ) had fbg ! mg/dl (table ) . abdominal obesity was observed in individuals ( women, men). thirty % had known diabetes mellitus (dm). among patients with abdominal obesity and without dm diagnosis, % had dysglycemia (table ) . among obese individuals, % had a history of dm. dysglycemia rate among obese persons without a history of dm, was % (table ) conclusion: abdominal obesity is a strong predictor of diabetes as obesity and its presence should be considered as an indication for screening diabetes. internal medicine and cardiology, expertise centre of aviation medicine of tunis, mhiri, tunisia type diabetes is a rare disease compatible with aviation activity with restrictions and constraints of regular medical checks. this retrospective study was interested in drivers with type diabetes cemeda monitored since until . the aim of this work is to investigate the incidence of diabetes in the tunisian population of seafarers and show the difficulties of management of diabetic driver. sailors have diabetes type (or # %) and three student pilots (two civilians and military) had type diabetes resulting inability final flight. average blood glucose of diabetic patients was . g/l with a range of . and . g/l; glycosylated hemoglobin a c is an average of . % [range: . - . %]. the average age of diabetes is years and mean bmi of kg/m². a mild to moderate hypertension was found in % of diabetics; dyslipidemia was found in two-thirds of diabetics. the treatment of diabetic subjects: rules dietary guidelines were prescribed in only about % of cases. moreover, these measures were associated with treatment with oral antidiabetic (biguanide alone in % of cases; biguanide + pioglitazone in % of cases associated biguanide a sulphonylurea in approximately % of cases. conclusion: : the prevalence of niddm is significantly lower among sailors in the general population. the balance diabetic seafarers is the only guarantor of declining maturity of micro and macrovascular disease and strengthen the doctor′s attitude towards pn medical ethics and flight safety. methods: is a retrospective cohort study that included patients who attended a preventive evaluation unit between and , with at least three visits in that period. results: a total of patients were included, of whom ( %) had nafld at their first visit. the basal variables were similar between groups, with male predominance in the nafld group. high blood pressure and dyslipidemia predominate in the nafld group until visits and respectively. the other cardiovascular risk factors were similar until visit . the study showed a tendency to present high blood pressure, dyslipidemia and gallstones in the nafld group in a shorter period of time than the control group. levels of aspartate aminotransferase raised in a period of . vs. . years in the control group (p = . ). the study was not able to demonstrate a clear difference in the presentation of cardiovascular risk factors and liver function tests in patients with nafld and although there was a higher presentation of gallstones, it requires a larger sample and a longer follow up period to have significant results. objective: to determine the relationship between metabolic syndrome (ms) and exaggerated blood pressure response to exercise (ebp) in adolescents. methods: this cross sectional study was conducted in adolescents ( males, females), randomly selected of high schools, in maracaibo, venezuela. they underwent an exercise treadmill testing. the ms was defined according to the definition of the national cholesterol education program, adult treatment panel iii modified for adolescents. the bp was measured at rest and during the treadmill test (bruce protocol), and it was registered the systolic bp (sbp) in maximal exercise to define adolescents with ebp ( ! mmhg). statistical analysis: chi square test was used to establish associations between ms and ebp. results: the ms prevalence was . % (n = ) in all subjects, . % (n = ) in males and . % (n = ) in females (p: . ). the sbp in maximal exercise values were: . ae in adolescents with ms and . ae in adolescents without ms (p: . ). the prevalence of the ebp was . % (n = ) in all, . % (n = ) and % (n = ) in subjects with ms and without ms, respectively (p: . ). the ms is closely linked to the sbp response to exercise in adolescents. those adolescents with ms are more likely to have exaggerated sbp during exercise, indicating an important information about their cardiovascular risk. background: metabolic syndrome (mets) is a cluster of risk factors that carries a great risk for atherothrombotic events leading to significant morbidity and mortality. few studies evaluated the association between mets and acute stroke. the aim of this work was to study the prevalence of mets and its effect on icu mortality in acute non embolic ischemic stroke patients. patients and methods: we studied patients presented with acute ischemic stroke diagnosed by ct brain in the medical icu, zagazig university hospital for the presence of mets and its relation to age and sex as well as the number of components of mets. we studied also the relative risk of mets with its different components as well as age, sex, glasgow coma scale (gcs) and apache ii score on the mortality in those patients. results: mets was found in . % of patients. it was more prevalent in males ( . %). this prevalence increase progressively in males aged - years then decrease progressively while in females, prevalence increase progressively with age. . % of patients have three components of mets compared to . % with more than three components. the relative risk of mortality was found to be increased with increasing age, male gender, obesity, hyperglycemia, low hdl-c, increased serum triglycerides, lower gcs, increased map, mets per se and higher apache ii score. mets and apache ii score were good predictors of mortality. contrary to the usual approach, we could leave the future open to a bi-therapy associating glp- mimetics and dpp- inhibitors (before the supplementation in metformin and sulfamids or glitazones). case report: diabetes type in balance for years after being treated first with metformin only then added glitazone, to end by glp- mimetics at maximum doses and metformin but still not under control. it was decided to associate glp- mimetics and dpp inhibitor, ending up to a glycemia and insulin . and hba c: . . after stopping the treatment for days we observe: fast glucose , postprandial (on a diabetic diet), relative hypoglycemia generating a multi metabolic syndrome spiral. the increase of the fast glucose being explainable by the non-control of the glucagon produced during the night. pattern proposed: glucagon would not work on demand but time continuously. it has to be inhibited thanks to the glp as soon as the glycemia increases and this would be irrespective of food intake. therefore, there is no reason to use the dpp inhibitors only in case of resistance to endogen glp and let the glp -mimetics being destroyed by the dpp . this would lead to a therapeutic failure or usage of very high doses. we could treat upstream the sequence of energetic metabolism. first of all: glp -mimetics or dpp inhibitors. secondly: glp -mimetics and dpp inhibitors. those steps could be part of tomorrow′s decisional algorithm of type diabetes. abstracts of the th international congress on prediabetes and metabolic syndrome aim: to evaluate the prevalence tipe diabetes mellitus (dm ) and ischemic heart disease (ihd), and diabetogenic/atherogenic factors in patients with newly diagnosed long-term gout material: seventy males - -years (mean ) with untreated tophaceous primary gout - years (mean- ) duration (without renal insufficiency) were studied. uric acid level was fasting serum glucose, insulin (control- - , mean pmol/l), total and hdl cholesterol, triglyceride, bp and ecg monitoring mmol/l, insulin and pmol/l. one more patient, years, with ihd and triglyceride . , cholesterol . mmol/l, insulin pmol/l levels. thus, diabetes was in one and ihd in three patients two patients ( - years) with and years of gout and hyperinsulinemia thus, long-term gout (hyperuricemia) even with concomitant high bmi, insulin, cholesterol and triglyceride levels is not an evident risk factor for diabetes and ihd development. probably, antioxidative effects of uric acid play a role montes claros, brazil background: the leptin receptor is an important regulator of leptin activity and a potential mechanism for the obesity. the polymorphism leprgln arg could be associated with high body fat percentage (bf%) and body mass index (bmi) objective: to investigate the association leprgln arg with obesity indexes we obtained oral swab and anthropometric measures including waist circumference (wc), bmi and bf% for subjects aged ! years. the genotypes were determined by pcr-rflp method. the statistic analyze were carriedout in stata software. results: there were no differences of age average between sex (female . ae . ; male . ae . ). the prevalence of the overweight (bmi > kg/m ) was . %( ), normal, . % ( ) and obesity (bmi > kg/m ) . % ( ). the prevalence of high wc (> cm for women or > cm for men) was . % ( ) and . % ( ) in women and men, respectively (p = . ) and of the high bf% (> % for women and > % for men) was adiposity was not associated with genotypes. the frequencies of overweight were . %, . % and . % and of the obesity were . %, . % and . % in the genotypes aa, ag and gg, respectively. there was not also association for high wc conclusions: these findings suggest that the leprgln arg is not associated with high bf%, bmi or wc in this population hydrogen breath test (bth ), based on lack of source for hydrogen gas in humans other than bacterial metabolism of carbohydrates, is use to detect carbohydrates malabsorption aims: to evaluate the utility of bth in detect carbohydrates malabsorption in overweight-obese subjects. patients and methods: hundred and six consecutive subjects ( overweight, obese; males/ females leptin injection did not suppress ei. importantly, ts treatment reinstalled leptin sensitivity as seeing a significant decrease in ei for h (À %, p = . ) and increase of pstat level (À %, p < . ) in the hypothalamus after i acknowledgements: this work was supported by a grant of the romanian national authority for scientific research, cncs-uefiscdi, project number pn-ii-id-pce- - - ". dr. lixandru, was supported by the postdoctoral program posdru/ / . /s/ , from european social fund. this cluster-randomized controlled trial study aimed to assess the effectiveness of the interactive multi-modality technology (imm) as an intervention to increase self-management among type diabetic patients in a -month period. the imm intervention contained email, short message system (sms), and website with four main functions (i.e., selfregulation, self-monitoring and assessment, social support, and reminder system -linked to email and sms). in this trial, four public offices in bangkok metropolis were recruited and randomly assigned into either the intervention or the control group. one hundred and twenty four thai patients who had met inclusion criteria (hemoglobin a c or a c > . %, no serious illness, and internet and mobile phone accessibility) were subsequently assigned to the intervention (n = ) and the control (n = ) group. patients in the intervention group received the imm intervention. those in the control group received selfmanagement knowledge via email only. outcome measures, a c and behavioral questionnaires (diabetes quality of life, self-efficacy, and division of endocrinology and metabolism, national institute of nutrition, secundrabad, india introduction: we showed earlier that increased visceral adiposity in the offspring of magnesium deficient rats was associated with altered gene expression and increased stress.aim: to assess whether maternal magnesium deficiency modulates the gene expression of adipogenesis and insulin sensitivity in utero due to increased stress.methodology: female weanling wnin rats received for weeks, an ain g diet (control: mgc) or the same with % restriction of magnesium (mgr) and mated with control males. half the pregnant mgr dams were rehabilitated from conception (mgrc) while others continued on magnesium restriction. total rna was isolated from the mgc, mgr and mgrc embryos collected on day of gestation and expression of βhsd , pparc and adiponectin was quantified by real time pcr. body composition was determined in month old offspring by total body electrical conductivity (tobec).results: plasma magnesium levels in mgc and mgr dams before pregnancy; and month old mgc, mgr and mgrc offspring were on expected lines. mgr embryos had significantly higher expression of pparc and βhsd than mgc, whereas adiponectin expression was lower. on the other hand in mgrc th day embryos βhsd and pparc expression was restored to mgc, adiponectin expression introduction: khaya senegalensis is presently used for the treatment of diabetes in some west african countries.objectives: this study was conducted to investigate the anti-diabetic effects of the plant using in vitro and in vivo models.results: ethanolic extract of the root sample of the plant was subjected to solvent solvent fractionation which yielded a butanol fraction that possessed significantly higher (p < . ) anti-oxidative activity as well as a-glucosidase and a-amylase inhibitory activities than other (aqueous, ethyl acetate and dichloromethane) fractions. enzyme kinetic studies indicated that the butanol fraction is a non-competitive inhibitor for a-glucosidase with an inhibition binding constant (ki) of . lg/ml and a competitive inhibitor of a-amylase with a ki of . lg/ml. subsequently, the butanol fraction was subjected to in vivo studies in a type diabetes model of rats. after weeks of intervention, the fraction, at mg/kg bw, was found to improve the feed and fluid intake, body weight gain, blood glucose, glucose tolerance ability, serum insulin concentration and β cell function of diabetic animals. phytochemical analysis of the fraction through repeated column chromatography led to the isolation of bicyclo [ . . ] hexane- , , -triol. the structure of the compound was established through detailed spectroscopic methods including h nmr, c nmr and d nmr (cosy, hsqc and hmbc) experiments.conclusion: data from the study suggests that the butanol fraction of k. senegalensis contains bioactive agents that could be exploited in the management of type diabetes. objective: to determine the progression rate to impaired fasting glucose (ifg), impaired glucose tolerance (igt), and diabetes (dm ) in normal glucose tolerant (ngt) people during years follow up study using who and new criteria of ifg (ifg , -fasting glucose . - . mmol/l).research design and methods: this is an year prospective study in a randomly selected urban population aged ! years living in krakow, poland. persons had ngt. based on who criteria, ( . % of invited, men and women, aged mean . sd = . ) attended the follow-up assessment.. subjects underwent a physical and biochemical examination and questionnaire examination.results: the prevalence of dm , ifg and igt according to who criteria in examined population with baseline ngt was . %, . % and . % respectively. the prevalence of ifg , using new criteria, was . %, lowering cutoff point for ifg caused . % increase in the prevalence of ifg.among people with diagnosed diabetes % had newly diagnosed diabetes during the control study. the prevalence of dm and igt/ ifg was increasing with increasing age and bmi categories (p < . ). the lowest obesity prevalence both baseline and after follow up was found in those who remained ngt.conclusion: in the baseline ngt population high follow-up progression rate to impaired glucose metabolism was found. the implementation of new ifg diagnostic criteria increased the prevalence of ifg by . %. according to our results prevention of diabetes initiatives should focus on normal body weight preservation. results: sbp was found to be elevated in . % subjects whereas dbp was elevated among . % subjects. out of all the subjects, . % were overweight and . % obese. obese subjects were found to be more hypertensive than non-obese subjects (r = . ). sbp had strong correlation with age (r = . ), bmi (r = . ), whr (r = . ), fbs (r = . ), chol (r = . ) and ldl (r = . ) whereas dbp was found to be strongly correlated with same parameters and triglycerides (r = . ) also. no significant correlation was found with hba c levels and hdl-cholesterol. conclusion: hypertension was found to be more prevalent in males as compared to females in this diabetic population. there was an background: the medicine faculty, chiang mai university provided health screening to detect health problem and risk group for high school students who past entrance examination in this academic year . there is no official cutoff value of waist circumference (wc) measured at superior iliac crest level (wci) for overweight and obesity in thai young adolescence. we aimed to determine correlation between wci and to those measured at midpoint between lower costal margin and superior iliac crest (wcm) and to define appropriated wci and body mass index (bmi) cutoff levels for admission students in northern thailand.methods: the admission students had weight (kg), height (cm), wc, and blood pressure measurements.results: there were admission students. . % of them were female. the correlation between wci and wcm was . . for receiver operating characteristics analysis of having high bp (systolic ! mmhg or diastolic ! mmhg.) using wcm of cm in male and cm in female as standard (wcm ), area under curve ( . ) of wci of cm in male and cm in female (wci ) andabstracts of the th international congress on prediabetes and metabolic syndrome all patients were asked to follow a dietary plan for weeks before bth , day before the test, subjects were instructed to take a low fibre diet. bth was carried out both after overnight fasting (t ) and during oral glucose tolerance test (ogtt). hydrogen gas is detected in exhalate, cut-off value was settled at ppm.results: at t bth was positive in % of overweight and % of obese subjects.particularly, bth was positive in % of subjects with ms and in % of those without ms.during ogtt, % of bth results, negative at t , became positive.conclusions: obese subjects with ms had an bth altered value at t suggesting a intestinal dysbiosis.on the basis of our preliminary data, bth at t can be helpful to diagnose gastrointestinal disorders driving the idea of intestinal dysbiosis as a possible cause in pathogenesis of obesity, thus a probiotic supplementation is to be considered as baseline therapy in overweight-obesity. department of clinical physiology and pathology of locomotor apparatus, institute of gerontology ams ukraine, kyiv, ukraine aim of research: to determine uric acid level in blood serum and incidents of hyperuricemia among women and men of different age and their relation with some components of metabolic syndrome.object of research: age of examined patients was from to years old: women (n = ) and men (n = ). they were divided in following groups: i group (bmi = . - . ), ii -(bmi = . - . ), iii -(bmi = . - . ), iv -(bmi > ). average age of examined patients was . ae . years.methods: uric acid level in blood plasma was determined by uricaseperoxidase method. aim: we studied the prevalence and prognostic impact of the metabolic syndrome (ms) in acute myocardial infarction (ami) patients (pts) with normal (ngt) or abnormal glucose tolerance (agt).material and methods: a total of consecutive nondiabetic ami pts performed an oral glucose tolerance test at hospital discharge being categorized using idf/nhlbi/aha ms criteria into four groups (gr): gr. i -ngt no ms (n = ), gr. ii -ngt with ms (n = ), gr. iii -agt no ms (n = ), gr. iv -agt with ms (n = ). clinical characteristics and cv events during . years follow-up were studied.results: ms was diagnosed in % pts, with a higher prevalence in agt vs. ngt subjects (p < . ). ngtms and agtms subjects were more likely to be older (p < . ), women (p < . ), hypertensive (p < . ), have stroke history (p < . ) and hypertriglyceridemia (p < . ) compared to pts without ms. in hospital heart failure rates were higher in gr. ii, iv vs. gr. i, iii (p < . ). agtms subjects showed more often atrial fibrillation and a lower lvef% compared to ngtms (p < . ). cv events incidence during follow-up was similar among groups excepting significantly higher mortality in pts with ms, especially in agtms subjects (rr = . ( % ci . - . ) for ngtms; rr = . ( % ci . - . ) for agtms).conclusions: ms was present in % of nondiabetic ami patients and was associated with high long-term mortality; its incidence and the risk of death increased in the presence of agt. methods: a cross-sectional study was realized in government workers during his medical review, from april to september . the screening included height, weight, waist circumference, blood pressure measurements, plus a blood draw sample to determine glucose, triglycerides, and total cholesterol. body mass index (bmi) was used to diagnose overweight and obesity according to cut-offs proposed by the world health organization ( ). the mets was defined according with aha/nhlbi criteria ( ) . waist circumference (wc) and waist-to-height ratio (whr) were used as fat distribution indexes. all statistical analyses were performed using the spss v .results: in total, workers aged - years, of both sexes ( % males and % females), were included. the overall prevalence of mets was extremely high with % ( % in male, and % in female). abdominal obesity was present in . %, high triglycerides in . %, high-density lipoprotein cholesterol levels in . %, fasting hyperglycemia in . %, and hypertension in . % of the sample. % of the overweight or obese were diagnosed with metabolic syndrome. the prevalence of overweight and obese was extremely high too, according with gender: % in male, and % in female. mets was associated with cigarette smoking, absence of physical activity, a higher bmi and a greater proportion of obesity. the mets prevalence in this sector of mexican government workers is a very serious health problem. it is urgent to develop innovative programs that improve health situation. our rehabilitation department targets obesity and take care of patients a year, either in a outpatient (op, day hospital) or in patient (ip) programme.we focus on therapeutic education, and our approach is medical, nutritional, physical, psychological and social.the aim of our study is to compare the efficiency of the day hospital vs. in patient in the rehabilitation of obesity.two samples of patients who exited our unit months ago were compared.investigated criteria were: loss of weight during the programme, way of life after the programme (physical activities, diet), medical and psychological follow up.the results showed: . a weight loss between the patient admission and the trial date of . kg for in patients vs. . kg for day hospital patients. . the diet prescription is followed by . % of ip patients and by . % of op patients. . the prescription of physical activity was followed by % of ip patients and . % of op patients. . a psychological follow up is done by % of ip patients and % of op patients.the efficiency of the therapeutical education programme is proven in either ip or op patients.the day hospital allows a smooth return to normal life after a nutrition inpatient rehabilitation. research design and methods: a total of asymptomatic t dm subjects ( men and women; mean age: . ae . years) were enrolled. clinical and laboratory parameters, including hba c, glycoalbumin, lipid profile were evaluated and cardiovascular magnetic resonance (cmr) was performed. abnormal findings of cmr were defined as any one of the followings: . silent myocardial infarction. . inducible ischemia. . suspected cad.within days after taking cmr, invasive coronary angiography (ica) was performed in selective patients.results: among patients, a total of patients (silent myocardial infarction (n = ), inducible ischemia (n = ), suspected cad (n = )) had at least one abnormal finding on cmr and ica was recommended. finally, patients underwent ica, and subjects had significant cad (a total of coronary territories assess) overall, in asymptomatic t dm patients, the positive predictive value (ppv) of sp-cmr, cmr-a, c-cmr are %. however, the ppv of each mri to detect signinficant stenosis are %, % and %, respectively. in asymptomatic t dm patients, stress perfusion cmr showed higher ppv than cmr-a. introduction: observational data suggests that low -hyroxyvitamin d is associated with metabolic syndrome in diabetic and non diabetic patients. we examined the difference between components of metabolic syndrome before and after treatment with calcitriol in type diabetic patients with vitamin d deficiency.method and material: a total type diabetic patients were selected. patients had vitamin d deficiency that underwent calcitriol treatment with . lg per day for weeks. in all cases, clinical parameters including weight, systolic and diastolic blood pressure and laboratory parameters including levels of fasting blood glucose, insulin, lipid profile, calcium, phosphorous, hba c and insulin resistance were measured, before and after the treatment period. the two sets of results were then compared with one another.results: following treatment with calcitriol hba c, total cholesterol, ldl, hdl and diastolic blood pressure decreased significantly. (p = . , . , . , . and . respectively). but the changes in other parameters were not significant. subjects and methods: the five components of mets following the criteria of the international diabetes federation (idf) were measured in men (mean age . ae year) and women (mean age . ae . year) participating in the pep family heart study. we determined percentage body fat using skinfold thickness. we defined high %bf > % for females and > % for males and elevated bmi as ! kg/m². spss version was used for the statistical analyses; multiple linear regression models were used. two-tailed p < . was considered significant.results: mean values of wc, blood pressure (bp), fasting plasma glucose (fpg), triglycerides (tg), hdl-cholesterol and bmi were significantly higher in men than in women who had higher %bf ( % vs. %). using multiple linear regression models, we found significant associations with wc, %bf and bmi. bmi had the strongest associations with tg (beta . ; ci % . - . ), hdl-c (À . ; À . to À . ), sbp ( . objective: patients with esrd have an increased risk for cardiovascular morbidity and mortality. metabolic syndrome (metsy) has been implicated in the progression of cardiovascular disease (cvd). this cross sectional study investigated the prevalence of metsy in maintenance hemodialysis (hd) patients using a joint definition for metsy.patients and methods: subjects had to meet at least three of the following five criteria for metsy: elevated waist circumference, elevated triglyceride levels, low hdl cholesterol, elevated blood pressure and elevated fasting serum glucose. demographics, medical history, anthropometric and laboratory data were collected from the medical records. serum chemistries were obtained mid-week and waist circumference was measured twice after a hd session and the mean value was calculated. the study cohort consisted of % male patients with the mean age of . ae . years. hypertension was the leading cause of esrd ( %) followed by diabetic nephropathy ( %). metsy was identified in % of the cohort, with %, % and % having , and risk factors, respectively. the prevalence of metsy was highest amongst patients on hd for > years ( %). for those patients on hd < months, - months and > to < years, metsy was identified in %, % and %, respectively. metabolic syndrome was not associated with gender and age.conclusion: metsy is highly prevalent in hemodialysis patients, which suggests an additional risk for cvd. early screening for metsy may have protective role on cvd morbidity and mortality. department of family medicine, kangwon national university hospital, chuncheon, republic of korea introduction: it was reported decreased relative muscle mass was related with insulin resistance and prediabetes in us. the aim of this study is to investigate the association of relative muscle mass with cardiovascular disease risk factor using the nationally representative sample of korean adults.methods: this is a cross-sectional study using the data of the subjects who participated in the korean national health and nutrition examination survey (knhanes) in - . multiple linear regression analysis for survey design was used to explore the association between relative muscle mass and the factors of metabolic syndrome and homa-ir with adjustment for confounding factors.we also conducted multiple logistic regression analysis for survey design to investigate the relationship of relative muscle mass with metabolic syndrome.results: in comparison with subjects in the first quintile of relative muscle mass, the odds ratio ( % confidence interval) for metabolic syndrome for subjects in the fifth quintile was . ( . , . ) in the age < group and . ( . , . ) in the age ! group respectively after adjusting for confounding variables. relative muscle mass was inversely associated with sbp, dbp, serum tgs, fbs and homa-ir in both age < and age ! group, showing significant liner trend.conclusions: decreased relative muscle mass was inversely associated with the prevalence of metabolic syndrome, and the factors of metabolic syndrome except hdl-c. the causal relationship is not exactly known and would be elucidated through further longitudinal study. endocrinology, moscow regional research clinical institute, moscow, russia background: there has been growth in registered prevalence of type diabetes (t d) in russia. real prevalence of t d is much more higher. new approaches for early detection of glucose metabolism disorders are important.aim: assess effectiveness of new approach to screening of glucose metabolism disorders based on using diabetes bus in remote areas of moscow county. objective: to study the frequency of metabolic syndrome according to the atpiii criteria among elderly people attending the family practice clinic at the jordan university hospital, and to investigate the pattern of antihypertensive medications used for patients with metabolic syndrome.design: a total of elderly people ( males and females) aged years or more attending family practice clinic at jordan university hospital.materials and methods: elderly patients included were studied regarding the frequency of metabolic syndrome and its individual components according to the atpiii criteria. antihypertensive medications used by elderly patients with metabolic syndrome were also investigated.results: the frequency of metabolic syndrome was found to be . %. hypertension was the most frequent risk factor among all patients including males and females ( % in the whole sample, . % in males and . % in females). all risk factors except hypertension were significantly more frequent among patient with metabolic syndrome compared to those with no metabolic syndrome. the most commonly used antihypertensive medications were the angiotensin converting enzyme inhibitors ( . %), followed by beta blockers ( . %), calcium channel blockers ( %), and finally angiotensin receptor blockers and thiazide diuretics (both . %).conclusion: the frequency of metabolic syndrome was relatively high, which highlights the need to take some action to combat the syndrome. hypertension in particular showed the highest frequency among all risk factors. optimum control of hypertension by following the guidelines is essential in this context to better achieve control without adversely affecting the metabolic syndrome out come. introduction: metabolic syndrome is associated with a significantly increased risk of morbidity and mortality.objective: to assess incidence of the metabolic syndrome in patients of the team in the family medicine centre in kalesija through the medical audit.patients and methods: we have analyzed the medical records of all the patients with team with years of age and over ( records).we have used the international diabetes federation and the american heart association (aha) criteria for the definition of metabolic syndrome diagnosis. the analysis is done separately by sex, age and body mass index (bmi). the results of this study shows that ( %) of adults meet the criteria for the metabolic syndrome. of these, ( %) were women and ( %) men. % of patients in age group of - years meets the criteria for the metabolic syndrome. % of patients - years old, and % of patients ages and older, meets the criteria for the metabolic syndrome. out of the total number of female patients who meet the criteria for the metabolic syndrome, % had increased and % had normal bmi. from the male patients who met the criteria for metabolic syndrome, % had increased, and % had normal bmi.conclusion: the incidence of the metabolic syndrome in family medicine is high. metabolic syndrome is prevalent and significantly increased with age and bmi. more effective interventions in primary care are needed in order to reduce cardiovascular morbidity and mortality. methods: after weeks of high-fat diet, dio mice (n = ) were divided into two groups received either intraperitoneal (ip) injection of ts ( mg/kg, daily) or saline for days. another group of mice were fed low-fat diet (lf) as control (n = ). then both dio mice and lf mice were given intracerebroventricular (i.c.v.) injection of leptin or saline. results: ts significantly decreased final body weight gain (À %, p < . ) and average ei (À %, p < . ) in dio mice. ts significantly decreased pro-inflammatory markers (tnf-a, il- , il- β, p-ikk and p-ijba) in epididymal fat, liver and hypothalamus of dio mice. in lf mice, i.c.v. injection of leptin significantly suppressed ei compared to saline injection (À %, p = . ). however, central leptin sensitivity was blunted in dio mice evidenced aim: non-alcoholic fatty liver disease (nafld), which is characterized by the accumulation of fat in the liver in the absence of alcohol intake, strongly linked to metabolic syndrome. recently, proinflammatory cytokines and oxidative stress mechanisms have been implicated in the pathogenesis of psychiatric disorders. in addition, patients with drug-free schizophrenia have significantly higher body mass index than in aged-matched healthy controls. the purpose of the study was to investigate the effects of metabolic syndrome on the apomorphine-induced stereotypy in a rat model of nafld.materials and methods: eighteen male sprague-dawley rats were included in the study. in order to develop nafld model, rats (n = ) were provided with drinking water containing with % fructose for weeks, while control group (n = ) received only tap water. after the verification of fatty liver by ultrasonography, apomorphine-induced stereotypy was investigated as described by kenneth and kenneth ( ) . then, all rats were sacrificed; homovanillic acid (hva), a dopamine metabolite, levels were measured in brain homogenates. prefrontal cortical il- immunoexpression was evaluated by immunohistochemistry and hepatocellular changes were determined histologically.results: histological evaluation of liver sections confirmed macrovesicular steatosis in nafld rats. moreover, the stereotyped behavior scores, brain hva levels and il- expression were found significantly higher in nafld group than in the control group (p < . ). our results suggest that metabolic syndrome and fatty liver significantly induce dopaminergic activity and stereotyped behavior in rats. the neuromodulatory effects of pro-inflammatory cytokines and imbalance between oxidative and anti-oxidative status may underlie these alterations. the classical thinking in type diabetes is that the plasma glucose levels are regulated by interplay between insulin, glucagon and other peripheral mechanisms. a combination of insulin resistance and relative insulin insufficiency is considered to be causal to hyperglycemia. this traditional wisdom is now being challenged and an alternative model is proposed where the central nervous system (cns) plays a vital role in plasma glucose regulation. the role of cns in glucose regulation is well known. for example it has been shown that intracerebroventricular injection of glucose results in a decrease in plasma glucose level in rats. however whether and to what extent the cns has an active role in diabetic hyperglycemia is not known. we make mathematical models of different versions of the peripheral and central mechanisms and make differential correlational predictions which can be tested on oral glucose tolerance test ( background and aims: high calorie diets leads to fat liver and changes in the metabolic pathways. therefore the gluconeogenic capacity of the livers in a condition of high levels of exogenous fatty acids was evaluated in cafeteria-fed rats.methods: two groups of weaned wistar rats received cafeteria or balanced diet during days. the fasted livers were perfused with mmol/l lactate plus . mmol/l pyruvate in absence or in presence of mmol/l stearate plus traces of [ - c]-stearate. measured parameters: glucose, ketone bodies, [ c]co , oxygen uptake, hepatic contents of lipids and glycogen.results: cafeteria-fed rats presented increase in: body and liver weight, fat in the tissues and hepatic glycogen. perfusion experiments revealed that in cafeteria-fed rats the gluconeogenic flux was lower than in the control, but the infusion of stearate, caused a higher stimulus on glucose production. the co and ketone bodies production was reduced during the active gluconeogenesis in cafeteriafed and control rats, being the former less sensitive, whereas no differences were found after stearate infusion. background: despite advances in option of treatement diabetes, optimal glycemic control is not often achieved. glucose homeostasis is dependent on a complex interplay of multiple hormones and glucagon like peptide- (glp- ) receptor agonists are a new class of drug for the treatment of type diabetes. they are not considered as initial therapy for the majority of patient with type diabetes and their clinical use, long-term benefits, risks and their role in combination with other diabetes medication are still under investigation.study: in the retrospective study in we enrolled patients with poorly controlled type diabetes on one or two oral agents, who received additional therapy with glp- receptor agonist: liraglutide or exenatide. we monitored hba c value and body weight before and after modification of therapy.results: fifty-one patients, men, were - years old (mean years). their mean body weight was . kg (sd ae . ) and mean hba c . % (sd ae ). after - months of combined therapy with metformin and/or sulfonylurea and glp- agonist their mean hba c dropped to . % (sd ae . ) and their body weight reduced to . kg (sd ae . ). in patients with type diabetes and suboptimal control on one or two oral agents adding glp- receptor agonist was effective in improving glycemic control and body weight reduction. despite lack of evidence on their clinical use, long-term benefits and side effects these agents have the potential to change the diabetes treatment by replacing traditional secretagogues because of superior control and association with weight loss. objective: the metabolic syndrome (ms) is a particular affection that has been associated with so many factors such as hypertention. both increase cardiovascular diseases. due to the higher prevalence of hypertension in our country, this study aim to determine the frequency of ms in newly diagnosed hypertensive patients in oder to improve the follow -up of these subjets.methodology: over a period of months, we conducted a crosssectional and descriptive study on patients recently diagnosed as hypertensive for < months. the selection of patients was done during external consultation in the cardiology unit at the university teaching hospital of yaounde. it was based on high blood pressure, anthropome´tric parameters such as weight, bmi, waist, abdominal circonference and biological values (lipid profile, blood glucose, uric acid). we identified patients aged between and years, with a mean age of years. people aged more than years were mostly affected. stage was the prominent stage of hypertension.the prevalence of metabolic syndrome was . % with a higher rate in female.the cardiovascular risk factors were obesity, alcoholism, sedentarity and hypo hdlc factors differenciating population with metabolic syndrom was obesity (p = . ), hyperglycemia (p = . ), hypo hdlc (p = . ) while the phenotypes most represented were hyperglycemia, abdominal obesity and hypo hdlc respectively. the metabolic syndrome is frequent in newly diagnosed hypertensive subjects; the females were most affected. metabolic syndrome should be investigated systematically in all hypetensive patients. background: although mainly inhibits osteoclastogenesis, osteoprotegerin is produced by vasculature too. serum opg (sopg) is elevated in both diabetics and patients with coronary artery disease (cad) but there are still insufficient data for its concentrations in impaired glucose tolerance (igt) subjects. aims: to determine sopg in males with igt and concomitant cad and to investigate its relationship with certain glucometabolic parameters.materials and methods: sopg was measured in males with performed percutaneous coronary interventions for cad- with igt and normoglycemic, and in age-and bmi-matched healthy normoglycemic controls. glucose abnormalities were screen-detected using a standard ogtt. mean intima-media thickness (imt) of common carotid arteries was measured by b-mode ultrasonography. opg was measured by elisa.results: sopg was significantly higher in igt patients compared to controls ( . ae . vs. . ae . pmol/l; p = . ) but did not differ between igt and normoglycemic cad patiens ( . ae . vs. . ae . pmol/l, p = . ). in all participants, sopg correlated positively with imt (p . ; pr . ). similarly, in igt males with cad, sopg correlated only with imt (p . ; pr . ). there were no associations with fasting and postchallange plasma glucose, hba c, fasting insulin, homa-ir, lipid parameters, blood pressure, bmi or waist circumference. we found higher sopg in males with igt and cad compared to the controls. opg did not correlate with glucose parameters but rather with markers of atherosclerosis. we speculate in cad patients with igt, the increased sopg might reflect the vascular damage and not glycemic status which requires further investigations. internal medicine, umf iuliu hatieganu cluj-napoca, cluj-napoca, umf 'victor babes' timisoara, timisoara, romania objective: the pro ala polymorphism in the pparg gene (c>g) is associated with less weight loss after treatment for obesity. this study aimed to investigate the association of rs polymorphism with weight loss year after bariatric surgery. the sample was composed of individuals with grade iii obesity undergoing roux-en y gastric bypass. anthropometric data were collected in the preoperative period and year after surgery. genotyping was performed by the method of allelic discrimination in real time pcr (polymerase chain reaction) using the taqman predesigned snp genotyping assays kits (applied biosystems, foster city, ca, usa). individuals with at least one variant allele were grouped and compared with those with the reference genotype.results: subjects ( . % females, mean age . ae . years) participated in the study. genotyping showed % (n = ) of individuals homozygous for the c allele (c/c) and % (n = ) heterozygous (c/g). there was no homozygous mutant (g/g). individuals with the c/c and c/g genotypes respectively showed a loss of . ae . and ae . kg; . ae and . ae . % of initial weight and . ae and . ae . % of excess body weight. there was no difference in weight loss between groups.conclusion: the pparg pro ala genotype seems to have no association with weight loss year after bariatric surgery. objective: evaluated determine the prevalence of ir, ms and associated factors among banking workers in southeastern brazil.methods: out of males and females banking employees, years old were evaluated by cross-sectional study including demographic, biochemical, anthropometric and hemodynamic. the ms was determinate by ncep and idf. the ir was determined by homa-ir, with the cut off > . .results: ( . % % ci . - . ) and ( . % % ci . - . ) of employees with ms, according to the ncep and idf, respectively and ( . %) with ri. the likelihood of developing the syndrome is greater in individuals with high level of education (or . ( % ci . - . ) and among those with overweight and obesity, the possibility of having ms is , ( % ci . - . , p = . ) and . ( % ci . - . , p = . ) times over, respectively. persons who are overweight are at risk of . ( % ci . - . ) times more likely to have elevated homa, and among those who are obese, the risk rises to . ( % ci . - . ).conclusion: this study showed the higher number of employees who have similar characteristics of the total active working, that despite high education, also have ms and ir, and the consequent risk of developing cardiovascular disease. prediabetes is considered as a strong risk factor for type diabetes (dm ). tcf l is a gen involved in dm susceptibility related with glp-l. objective: study the relationship of rs and rs variants of the tcf l gene with insulin levels, c-peptide and glp- in normoglycemia and prediabetes subjects. we included pre-diabetic and normoglycemic subjects. we measure fasting glucose, lipids, insulin, c-peptide and glp- ). insulin resistance and beta-cell function were calculated with the homa model. tcf l polymorphisms rs c/t and rs g/t were determined by pcr-rflp. for analyses two groups were compared: wild-type and carriers of two allele risk. we included a total of subjects aged ae years. weight, bmi, systolic and diastolic blood pressure and triglycerides were significantly lower in the group of healthy subjects. glp- was higher in normoglycemic subjects. the frequency of rs t allele was higher in pre-diabetic subjects, while the allele frequency of rs t was not significantly different between the groups. in carriers of rs t, serum insulin and homa-beta were significantly higher. plasma levels of glp- were lower in prediabetic subjects with and without the risk allele variant. in prediabetic subjects carriers of the rs g/t or tt had also lower levels of serum insulin, homa-ir and homa-beta. the glp- concentrations were lower in both groups.conclusions: in this work the rs polymorphism tcf l gene was associated with prediabetes. the frequency of the rs t allele tcf l gene was not different between groups. objective: determine hba c, igfbp , fgf and other metabolic markers in non-diabetic, prediabetic, type diabetics (t dm) of recent diagnosis. material and methods: a cross-sectional population based study was carried in - years old subjects classified with fasting glucose (fg) and after h g oral glucose load (gt), as normal with impaired fg (ifg), impaired gt (igt), with both alterations (ifg/igt) and dm . after - weeks subjects were re-classified and registration of anthropometric data, food intake and determination of a c, lipids, insulin, fgf and igfbp .results: we found . % for prediabetes and . % for dm (n = ). in the re-classification we classified: normal, ifg, igt, ifg/igt, dm . with anova analysis we found that hba c in dm patients was different from normal, ifg, ifg/igt subjects (p < . , p < . and p < . respectively). fgf levels was different among all groups (p < . ). normoglycemic subjects were better educated and had higher income than the prediabetic and dm subjects. dm subjects reported more screen time. prediabetic subjects had higher hdl-cholesterol. with multiple regression analysis we found igfbp positively correlated with daily caloric intake and triglycerides and negatively with bmi. the fgf correlated positively with insulin. the prevalence of pre-diabetes is more than twice of that of undiagnosed diabetes. we find fgf and insulin related with the metabolic status. igfbp was negatively correlation with bmi finding compatible with an association with insulin resistance. we have previously found that the expressions of several homeobox transcription factors, including irx , were reduced in subcutaneous fat in human obesity. a knock-out (ko) mouse line was acquired for the purpose of investigating the in vivo effects of irx deficiency with the main perspective on how these mice would handle a high-energy dietary intake. though initially undersized, male irx ko mice fed a high-fat ( %) diet approached similar weight and size as their wildtype (wt) littermates. yet, mri show that the irx ko mice have smaller adipose tissue depots and store less fat around organs in aim: to examine the role of mir- in the pathogenesis of diabetic cardiomyopathy.objectives: to study the cardiac expression of mir- and its effect on regulation of genes involved in akt-pkb signalling pathway in animal model of diabetic cardiomyopathy (dcm).methods: type diabetes was induced in adult wistar rats by high fat diet and i.p streptozotocin injections. the animals were sacrificed at weeks and development of cardiomyopathy was confirmed by heart/body weight ratio, histopathological examination, myocardial fibrotic and hypertrophic genes. cardiac tissues were examined for expression of mir- , its target genes by real time pcr.results: myocardial expression of mir- was significantly increased and showed a positive correlation with myocardial mrna levels of fibrotic genes (ctgf, fgf-b & tgf-b) in diabetic rats. myocardial mrna levels of potential targets of mir- , phosphatase and tensin homolog deleted on chromosome (pten) and programmed cell death protein (pdcd- ), were increased and their protein expression was decreased in dcm group and in fibroblasts exposed to high glucose (p < . ). increasing mir- levels promoted, whereas knocking down mir- attenuated, pten, pcdc- activity in cardiac fibroblasts. our results suggest that mir- contributes to cardiac fibrosis in dcm by modulating activity of akt/pkb pathway through pten and pcdc- . objectives: many studies have revealed that prevalence of metabolic syndrome may be related to lifestyle components. the aim of this study was to investigate the influence of dietary patterns on prevalence of metabolic syndrome (mets). the data was based on health and nutrition survey for japanese men and women aged - year. factor analysis was used to obtain dietary patterns applying to intake of food groups. the definition of mets was followed by the modified version of the criteria of idf that is applied to japanese population. values of waist circumference, hdl-cholesterol, blood pressures, and hba c were used to identify mets. logistic regression analysis was used to examine the association between dietary patterns and prevalence of mets.results: three dietary patterns of "fruits", "rice", and "meat" were identified. in males, greater values of "fruits" pattern was associated with a significantly lower prevalence of mets after adjustment for age, physical activity level, smoking and drinking status and other confounding variables (or = . , % ci . - . ).conclusions: fruits consumption was inversely associated with mets and this association may be explained by much intake of mandarin orange specific to this surveyed population. this finding necessitates further investigation on the mechanisms of fruits consumption on health benefits. introduction: the impaired glucose regulation shows a double risk of cardiovascular morbimortality and development of type diabetes, especially in patients with high cardiovascular risk.objective: identify the carbohydrate abnormalities in unknown diabetic patients with high cardiovascular risk.patients and methods: hundred and forty-eight non-diabetic patients were involved in this single-center study, with at least three known vascular risk factors, metabolic syndrome or with known cardiovascular event over months.all had a test load of g oral glucose (ogtt) followed by h after dosing plasma glucose, serum glycated hemoglobin (hba c) and lipid abnormalities exploration. cardiovascular exploration also concerned all patients.results: among these patients, were in primary prevention and in secondary prevention. cardiovascular events were reported to be dominated by myocardial infarction ( . %) and stroke ( . %).dysglucoregulation concerned patients ( %); the sex ratio was . and the average age was , . unknown diabetes, ifg and igt were diagnosed.these glucose abnormalities were found equally in both primary and secondary prevention.in the family, diabetes was concerned with % and cardiovascular events mainly expressed by early myocardial infarction and stroke were observed in %.the vascular risk factors were more present in igt group.hypertension was found in %, followed by dyslipidemia in %; % met metabolic syndrom's criteria (idf ) .conclusion: in primary prevention context, ogtt not only detects unknown diabetics but identifies igt patients who dysplay a high risk of cardiovascular events. the aim was to study some indicators of inflammatory process and oxidative metabolism in the patients arriving for surgical treatment of pathological obesity. laboratory tests have been carried out by conventional methods in patients with pathological obesity of abdominal type with a body mass index > kg/m before and after biliopancreatic shunting operation.rise of blood glucose level up to . % (p < . ), uric acid level up to . % (p < . ), as well as dyslipidemia were determined in patients. the content of malondialdehyde (mda) increased . times, the general antioxidant activity (aoa) decreased . times. concentration of c-reactive protein (crp) exceeded . times the control value. the long-term results in these patients within - months have shown normalisation of level of blood glucose, uric acid, high and very low density lipoprotein cholesterol, a tendency of decrease in the general cholesterol concentration. triglycerides decreased by %, still remaining at sufficiently high level. mda concentration decreased by . %, aoa increased by . %. crp level which was considerably raised before operation decreased within the next months but in months its average value increased five times in relation to normal rate.the obtained results are evidence of the interrelation of inflammation process and oxidative stress in patients with pathological obesity and metabolic syndrome. efficiency of surgical treatment was shown in the insulin resistance syndrome includes well-recognized cardiovascular risk factors such as low hdl levels, hypertension, hypertriglyceridemia, which is highly correlated with small dense ldl and increased lp(a) levels, which is cardiovascular risk factor. we aimed to study dyslipidemia, especially lp(a) level in addition to carotid intima media thickness (ca-imt) as a marker of atherosclerosis in normal and impaired glucose tolerance offspring of type dm. subjects were included and divided into two main groups; group(i) apparently healthy subjects with no family history of diabetes mellitus, as control group, group(iia) non diabetic offspring of type dm with normal glucose tolerance and group(iib) non diabetic offspring of type dm with impaired glucose tolerance. a statistically significant increase in mean ae sd of serum level of lp(a) and ca-imt in non diabetic impaired glucose tolerant offspring of type diabetes as compared to non diabetic normal glucose tolerant group, significant positive correlation between lp(a) and ca-imt vs. each of ldl-ch, triglycerides and cholesterol. also, a significant positive correlation between lp(a) and ca-imt and hdl-ch. in non diabetic impaired glucose tolerant offspring of type diabetes as compared to non diabetic normal glucose tolerant group. in conclusion the increase in serum level of lp(a) and increase of ca-imt in non diabetic offspring of type dm were associated with increasing severity of insulin resistance and increasing the degree of atherosclerosis explaining the high prevalence of cardiovascular diseases in subjects who are genetically prone to the development of diabetes. a. kostrzewa-tarnowska, m. człapka-matyasik, m. fejfer, j. jeszka weight loss can be achieved by any means of energy restriction, but the challenge is to achieve sustainable weight loss and prevent from weight gain without increasing the risk of chronic diseases. conventional high carbohydrate diets, even when based on wholegrain foods, increase insulinemia and may compromise weight control via mechanisms related to appetite stimulation and metabolic rate. the success of low fat diets has given a push for researches on alternative dietary strategies, including high content of bioactive compounds and low glycemic index (gi) diets.the aim of this study was to determine if high content of bioactive compounds using capillary blood sampling lead to any significant difference between the gis of the products mentioned. investigated group consisted of healthy people with normal weight, aged ae years (bmi . ae . kg/m ).foods with a low gi produce a lower peak in postprandial glucose and a less overall blood glucose increase during the first h after consumption compared with foods with a high gi. studies have shown that bioactive products lead to increased satiety, delayed return of hunger, and decreased food intake after ingestion of low-gi compared with high-gi foods.low-gi products may also play an extensive role in weight loss. this strategy can be associated with reducing total energy intake, modifying the macronutrient composition of the diet and lower postprandial glycaemia.research funded within the framework of the project po ig . . . - / . physiology, school of medicine, national university of ireland, galway, ireland introduction: current diagnostic criteria for type diabetes mellitus rely on increased blood glucose concentration following an oral glucose tolerance test (ogtt) or increased glycated haemoglobin. changes in these parameters occur long after insulin resistance manifests as plasma glucose concentration is homeostatically defended. in contrast, glucose oxidation measured by the c-glucose breath test ( c-gbt) is reduced as a direct consequence of insulin resistance. it is important to establish normative data and define the reliability of any diagnostic or scientific test therefore the aim of this study was to determine the reliability of the c-gbt as a diagnostic tool for type diabetes.methods: sixteen apparently-healthy controls { . ( . ) yrs, . ( . ) kg, . ( . ) cm, all data mean (sd)} underwent simultaneous ogtt and c-gbt on two separate occasions following a h overnight fast. mixed capillary blood and breath samples were collected at baseline and every min for h following ingestion of a . g glucose solution (shamrock, ireland) labelled with . g - c glucose.results: mean baseline co was . ae . delta viennapeedeebelemnite (d-vpdb) and peak co was À . ae . d-vpdb. fasting and h mixed capillary glucose concentrations were . ae . mmol/l and . ae . mmol/l respectively. per cent dose recovered c had a cronbach's alpha of . , while fasting and h glucose concentration were . and . respectively. we established normative data for the c-gbt. the c-gbt is a reliable test of whole body glucose oxidation which has the potential to be developed as a diabetes diagnostic test. introduction: outcome studies in morbidly obese patients (mo) have shown that diabetic patients have the highest benefit from bariatric surgery interventions. therefore it was of interest to study a variety of cardiovascular risk factors in a very large group of patients with mo (n = ), who were investigated in our center. we included patients with mo, of whom . % (n = ; mean hba c . ae . %) were diabetic. in a subset (n = ), patients were followed up years after bariatric surgery of whom . % (n = ) were diabetic. all patients without manifest type diabetes underwent a g oral glucose tolerance test, insulin levels were assessed, homa-insulin resistance (ir) was calculated. diabetes was diagnosed after ada criteria. apart from that demographic, cardiovascular risk-markers (blood pressure, lipids) renal and inflammation parameters were assessed. background: obex â is a dietary supplement to help lose weight. in addition, this supplement is specifically made with natural antioxidants molecularly activated to enhance their biological properties without altering their molecular structure.objectives: the purpose of this study was to evaluate the effect of obex â on anthropometric measurements and metabolic disorders in overweight and obese subjects. this was an open label pilot study conducted with overweight and obese adults (bmi > kg/m and < kg/m ), aged between and , who took obex â (without changes in lifestyle), at a dose of two sachets before the two main meals of each day for months. in addition to anthropometric measures and blood pressure, fasting plasma glucose, lipid profile, insulin, creatinine and uric acid were determined. insulin resistance by homa-ir and betacell function by homa-b were assessed. three indirect indexes were used to calculate insulin sensitivity.results: compared to baseline, obex â significantly reduced body weight (p = . ), body mass index, waist circumference, waist/hip ratio, waist/height ratio (p < . , respectively) and conicity index (p = . ). there was also a reduction in fasting glucose levels. compared to baseline, the use of obex â improved insulin secretion (homa-b) and hdl-c concentration (p < . ). no adverse effects were seen in any of the participants during the pilot study.conclusion: short-term treatment with obex â improved visceral and abdominal obesity, as well as ameliorating levels of select markers of metabolic disease risk in overweight and obese adults, indicating that further studies are warranted. methodology: a descriptive cross sectional study was conducted with families. the sample was family members (partner, offspring, blood family members and not family related individuals-all living in the same house). body mass index (bmi), lipid profile and glucose measured. also, the family functionality (ff) and perceived health status (phs). results: age mean was . years (sd, . ); female ( . %) and males ( . %). the rf were analyzed by the role in the family. seventy-five percent of the housewives were overweight, with high levels of glucose ( . %), cholesterol ( . %), triglyceride ( . %) and low hdl ( . %). husbands had overweight ( %), with high levels of glucose ( . %), cholesterol ( . %), and triglyceride ( . %). the children aged between and years, had glucose and cholesterol normal, but were overweight ( . %), and had high level of triglyceride ( . %) as well as low hdl ( . %). additionally, children and parents had only - portions of vegetables intake in - days in week; similarly . , had - portions of fruits or juice, but only - days by month. family functionality was reported with a mean of . (sd, . )- - scale and . (sd, . ) in phs. the family members in the ua are at high risk for developing dt . among them are underscored obesity, high levels of lipids, low consumption of vegetables and fresh fruits. ff and phs are also risk factors in these families. this study designed to compare the effect of three dietary oils: canola, rice bran and grape seed on lipid profile and paraoxanase activity of hyperlipidermic rats. method: hyperlipidemia was induced in wistar male rats by atherogenic diet. once hyperlipidemia was reached, the rats were randomly divided in four groups of animals according to the treatment received. treatment groups were fed canola, rice bran and grape seed oil for weeks. control rats fed regular rat chow diet which contains corn oil. baseline fasting blood lipid profile and paraxonase activity of experimental and control rats were compared at the beginning and at the end of the experiment.result: after -weeks of treatment, a significant decrease was found in serum triglyceride, total cholesterol and ldl-c concentration of rice bran and grape seed oil fed rats (p < . ), serum hdl-c concentration also increased significantly (p < . ). canola oil fed rats showed a significant decrease in total cholesterol, and triglyceride level and an increase in paraoxanase activity (p < . ), however, no significant differences were found in ldl-c and hdl-c concentration. the present study suggest that consumption grape seed, canola and rice bran oil may have beneficial effect on serum lipid profile, but in comparison of the tree dietary oils grape seed oil showed more beneficial effect in reducing hyperlipidemia. key: cord- -pol qm authors: nan title: third international congress on the immune consequences of trauma, shock and sepsis —mechanisms and therapeutic approaches date: journal: intensive care med doi: . /bf sha: doc_id: cord_uid: pol qm nan this issue of the journal contains the abstracts for the third international congress on the immune consequences of trauma, shock and sepsis -mechanisms and therapeutic approaches. we hope that the information contained in this special issue will stimulate you to participate in the congress, to contribute to the knowledge being developed in this field and to use this information to help you in providing better care for your patients. we thank the editors and the editorial board and publishers of the journal for their interest and support in preparation of this special issue. we also, on behalf of the scientific committee, welcome you to the third international congress in munich on - march . when, in the mid- s, we thought of having a worldwide congress, we hoped to bring together investigators to discuss this theme. the explosion of knowledge occurring around that time provided an excellent background against which the first conference in provided stateof-the-art information and consensus on factors involved in injury and sepsis. in , the second congress was held at the time of another resurgence of research, study and information on injured and operated patients. it seemed then that there would be a lull in the development of new information and therapy, and that another state-of-the art conference might not be necessary until or . however, the explosion in molecular biology has continued. the wonderful world of cytokines has gone from ill to il- to il- , il- and il- and beyond. the vast amount of information about mediators and their importance in disease is impressive. this has all suggested a magic bullet that might be used to alter or block inflammatory responses. this has not happened, however, and the question is "why not"? our science is powerful, but our therapy is still weak. what are the issues, then, in , to be dealt with at this symposium and congress? ( ) proposals for new terminology. there have been a number of proposals for new terminology and new classifications of injury, sepsis, inflammation and various other problems related to human illness. the question is whether this is the way to go. will this contribute to better clinical trials, information basis and better research? the pros and cons of this development will be reviewed by those making the proposals and those questioning the need for and wisdom of this effort. ( ) magic bullets: the prospect of a magic bullet to deal with inflammation in injury and infection seemed highly promising earlier. many preclinical trials and a lot of animal research suggested the possibility of a great breakthrough in clinical care. what has become, then, of all the expensive and extensive multi-institution randomized, placebo-controlled, double-blind clinical trials of agents that block mediators and endotoxin. many such studies have yielded equivocal, marginal or negative results. the reasons for this and the future of clinical research will be the subject of presentations and discussions to set the stage for further work. ( ) should future clinical trials be based on new classifications of illness such as mods, sirs, apache iii, sap ii, mrm, etc., or should trials be dedicated to specific diseases -urinary tract infections, pneumonia, trauma patients, cardiac surgery and other specific problems, rather than generalized problems of sepsis, the sepsis syndrome and other classifications? in other words, should we now begin to have clinical trials on specific diseases with causes that are known and can be attacked? the causality of disease becomes an important consideration in this regard. ( ) a multitude of potential therapeutic agents has been proposed on the basis of animal studies. how should we decide which of them should be brought to clinical trial? the possibilities are endless as we develop new clinical information about the mechanisms and pathogenesis of human disease. ( ) information on the pathogenic mechanism of disease states and of injury continued to emerge in an explosive fashion, and in light of our gathering knowledge we can look forward to working out a cohesive system of response to injury. ( ) additional information will be provided in plenary sections, many symposia and free communication sessions and posters, which will update the participants on a variety of relevant topics presented by many of the leading in-iv vestigators in these fields. topics will range from molecular mechanisms, such as signal transduction, through the explosive growth of information on the role of cytokines and pathophysiology, to practical considerations in the design of immunomodulatory therapeutic regimens. these merely touch on a few areas, from the basic to the clinical, which will be the subjects of those symposia. all this information will fit into the jigsaw of this exciting area and its stimulus to further research study. this promises to provide an exciting, educational programme with experts and participants from all over the world. we hope it will set the stage for many years to come and will increase our understanding of trauma, shock and sepsis and help us to provide better therapy for those of our patients who are affected by such problems. a. the clinical syndrome of mods versus mof will be reviewed in detail by those who have made these proposals. b. an extensive review of the design and interpretation of clinical trials in patients with shock and injury will be provided. the reasons why so many clinical studies in the recent past have been negative will be reviewed. the therapeutic strategies that are being developed for the treatment or prevention of mods or mof will be the subject of another panel discussion by experts who have been involved in and contributed to this area. a consensus conference or controversy conference will be presented about various aspects of mods or mof, including the benefits of supernormal oxygen delivery, bacterial translocation, parenteral nutrition, the immune response and other aspects. the successes and failures of completed clinical trials will be presented by those who are involved in these clinical trials, with a refreshing review of the problems related to that injury. there will be late news about studies just being completed at present or after the beginning of and where they stand. c. the mechanisms and biochemical profiles of specific organ dysfunction or failure will be reviewed. what are the definitions? what are the mechanisms? how can organ dysfunction and/or failure be defined? an extensive review of the biological mechanisms involved in production of injury by mediators will be presented. a session will be devoted to how future ongoing trials might be better designed and what can be done about the studies recently completed, many of which are negative. d. the immunological or inflammatory pathways resulting in organ injury will be reviewed in detail in presentations and a panel discussion. we look forward to welcoming you to an exciting and rewarding conference, which undoubtedly possesses the potential to become a landmark event and major reference point for any scientific discussion about the complex of host defense dysfunctions following trauma, shock and sepsis. studies over the past years have established that the contact system, which forms bradykin/~, is gax important mediator in hypotensive septicemia. in addition to hradyk{nln, another product of the contact system, kailikrein, can mediate inflammation by virtue of its chemotaetic mad neutrophj/activating properties. using functional and immunochemical tech~ ques, we have demonstrated activation of the contact system in the adult respiratory distress syndrome in typhoid fever and clin/cal sepsis. we have also been able to inhibit the hypotension but not the disseminated intravaseular coagulation in a model of primate sepsis by the use of a monoclonal antibody directed agsi~st factor xii, the initiating protein of the contact system, in volunteers given e. coil endotoxin, who did not develop hypotension, we were also able to demonstrate activation of the contact system with a rise of alpha- macrogiebulin-kalllkrein complex. we have also examined, j~ an i~tensive care situation, patients with sirs. we found that serial measuremezzts of the contact system were useful in eva~u~ting prognosis+ these studies suggest that inhibition of kalllkrein a~d l e r bradykinin actions might be useful i~ obviating many .of the features seen in sepsis and septic shock. dextran sulfate (dxs) activates the contact system and, in vivo, produces transient hypotension. in order to better define the mechanisms underlying the dxs-induced hypotension, we investigated the effects of either the plasma kallikrein inhibitor, des-pro -iarg] ]aprotinin (bay ) or the b kinin antagonist, hoe on the hypotensive response to dxs. in the first study, anesthetized miniature pigs ( pigs/group, randomly assigned) were given one of the following treatment protocols: ) dxs ( mg/kg), - ) dxs plus bay ( , , , or rag), or ) saline. dxs alone produced a profound but transient systemic arterial hypotension with a corresponding reduction in plasma kinin-containing kininogen. circulating kinin levels, complement fragment c adesarg and fibrin mom)mer were all increased. bay produced a dose-dependent delay or attenuation in these effects with the highest dose completely blocking dxs-induced hypotension and elevations of kinin, c adesarg and fibrin monomer levels. thus, the effects of dxs are solely dependent on contact system activation and this activation is sensitive to bay . llowev~:r, contact system activation is known to produce changes in a variety of vasoactive mediators, all of which can affect blood pressure. in a second study, two groups of pigs ( /group) were given either dxs alone ( mg/kg) or dxs minutes after a bolus injection of hoe ( #g/kg). dxs alone produced transient hypotenmon. this response was completely blocked by hoe pretreatment. both groups had identical reductions in kinin-containing kininogen. we conclude that dxs-induced hypotension is produced by activation of the contact system which results in the production of bradykinin. liberation of bradykinin is both necessary and sufficient to produce all of the hemodynamic changes observed. dr. matthias siebeck, department of surgery, university of munich, klinikum lnnenstadt, nussbaumstrasse , d- munich, germany in experimental animals exposed to i.v. injection of endotoxin accumulation of leukocytes in various organs as lungs and the liver is a prominent feature. as a part of these morphological changes damages of endothelial ceils are regularly seen. this process, which is a part of endothelial-cellular interaction, leeds to exposure of the sub-endothelial basement membran. the basement membran is known f r its capacity to activate the contact system of plasma. during this cascade activation, coagulation factor xii is converted to the active factor xii. this activation might produce increased plasma kallikrein activities and thereby give release of the vasoactive substance bradykinin. using a porcine model we have noticed that endotoxin infusion ( , mg/kg) induces elevated plasma kailikrein activities within two hours after the start of the infusion. this enzyme activity remained increased during the next hours and reached value of up to u/ . in patients with sepsis we also have observed elevated plasma kallikrein activities with enzyme activities up to u/ . in order to further elucidate the significance of these elevated enzyme activities, we prepared human plasma kallikrein and injected it intravenously in anaesthetized pigs ( ). when very small plasma kailikrein activities ( , u/kg bodyweight) were given intravenously a % decrease in arterial blood pressure was seen in the animals. in the patients with sepsis also decreases in prekallikrein values and functional plasma kallikrein inhibition are frequently seen. furthermore, degradation of high molecular weight kioinogen is found in these patients indicating formation of bradykinin. these experimental and clinical studies underline that contact activation in sepsis might results in the release of very powerful mediator substances which can be of pathophysiological importance in this disease. a number of pathological disorders as reperfusion injury, bone marrow transplantation, polytrauma and septic shock are associated with capillary leakage. as the activation of the complement system and the contact phase play a major role in these diseases we investigated whether cl-lnhibitor (c -inh), which inactivates cl-esterase, kallikrein and clotting factors xii and xl, could abolish vascular leakage. a capillary leakage was induced in rats by the administration of interleukin- ( x iu/kg). the increased vascular permeability was monitored for one hour as the extravasation of fitc marked rat serum albumin from a mesenterial vessel by a video-image processing system. ci-inh (berinert®, behringwerke) given as a single i.v. bolus in concentrations of , or u/kg dose-dependently prevented the capillary leakage. carrageenaninduced inflammation in the rat leads to vascutar leakage and to edematous swelling of the paw. ci-inh in this model leads to a dose-dependent decrease in paw edema formation. finally, we investigated the effect of ci-inh (infusion ( - u/kg x h) on a lps-induced shock in the rat by combination therapy with the antithrombotlc agents antithrombin ill (kybernin®) or rec. hirudin (both substances from behringwerke). in this animal model mortality was % in the untreated control. both antithrombotic agents decreased mortality rates by inhibiting formation of dic; a further significant improvement of survival was achieved by the treatment with ci-inh. thus+ it could be concluded that c -inh has a beneficial effect in diseases associated with a vascular leakage. iclb and laboratory for experimental and clinical immunology, university of amsterdam, the netherlands; thrombosis research center, temple university, penn., usa; oklahoma medical research foundation,. ok. city, usa. to evaluate the contribution of the contact system to activation of other mediator systems in an experimental model of sepsis, we investigated the effect of mab c b which inhibits activation of factor xli, on activation of complement and fibrinolytic cascades and activation of neutrophils in baboons suffering from a lethal sepsis. activation of the complement system was assessed by measuring circulating levels of c b/c and c b/c, and a significant reduction was observed in animals that had received a lethal dose of e. coli together with mab c (treatment group), compared to animals that had received a lethal dose of e. coil only (control group). activation of the fibrinolytic system as reflected by circulating plasmin-= antiplasmin complexes and tissue plasminogen activator, and activation of neutrophils, assessed by measuring circulating elastase-=l-antitrypsin complexes, was also significantly less in the treatment group. we conclude that activation of the contact system protein factor xll during the inflammatory response to a lethal dose of e. coil in this baboon model, modulates directly or indirectly activation of the complement and fibrinolytic systems and that of neutrophils. in a prospective study, plasma levels of c a, c , and c a were measured in patients from an internal intensive care unit. patients were clinically septic defined by the criteria of bone et al.(l) . the remaining patients were critically ill but didn't fulfill the clinical criteria of sepsis. from both groups of patients blood samples were taken over a l days period. during the first days blood samples were drawn every h, on day - every h and the last days once daily. mean plasma concentrations of c a within the first h after clinical onset of sepsis were + pg/ml, whereas non-septic-patients exhibited mean values of only +_ p_g/m/. c levels were lower for septic-patients ( + lag/ml) than for non-septic-patients ( _+ lag/ml). the most profound difference between both groups was found, when the c a/c ratio was compared ( . + . for septic-patients and . _+_ . for the control group). no significant differences between both patient groups were observed in c a plasma levels ( . + . ng/ml in septic-patients vs. . _+ . ng/ml in control patients). in of cases of clinically defined sepsis causative organisms like bacteria, protozoa or fungi could be cultured from blood, bronchoalveolar lavages and/or section materials. application of the complement parameters to survivors (n= ) and non-survivors (n=l ) within the septic-group revealed, that the c a/c ratio could also be used as a prognostic parameter for clinical outcome. the possibility of rapid and easy measurement of c a and c in only - minutes ( ) and the significant difference of the c ajc ratio between the septic and non-septic group renders this parameter a good candidate for early diagnosis of sepsis in the intensive care unit. hirudin, a single polypeptide chain composed of amino acids with cysteine residues (mr daitons), is the most potent and specific thrombin inhibitor, which is now available as a genetically engineered product (rec. hirudin -hbw , behringwerke; marburg). the aim of our study was to establish a rabbit model of tissue factor (tf) induced activation of the extrinsic pathway of coagulation and to evaluate the therapeutic efficacy of rec. hirudin. coagulation was induced in female nzw rabbits by infusion of . p.g/kgxh thromboplastin for hours. development of disseminated clotting was manifested by a decrease of fibrinogen and platelets to . % and , % respectively, and by an increase of fibrin monomers from . to > . ~tg/ml. we administered rec. hirudin to rabbits in different concentrations ( . , . and . mg/kg); treatment started simultaneously with the infusion as an i.v. bolus. rec. hirudin significantly prevented the decrease of fibrinogen, platelets and the increase of fibrin monomers. this effect was dose dependent and long lasting, even hours after the administration of rec. hirudin, clotting was still significantly reduced. as could be drawn from the plasma levels, rec. hirudin had been cleared from plasma at this time. in a post-treatment study we administered rec. hirudin ( . , . and . mg/kg i.v. bolus) as late as hours after the start of tf infusion. at this time there was already a prominent activation of coagulation. even in this post-treatment regimen rec. hirudin significantly prevented disseminated clotting. hence, it was concluded, that rec. hirudin by inkihiting thrombin could be effective in the prevention of coagulation disorders including disseminated intravascular clotting (dic) induced by a septic disease. research laboratories of behringwerke ag, marburg, germany $ novel protease inhibitory activities of the second domain of urinary trypsin inhibitor (r- ) and its effect on sepns-lnduced organ injury in rat atsuo murata , hitoshi toda , ken'ichi uda , hidewaki nakagawa , takesada mori , hideaki morishita , tom yamakawa , jiro hirese , atsushi ni~ , nariaki matsuura osaka university medical school, osaka, mochida pharmaceutical co. ltd. tokyo, wakayama medical schoof, wakayama, japan inhibitory-activities of the second kuntz-type inhibitor domain of human urinary trypsin inhibitor (uti) and its effect on sepsis-induced organ injury in rat were investigated by using the recombinant protein. uti is a glycoprotein with a structure in which kunitz-type inhibitor domains are linked in a row. we isolated the gene encoding the second kunitz-type inhibitor domain of uti, and then constructed expression plasmids by ligating it to the e. coli phoa signal peptide gene. these plasmids expressed the second domain in e. coil strain je which lacks the membrane lipoprotein. the recombinant second domain (r- ) innb[ted trypsin, plasmin, neutrophil elastase and chymotrypsin. in addition it inhibited blood coagulation factor xa and plasma kallikrein in a concentration dependent and competitive manner. the in vivo effect of the recombinant r- was investigated in a rat model of septic shock induced by cecal ligation and puncture. the administration of r- significantly improved the survival rate of the rats and attenuated the pathological changes of lung and iiver. we found out the novel protease inhibitory activities of the second domain of uti and its protective effects on sepsis-induced organ injury. macrophages are known to secrete lysosomal proteinases,mainly cathepsin b and cathepsin l, and also ~-proteinase inhibitor (pi),related to acute phase proteins.disturbances of proteinases/ proteinase inhibitors correlates with inflammatory process,leading sometimes to noncontrol "pathglogical" proteolysis (jochum et ai., ) . the cathepsin l-like and cathepsin b-like activity were measured in serum of patients with chronic bronchitis ( -with obstructive, -with nonobstructive bronchitis),acute bronchitis ( ) and healthy persons.simultaneously the level of~pi was determined in the same groups.cysteine proteinases were measured with help of fluorogenic substrates,as was presented earlier (korolenko et ai., ) , ~pi with help of immune enzyme method. it was shown increase of cathepsin l-like and cathepsin b-like activities during aggravation of chronic bronchitis comparatively to the controls ( - fold) .after treatment there was a tendency to normalization of indices,but the increase was about - % more than the control values.~pi level in this group was also increased (two-fold),in patients with acute bronchitis - - -times more comparatively to the control.it is possible to conclude that chronic bronchitis induced increased secretion both cysteine proteinases and d{pi into blood. some peculiarities of ratio were noted in patients with emphysema. endotoxins are microbial products derived from the outer cell membrane of gram negative bacteria. the active component of endotoxin is lipopolysaccharide (lps), a complex macromolecule consisting of polysaccharide covalently bound to a unique lipid, termed lipid a. now recognized to embody the endotoxic principle of lps, lipid a consists of a/ - diglucosamine backbone, both ester and amide linked fatty acids, some of which are acyloxyacylated, and charged constituents such as phosphate, phosphorylethanolamine and amino arbinose lps, exerts its biological effects in vivo by noncytotoxic interactions with a variety of host inflammatory mediator cells, primarily the mononuclear phagocyte and the endothelial cell, although other host cells also participate. these interactions are modulated by lps-specific binding proteins found in plasma, including lps-binding protein (lbp) scd and perhaps other proteins as well. specific receptors for lps have been identified on mammalian cells which mediate signal transduction via multiple pathways. lps-activated host cells are stimulated to secrete or express multiple proinflammatory mediators, including tnf-a, illa, il- / , ifn-a, il- , il- , il- , paf, pge, ltb and procoagulant activity. the overproduction of these proinfiammatory mediators results in the manifestations of endotoxemia, observed experimentally as fever, hypotension, disseminated intravascular coagulation and death. modulation of activity of these mediators protects animals against lethality. similar pathways are thought to be operative in gram negative sepsis, and control studies with human volunteers support such conclusions. immunotherapeutic approaches in clinical gram negative sepsis have, to date, been less successful. in vitro experiments and studies in animal models have recently shown that several proteinaceous bacterial exotoxins can evoke cytotoxic effects that ultimately lead to cardiovascular collapse and shock. since the possible relevance of bacterial exotoxins in the pathogenesis of septic shock has received very little attention in the past, an attempt will be made here to provide a brief overview of this generaily neglected topic. protein toxins act intracellularly or they dz~nage the integrity and function of the plasma membrane. major representatives of the former group are the adenosine diphosphate (adp)-ribosylating toxins, e.g. cholera and cholera-like toxins, diphtheria toxin), and the neurotoxins. most medically relevant toxins of this category have been studied in great detail. although often responsible for severe and sometimes fatal disease, their association with septic shock is rare. in contrast, experimental evidence is accumulating for a role of membrane<lamaging toxins in the pathogenesis of inflammatory lesions. formation of transmembrane pores is probably the most widespread mechanism via which such physical membrane perturbation can occur ( , ), the present discussion will be restricted to this category of toxins. the author shall first discuss basic properties of pore-forming proteins, and consider the factors that direct their attack to specific targets. thereafter, attention will be drawn to diverse functional consequences that may follow membrane damage so that a general concept of how pore-forming toxins may contribute towards the development of shock will evolve. i. bhakdi, s. and tranum-jensen. j. gram positive bacteria produce exotoxins that, at least in part, exhibit the unusual properties of superantigens. superantigens (sag) activate v/ selectively t cells to produce lymphokines including i - and tnf/lymphotoxin. systemic application of the sag staphylococcal enterotoxin b (seb) to d-galactosamine sensitized mice causes lethal shock within hours. seb reactive v/ + t cells accumulate within - min mrna for the ii- , i - , tnfai~ and ifn- ,. parallel in time high concentrations of bloodborne i - and tnf are noted. anti tnf t~// neutralizing mab protect mice against seb induced t cell dependent lethal shock thus indicating a key role of tnf in effecting lethal toxicity. within - h distinct levels of tolerance to seb become discernable on ligand reactive v/ t ceils, dependent of the dose of seb used. these levels include anergy, t cell receptor downregulation, loss of cd , cd , cd accessory molecules and programmed cell death. m.freudenberg, y.yaegashi, p.nielsen, c.galanos. the sensitivity towards endotoxin (lps) is genetically determined, however it may be increased under different experimental conditions. these include treatment with hepatotoxic agents such as d-galactosamine, and with live (infection) or killed bacteria. it is well established now that d-galactosamine sensitizes to lps by increasing the susceptibility of the host to toxic activity of lps-induced tnf~. sensitization by bacteria, especially by gram-negative once is of especial interest because it implies that infecting microorganisms not only produce lps, but als sensitize the host to its lethal activity. sensitization to lps by bacteria proceeds in all lps-sensitive (lps n) mouse strains that have been investigated so far. it also proceeds in lps-resistant (lps d) c h/hej mice. the absence of sensitization to lps in lps d c bl/ sccr mice was identified as being due to their inability to produce interferon- (ifn?). administration of exogenous ifn? to these mice conferred sensitivity to lps. conversely, administration of anti-ifn? to lpsn; mice inhibited the development of sensitization'by bacteria. it may be concluded therefore that ifn is the mediator of sensitization to lps by bacterial infection. the ifn? defect of c bl/ sccr mice concerns only the ifn response to bacteria, since the response to the t-cell mitogen con a and to cd monoclonal antibodies was not impaired. the ifn?producing cells themselves were shown to be intact. on closer investigation the impaired ifn? response was identified as the result of a defective accessory function of macrophages. macrophages of c bl/ sccr mice are incapable of producing interferon-~ (ifn~) which we could show to be obligatory for the production of ifn? in response to bacteria. although antibiotics are required to clear bacteremia, they do not reverse evolving shock, because endotoxin free in the bloodstream or exposed on the surface of circulating bacteria continues to activate the production of inflammatory mediators, furthermore, antibiotics have been shown to induce release of endotoxin from gram-negative bacteria during the treatment of severe infection. in an in-vitro study, using live escherichia coil, we have observed the release of endotoxin upon treatment with several antibiotics like cefuroxim, imipenem, ceftazidime and aztreonam. incubation with imipenem or ceftazidime induced an early lyeis and a mild rise in endotoxin levels, whereas incubation with cefuroxime or aztreonam resulted in the formation of filaments with a late but dramatic rise in endotoxin levels. in a second study we studied the influence of different antibiotics on the tnf-= production of e.coli stimulated human monocytes. we found again great differences in the production of this important cytokine among the different antibiotics according to their capacity to induce liberation of endotoxin. these differences in the amount of endotoxin release are probably caused by penicillin-binding-proteins (pbp) specificities of the antibiotics with resultant differential morphological changes, in a rat sepsis model treatment with imipenem or ceftazidime resulted in a transient increase in il- levels, whereas treatment with aztreonam resulted in progressively increasing levels of il- and a significant increase in mortality. the increased mortality in pbp- specific aztreonam treated rats might have been the result of filament formation in the abdominal cavity of the septic rats. the endotoxin sequestered at local sites may account for the precipitation of gram-negative shock. finally, we've also demonstrated that in patients under treatment for septic shock endotoxin release can be related to the administration of antibiotics. carbapenem-and cephalosporin-lnduced release of lps from smooth and rough pseudomonas aeruginosa: in-vivo relevance j. jackson and h. kropp, merck research laboratories, rahway, nj b-lactam (cell-wall active) antibiotics are generally deemed the class of antibiotics most responsible for the release of free endotoxin (lps) from gram-negative bacteria due to their cell lytic actions although all antibiotic classes studied thus far induce release of endotoxin. we have recently shown in-vitro that antibiotics within the b-lactam class (i.e. imipenem , meropenem and ceftazidime , with equivalent mics) differ in their propensities to release excessive amounts of lps from both smooth-(s-) and rough-(r-) lps laboratory and clinical and antibiotic-sensitive and -resistant p. aeruginosa isolates and that lps release is independent of cell lysis. additionally, variations in the induction of endotoxin release is antibiotic concentration dependant and correlate with antibiotic penicillin-binding protein (pbp) affinities which result in morphological changes. these studies also show that lps differences measured via chromogenic lps (c-lal) assay correlate with lps lethality in lps-sensitive mice. release of lps was compared to changes in cfus, cell mass, morphology and antibiotic pbp-specificity. corresponding in-vivo studies in cd mice against s-lps p. aeruginosa isolates show that, despite equivalent in-vitro protection, antibiotic efficacy in mice differ as much as -to lo -fold. to establish a possible in-vivo role for antibiotic-induced release of free lps we compared antibiotic efficacy results in mice challenged with virulent parent s-lps and its relatively avirulent r-lps mutant (lacking only its side chain) p. aeruginosa isolates. results show the relevance of quantity and physiochemical composition (bioreactivity) of free lps to virulence and in-vivo antibiotic efficacy. in other in-vivo studies chemical agents that destroy cells (m~) which mediate lps lethality in-vivo were used to pretreat mice prior to antibiotic therapy and bacterial challenge with wild type pseudomonas. we conclude that circumstances in which antibiotic-induced filamentation occurs are also conditions that yield excessive lps release, the in-vivo effects of which are shown through the requirement of larger amounts of antibiotic to afford equivalent protection. bacterial endotoxins have been reported to play a significant role in the pathogenesis of gram negative sepsis by their interaction with, and stimulation of, host inflammatory mediator cells to produce cytokines, biologically active lipid intermediates, and procoagulant activity (tfa). although both microbe-associated and free endotoxin are capable of stimulating mediator production, studies from our laboratory suggest that free endotoxin may be the more potent stimulus for tnf and tfa. further, our studies suggest that the majority of the proinflammatory activity released from antibiotictreated e. coli coisolates with lps by two different fractionation techniques. to assess whether actions of endotoxin directly contribute to lethality in gram negative sepsis, an experimental model was developed in which mice were made hypersusceptihle to the lethal effects of endotoxin by treatment with d-galactosamine (dgaln). challenge of cf- dgaln-treated mice with e. coli olll:b resulted in an lds of approximately . x cfu. resolution of the peritonitis and bacteremia by treatment with cell wall-active antibiotics resulted in an increase in the ldso. ceftazidime and imipenem, which differ in their mechanism of action and in their capacity to effect endotoxin release in vitro, also differed in their in vivo capacity to provide chemotherapeutic protection ( fold vs fold respectively, p< . ). parallel studies with endotoxin hyporesponsive c h/hej mice indicate significantly greater levels of protection with imipenem (> fold vs saline controls). collectively these data suggest that endotoxin may contribute directly to the pathogenesis of experimental gram negative sepsis. bacterial lipopolysaccharides (lps) are the endotoxins of gram-negative bacteria and represent their major surface antigens. lps is made up of three chemically, biologically and genetically disctinct regions, i.e, the o-chain, the core region and the lipid a moiety whereby the latter represents the endotoxic center. it is our current understanding that lps is responsible for many of the pathophysiological events observed during gramnegative infections and that one of the major mechanisms leading to shock and death is the lps-induced activation of macrophages resulting in the production and release of lipid and peptide mediators, among which tumor necrosis factor seems to be the most important. therefore, in the fight against the lethal outcome of gram-negative infections, modern strategies, in addition to antibiotic treatment, aim at i) the neutralization of tumor necrosis factor, ii) the inhibition of the production of tumor necrosis factor or iii) the neutralization of the activation potential of lps for macrophages by monoclonal, preferably human antibodies. the latter approach, to be effective against a broad spectrum of gram-negatives, must be directed against common structures of lps (lipid a and core region). the molecular basis of this approach and the controversy in this field will be discussed. passive immunotherapy has been used since , when von behring described the administration of immune horse serum to treat a patient with diphteria infection. even if this therapy was sometimes successful in bacterial infections, it has been largely replaced by antibiotics. however, antibiotics have their limitations, especially in critically-ill patients. to improve outcome, adjunctive therapies such as immunotherapy with polyclonal and monoclonal antibodies particularly against endotoxin are again considered. the role of humoral immunity in host defenses against bacterial infections is weu known. for instance, tile importance of antibodies in the defense against gramnegative infections has been established clinically by studies relating the outcome of patients with gram-negative bacteremia to tilers of antibodies directed at the offending pathogens at the onset ofbacteremia (mccabe ; pollack ) . ever since we know the role of endotoxins in the pathophysiology of sepsis, antibodies against the s-and r-lps have also been detected in sepsis patients. the aim of the administration of iv/g to the sepsis patient is as follows: ) enhancing of opsonization and phagocytosis(antibactericidai activity) ) synergistic effects with [ - actam antibiotics ) neutralization of endotoxin, the main pathogenic mediator of gram-negative sepsis ) modulation and/or inhibition of cytokine release the enhancement of opsonic-and phagocytic-activity especially with igg via fc and c receptors has been well documented. monoclonal antiendotoxin antibodies, proven in clinical studies, do not appear to neutralize endotoxin in vitro and are not reproducibly protective in animal models of sepsis. also they can not suppress endotoxin-induced tnf-~, il- release in mice (baumgartner , corriveau and danner ) . in conlrast, recent studies of a polyclonal immunoglobulin preparation, containing high levels of antibodies against gram-negative bacteria and their o-antigen of lps in igg, igm and iga classes (pentaglobin®) provide evidence to neutralize endotoxin. this effect is demonstrated in vitro (berger (berger , , in animal models (stephan , berger and also in prospective, randomized, controlled clinical trials (schedel , poynton , behre . furthermore mortali b' was reduced statistically in patients with septic shock and endotoxemia by using this preparation, as has been demonstrated by sehedel. anti-core lps monoolonal antibodies: binding specificity and biological properties f.e. di padova, r. barclay, e.th. rietschel. bacterial lps and cytokines are responsible for the pathological processes of gram-sepsis and are suitable targets for therapeutic interventions. chemical characterization and structural analysis of different lps have revealed common features. the inner core region of lps shows a high degree of similarity among e. coli, salmonella and shigella. among a large number of broadly cross-reactive murine anti-core lps mab one of these igg ak) has been selected and chimerized into a human igglk (sdz - ). in elisa and in immunoblots on purified lps both sdz - and wni - show a strong reactivity with all smooth lps from e. coli and salmonella. reactivity with all the known complete core structures from e. coli and salmonella (ra) is evident. reactivity with re structures or free lipid a is not observed. this mab cressreacts with all clinical e. coli isolates from blood, urine and feces and with other enterobacteriaceae. sdz - and wni - have biological activity as they inhibit the lal assay and the secretion of monokines (il- and tnf) by mouse and human macrophages. moreover, sdz - and wni - inhibit the release of il- and tnf in vivo. in vivo sdz - as well as wni - neutralize the pyrogenic activity of e. coli lps and protect mice from lethality in d-gain-sensitized mice. the possibility to use wni - as a capture antibodies in the immunolimulus assay opens the possibility to differentiate the origin of the lps in patients with endotoxemia. franco di padova, sandoz pharma ag, ch basel, $chweiz $ presentation of lps to cd by lps binding protein peter s. tobias, julie gegner, katrin soldau, lois kline, loren hatlen, douglas mintz, and richard j. ulevitch. the activation of myeloid cells by lipopolysaccharides (lps) has been shown to require the serum glycoprotein lps binding protein (lbp) and binding of lps to membrane bound cd (mcd ). other cells such as human umbilical vein endothelial cells (huvec), smooth muscle cells, and some epithelial cells, which do not express mcd but nevertheless respond to lps in the presence of serum, have receptors for complexes of lps with the soluble form of cd (scd ). these complexes of lps with scd are only formed efficiently in the presence of lbp. we have begun to characterise the mechanisms by which lbp enables lps to bind to cd , either soluble or membrane bound. with the use of fluorophore and radiolabelled reagents we have developed procedures for quantitative measurement of the association of lps with lbp and of lps-lbp complexes with cd . these results show that the delivery of lps to scd is catalysed by lbp, i.e., lbp is not included with the lps-scd complex. in contrast, on the surface of cells, lbp does not dissociate from the cells after lps binds to mcd . the kinetics, equilibria and stoichiometry of these reactions will be discussed in the context of models for cellular activation by lps and cellular uptake of lps. supported by nltt grants gm , ai , ai , gm , and assistance from the pharmaceutical research institute of johnson and johnson. the scripps research institute, imm- , n. torrey pines rd. la jolla, ca usa . modulation of endotoxin-induced cytokine production by lps partial structures h.-d. flad, h. loppnow, t. mattern, and a.j. ulmer department of immunology and cell biology, forschungsinstitut borstel, d- borstel lipid a constitutes the active moiety of endotoxin (lps) of gramnegative bacteria. it activates mononuclear phagocytes to produce cytokines, such as tnf, i _- , and il- , which are the major mediators of the endotoxic effect of lps in vivo. lipid a precursor la (synthetic compound ) does not induce cytokines, but is able to specifically antagonize lps-or lipid a-induced mediator production in human mononuclear cells, vascular endothelial cells, and smooth muscle cells. furthermore, we present evidence for the first time that t-lymphocytes proliferate in response to lps and express mrna for interleukin- and interferon-~ and that these responses are also antagonized by synthetic lipid a precursor la. when comparing the agonistic and antagonistic activity of lipid a and different partial structures at the functional and binding level, the number and length of the fatty acids and the number of phosphoryl groups were pound to be of crucial importance. unexpectedly, lipid a precursor la, although biologically inactive, turned out to be both the most potent antagonist and competitor in inhibiting the binding of lps. taken together, our results provide evidence for a model in which lipid a partial structures compete with lps for specific cell surface receptor(s). in this sense, biologically inactive lipid a analogues may be good candidates as therapeutic agents for the prevention of gram-negative septic shock. two mammalian lipid a-binding proteins have been identified that are believed to have important roles in mediating the host response to endotoxin: lipopolysaccharide-binding protein (lbp) and bactericidal/ permeability-increasing protein (bpi). human lbp shares a % amino acid sequence identity with human bpi. despite the sequence homology, the two lipid a-binding proteins have very different functional activities. lbp is an acute phase serum protein that markedly potentiates the proinfiammatory host response to gram-negative infection by a mechanism which involves binding of the lbp-lps complex to cd receptors on monocytes, neutrophils and endothelial cells. in contrast, bpi is a neutrophil granule protein with potent bactericidal and lps-neutralizing activities. the divergent functional properties of these two lps-bindlng proteins can be explained by the inability of bpi-lps complexes to bind to cell-surface cd receptors. a recombinant protein (rbpi ), corresponding to the amino terminal kd fragment of human bpi, has been shown to retain the potent biological activities of the hdlo protein and may represent a novel therapeutic agent for the treatment of gram-negative infections, sepsis and endotoxemia. for therapeutic effectiveness in many clinical situations, rbpi will have to successfully compete with relatively high serum levels of lbp ( - ~g/mi) for binding to endotoxin and gram-negative bacteria. to evaluate this issue, experiments were conducted to compare the relative binding affinities of rbpi and human recombinant lbp (rlbp) for lipid a. the binding of both proteins to iipid a was specific and saturable with apparent kd's of . nm for rbpi and nm for rlbp. in a competition assay format rbpi was approximately -fold more potent than rlbp in inhibiting the binding of nsi-rlbp to lipid a. these results demonstrate that rbpi has a significantly higher affinity for endotoxin than does rlbp and may explain the potent inhibitory activity of low concentrations of rbpi in a variety of in vitro functional assays for lps activation of cells despite the presence of high lbp levels. for example, rbpi at . ~tg/mi was able to totally inhibit lps-induced tnf release from monocytes despite a -fold weight excess of rlbp over rbpi . and for heparin binding. three separate domains which inhibit the lal reaction to lps and bind to heparin were identified in amino acid regions - , - and - . a single synthetic peptide ( - ) was bactericidal. these results suggest that rbpi contains three separate functional domains which may contribute to its high affmity interaction with gram-negative bacteria and heparin. the individual activity of each domain and the cooperative interaction among domains provide the basis for developing rbpi analogues with increased biologic efficacy. a considerable body of experimental data has accumulated implicating tumour necrosis factor (tnf) as a principal mediator of the pathophysiological features of septic shock. these data prompted the development of clinical strategies designed to limit excess (inappropriate) tnf production. monoclonoal antibodies (mobs) were developed and a phase ii dose escalation trial in patients confirmed that the mab was safe, and suggested that it was having a beneficial effect on certain parameters. preliminary results of a large phase iii study indicated that (a) the mob was safe; (b) that it was of no discernible benefit in non-shocked patients; (c) that it reduced mortality in shocked patients, especially during the first days. an alternative strategy was to take advantage of the high binding affinity of soluble receptors for tnf (stnfr). stnfr-iggfc constructs were made for both the p and p receptors. both were effective in animal models of lps challenge, but when a clinical trial was done with the p stnfr-fc there was unexpected mortality in the treated arm. using an animal model of live e.coli sepsis, we have shown that this may have been due to the release of bound tnf from the construct. plasma enhances while bpi inhibits lps-induced cytokine production from peripheral blood mononuclear cells (pbmc). pseudomonas species produce cytokine-inducing substances which are different from lps as indicated by the fact that polymyxin b blocks only % of the cytokine-inducing activity of these pyrogens. we now tested the effect of plasma and bpi on the il- [ -inducing activity of pseudomonas maltophilia -derived pyrogens (pmp). bacteria were cultured to the log phase and filtered ( kd) to obtain prop. dilutions of pmp or lps were added to pbmc alone or to pbmc in % plasma +/-bpi ( ng/ml). pbmc were incubated for hours at °c and total il-i~ was measured by ria. results: il-i[~ in ng/ml (n= , mear~+sem, *p< . vs control). control . _+ + bpi . + % plas. . _+ + bpi . _+ pmp (ng/ml) lps (ng/ml) . _+ . _+ . _+ . _+. . +. . _+. . _+. " _+ " . _+ " . _+ " . _+. . + _+ _+. * _+ " . +. " . + -+ . -+ " . _+. " cba, c bl/ , balb/c, akr, dba, swiss mice, guinea pigs, rabbits have been used in research work. the toxicity, immunogenicity, mitogenic and immunomodulating activity of lps have been studied. the possibility of reduction of the toxic activity of lps on macroorganism by bioglycansimmunomodulators obtained from sea invertebrates anymals (crenomytilus grayanus, stromhus gigas) have been investigated too. lps has been shown to induce specific antibody response of laboratory animals. cba mice are high responsive to lps. lps stimulates humoral immune response of mice to tdependent and t-independent antigens and suppresses intensity of the delayed hypersensitivity. the small doses of lps stimulate functional activity of macrophages, the large doses of lps -decrease one and show the cytotoxic effect. the bioglycans enhance the resistance of mice to the lethal effect of lads and provide protection - % of mice. one opens possibility to use of bioglicans for reduction of toxinemia in generalizated forms of pseudotuberculosis. thus, lps from y.pseudotuberculosis is immunogen and immunomodulator wich has influence on humoral and cellular factors of immunity and plays the important role in immunopathogenesis of infection. endotoxaemia is implicated in the pathophysiology of obstructive jaundice. the lirnulus lysate (lal) assay is the gold standard method for measuring endotoxin concentrations, but inherent biochemical and technical problems limit the usefulness of this assay. the endocab elisa is a novel assay which measures endogenous antibody (igg) to the inner core region of circulating endotoxins (acga). objectives we evaluated the significance of endotoxaemia in biliary obstruction using the endocab assay and subsequently the specificity of the humoral response to endotoxin compared with an exogenous antigenic challenge [tetamls toxoid (tt) ]. materials and methods in experiment i three groups of male wistar rats ( - g) were studied [no operation (n= ) , sham operation (n= ), and bile duct ligation for days (bdl)(n= )]. plasma was collected and assayed for bilirubin, endntoxin(lal) and acga(endocab). in experiment ii rats were actively immunised with tetanus toxoid ('it) and then randomised to have no op(n= ), sham op(n= ) or bdl(n=i ). blood was taken at this time (to) and days later(t at sacrifice for acga concentrationslendocab] and igg produced to tt(ttab) [elisa] . antibody concentrations are expressed as % increase from control values.results in bdl rats, acga concentrations were significantly increased compared with controlslp< . , mann-whitney]. endotoxin concentrations were sporadically elevated in the jaundiced rats but the rise was not significant. in experiment [i there was no difference between the acga or ttab concentrations in the fllree groups at to, bdl rats had a significant rise in acga concentrations by t [p< , ,paired t-test] and humoral response to tt was significantly impaired in bdl rats compared with control groupslp< . , paired ttest data plasma endotoxin was measured by means of an endotoxinspecific endospecy test after pretreatment of the plasma with a new perchloric acid method that we developed. the normal value of plasma endotoxin is less than . pglml. polymyxin b was administered at a dose of , u every hours. plasma endotoxin rapidly decreased to the normal range in of the patients. body temperature fall significantly. apache ii scores were also significantly improved. tumor necrosis factor-o~ and interleukin decreased in survivors, while in high values tended to persist in patients died. no side effects were observed in any of the patients. in conclusion, intramuscular injection of minute of polymyxin b was useful in the treatment of endotoxemia. - uchimaru, morioka , japan. l e v a n t g r a m n e g a t i v organisms. m e t h o d s : u n d e r general anesthesia, n o r w e g i a n b r e d landrace pigs ( - kg) of either sex, pr group, u n d e r w e n t t r a c h e o s t o m y a n d w e r e v e n t i l a t e d on a / air a n d o x y g e n m i x t u r e a i m e d at m a i n t a i n i n g a n o r m a l p h a n d a isocapnic level. ventilation w a s not readjusted d u r i n g the observation period. the anesthesia w a s k e t a m i n e . m g / k g h a n d d i a z e p a m . m g / k g h i n t r a v e n o u s l y . h e m o d y n a m i c m o n i t o r i n g of m e a n aorta, p u l m o n a r y artery, central v e n o u s a n d p u l m o n a r y capillary w e d g e pressures w a s p e r f o r m e d w i t h a f s w a n -g a n z catheter a n d an aorta catheter. a continous infusion of r i n g e r ' s acetate ( m l / k g h ) w a s g i v e n intravenously. w h e n stabilised, the a n i m a l s w e r e g i v e n . x l cfu of e colt intraperitoneally as a bolus in ml saline, the a n t i b o d y g r o u p received in a d d i t i o n m g / k g e a n t i e n d o t o x i n i n t r a v e n o u s l y over h o u r via a n infusion p u m p at the start of the observation period. the a n i m a l s w e r e observed for hours. results : a t a n d hours, the o x y g e n c o n s u m p t i o n increased by % in the a n t i b o d y treated g r o u p w h e r e a s there w a s a significant fall of % in the sepsis group. in the a n t i b o d y group, the arterial p h a n d the cardiac index were also significantly h i g h e r at the s a m e p o i n t s in time. there w a s no significant difference in arterial po . in severe bacterial infections it would be beneficial to neutralize the plasma endotoxin content with complex forming compounds. the phenothiazines are able to form complexes with endoto×in and the existence of these complexes were already shown in differential speetrophotometry and animal experiments, however, the mechanism of partial neutralization was not clarified. therefore some representative phenothiazines and structurally related compounds were tested for anti-endotoxin activity. the endotoxin neutralizinb effects of several benzophenothiazines were investigated in differential speotrophotemetry, tnf induction and in the conventional limulus test. in animal experiments some beneficial effect of complex forming compounds was found. the benzophenothiazines were not able to inactivate the biological effect of endotoxin in the limulus test. the recent findings indicates that a multifocal effect can be responsible for "anti-endotoxin action in vivo". effects of tnf inducing effect of endotoxin in leukocytes and bypotensiv action in experimental animals were reduced by some phenothiazine derivatives. monophosphoril lipid a was without effect. of microbiology, albert szemt-gydrbyi medical university, odm t~r lo, h- szeged~ hunbary involvement of streptococcus pyogenes erythrogenic toxins in the induction oflstreptococcal toxic shock syndrome heide mgller-alou~* , joseph e. alouf , die [er gerlach , ~atherine fitting., and jean-marc ca~aillon . unit des toxines microbiennes and "unit d'immuno-allergie, institut pasteur, , rue du docteur roux - paris (france) ; institut f~r experimentelle mikrobiologie, jena (germany). superantigen erythrogenic toxin a (eta) is thought to be involved in toxic shock syndrome in humans by inducing massive release of cytokines by patient immune cells. the cytokineinducing capacity of eta w~:s £:ompa~ed to that of lps, a gram-negative bacterial cell wall component. eta elicited weak production of il- d and ~, tnf ~ and il- in purified human monocytes whereas lps stimulated the production of high amounts of these cytokines. in the presence of t cells, eta elicited the production of significant amounts of il-i~, il-i~, il- and il- . however, the most preponderant cytokine was tnf~, which peaked at i ng/ml after stimulation with i ~g eta. comparable amounts of tnfd (ca ng) were induced by .i ~g eta and .i ~g lp$. in contrast to lps, eta was a strong inducer of tnf~ which was produced only in marginal amounts by lps. these results suggest that the septic shock induced by gramnegative bacteria (lps) and by gram-positive bacteria {extracellular superantigens) follows different pathogenic pathways. lps-induced shock is mainly mediated by monocytes and monocyte-produced cytokines (il-i and tnf). the eta-induced shock is mediated by t-cells or depends on t cell help for the production of monocyte-liberated cytokines. production of t cell cytokines such as tnf~ and interferon in addition to the other cytokines contribute very likely to the severity of the toxic-shock resulting from s. auzeus and s. pyogenes infections in humans. the present study was utidertakc~l to cvalu~tlc the effect of soluble chemically modified giucan during septic shock. carboxylnethyl-b-i, -glucan (ram ) was injected twice and h before the shock i.v. in a dose of ing/kg. shock was induced in u~?esthetizcd (sodikm~. l)mntobarbital) rats by i.v. injection of endotoxin of escherichia colli bs, mg/kg. aiiofcmg pretreated ruts survived during first haher ¢ndotoxine, while in controi shock group the lethality was %. the concentration of ~col)terin in serum was significantly elevated hafterthc second cmginjection (appare~tly % if compare with the control rats), but didu't chartged rain and s rain after endotoxin injectjom cardiac output in cmogroup was higher a* the i and min after endotoxine onset ( i % trod ~, respectively of initial level) than in the control shock group ( % and % at the same time). pretreatment of rals with soh~ble giucan w~ts associated with beneficial effects o~ the hepatic c~ergy $ia[tls after h after challenge of endotoxiae: the tissue level of lactale was ahnost twice lower than in the control ruts, me~mthne the tissue atf in cmg pretreated group was higher at %. twice injected macrophage stimuhttor soluble glucan can prevent the endotoxic shock, and extremely ir~creased survival rate after endotoxine injection. the national committee of surgical infections of the spanish association of surgeons have produced a computer program for the collection and analysis of information on surgical infections. the program is suitable for ibm compatible hard disk personal computers and works through the ms-dos system. the main menu is called up on the screen when the operating disk has been installed; it reads as follows: i. new record; . modify records; . erase records; . searches; . reports; . configure; o. ouit. if you ask fdr a new record the screen will prompt you to enter the number of case, record number, hospital, age and sex. the next screen will come up and the words "topographic diagnosis" will flash. a menu of areas or organs will be displayed. then, the words "type of pathology" (inflammatory, neoplastic, traumatic and other). days of postoperative period. type of surgery (programmed and emergency). type of operation (clean, clean contaminated, contaminated and dirty). duration of surgery. this is followed by "order of operation" and the "type of anaesthesia (general, regional or local). you are then required to supply the "diagnostic code of who" (icd ) and the "procedure code of who. analytic and concurrent illnesses (total proteins, albumin, haemoglobin, haematocrit, leucocytes, red corpuscles, glucose and bilirubin). the next screen asks for "risk factors" (obesity, uraemia, neoplasia, malnutrition, urinary catheter, distant infection, artificial valve, immunosuppressive drugs, over years and anergy. this is followed by a screen headed "postoperative complications". "evolution" (the questions asked are drainage, systemic antibiotics, and on each ocasion a choice of antibiotics is displayed), local antiseptics, reoperation, etc. under "microhiology" is a choice of organisms and the chance of identifyin organisms. finally, "sepsis score". our recent work had shown that renshen-fuzi-chaihu mixture could increase the survival rate in experimented study. the purpose of this study was to determine the effect of combined administration of renshen-fuzi-chaihu mixtuer and antibitics (sa) in patients with septic shock. the result showed that, in sa group ( cases), the total effective rate was , %, in the contral group (combined administration of gentamycin and dexamethasone, cases) the total effective rate was %. however the obviously effective rate in sa group % was significantly higher than in contral group % (p<o.os). sa group appeared to be more obvious than the contral group in raising arterial pressure, recovering consciousness and pulse, improving cold lilmbs and reducing fever (p<o.o ). it was found that sa could inhibit the pathogeneses changes of septic shock such as the decreases of superotide dismutase (sod) and glutathione peroxidase (gsh-px) in erythrocytes and the increases of plasma free hemoglobin (phb), plasma malondialdehyde (mda) and -glucuronidase ( -gc) occured in septic shock. sa had stronger effect than gd in inhibiting the changes mentioned above. hence, these results suggest that sa has beneficial effect in the treatment of septic shock. sa could diminish the decrease of the antioxdase activities and inhibit lipid peroxidization and stabilize cellmembrance. this may be one of the principal mechanisms of the beneficial effect of sa in the treatment of septic shock. donna l. lehman, heather a. childers, irshad h. chaudry and alfred ayala. the thymus is thought to be a privileged sight for tcell generation. here the t-lymphocytes are either selected for their potential to recognize and react competently to foreign antigens or de-selected, due to their potential to react to auto-antigens, de-selected. tcells with this latter capacity are thought to be deselected through a process referred to as programmed cell death or apoptosis. while it is known that thymic apoptosis is elevated by a variety of stressers associated with infection and inflammation, little or no information is available concerning its presence in polymicrobial sepsis. it was, therefore, the aim of this study to determine whether thymocytes exhibit increased apoptosis during sepsis. to assess this, thymocytes were harvested from c h/hen mice at i and h following cecal ligation and puncture (clp; to induce sepsis) or sham-clp (sham). thymic yields were assessed and the extent of apetosis determined by staining the cells with propidium iodide (a dna intercalating dye) for facs analysis or by examining the extracted dna electrophoretically for the endogenous endonuclease activity the results (n= /grp) indicate that at i h post-clp there was no marked changes in any of these parameters. however, at h the thymic cell yield from clp mice was significantly decreased (sham: . ! . x l vs clp: . i . x * cells; *,p< . ), the % of cells apoptotic by facs analysis increased from . i . % in sham to . ± . %* in clp, and the septic mouse genomic dna exhibited dna degradation these results indicate that clp, but not simple laparotomy, induces marked thymic apetosis, which may contribute to the lymphocytic immune deficiency seen in these mice the purpose of this retrospective study was to evaluate effectiveness of irrigation to treat septic knee joints from longterm results. from to patients with septic knee joints have been treated. treatment in acute cases started with asp#at[on of the effusion to evaluate for cultures. without awaiting the result treatment was continued with immediate joint irrigation under arthroscopic control. three redon tubes ( ch ) were introduced for continuous irrigation and for intermittent distention of the joint cavity. in case of chronic joint infection additionally all foreign and synthetic material was removed. systemic antibiotics were given. patients could be re -examined with a mean follow-up of years. re-examination showed that immediate arthroscopic lavage started at the onset of septic sings had best results (less signs of osteoarthr[tis, less synovitis, less pain while loading and less range of motion loss ). patients ( %) out of patients with s tre_=.tsd acute se.~tic knee joint had excellent functional recovery, whereas all patients with chronic septic knee joints showed poor results. additionally, in of these patients with chronic septic knee joint after irrigation a further procedure was necessary due to recurrent septic knee joint. the concept that bacteria can translocate across the intestinal mucosa under a variety of circumstances is well established. however, due to the inherent limitations of in vivo studies, the cellular mechanisms underlying the process of bacterial translocation (bt) across the epithelial barrier are poorly understood. this is especially true in those circumstances in which there is no merphologic evidence of mucosal injury. consequently, we have utilized an in vitro cell culture model system to investigate the cellular events involved in the translocation process. in this model system, a polarized monolayer of intestinal cells (caco- cell line) is grown on a micron filter in a two compartment system. after tight junction integrity is established, bacteria are placed in the apical surface chamber and bt across the caco- monolayer is measured by culturing the basal chamber. the results of our studies utilizing the caco- system indicates that; l) several strains of non-pathogenic bacteria will translocate across the caco- monolayer in a time-dependent and dose-dependent fashion. however, the incidence and magnitude of bt are highest for those strains of bacteria (gram-negative enterics) that are most commonly cultured in vivo. ) caco- cells are actively involved in the transcellular passage of bacteria across the caco- monolayer, since inhibition of caco- microtubule or microfilament function decreases the magnitude of st. ) lectin but not integrin receptors are involved in bacterial translocation of e. col~ across the caco- cell monolayer. ) caco- cells have the ability to ingest and kill certain strains of bacteria. the mechanisms involved in caco- bactericidal activity appear similar to that of pmns to the extent that both are oxidant but not nitric oxide mediated. these in vitro studies suggest that caco- cells can function as "nonprofessional" phagocytes and that both bacteria and enterocytes are involved in the translecation phenomenon. bacterial translocation due to gut barrier dysfunction is considered to be a major cause of septic complications and multiple organ failure following trauma, burn injury, hypoxia, shock and shock-like states. the invasion of bacteria into the circulation from the gastrointestinal tract or even from other sources, however, should not necessarily result in systemic infection or organ cohinisation, as long as the humoral and cellular defense mechanisms are not impaired. thus, a reduced res clearance capacity and hepatic clearance function of bacteria and toxins can be observed under the same conditions which enable bacterial translocation from the gut. in order to evaluate the influence of circulatory, metabolic and humorul disorders on the elimination of bacteria out of the blood circulation, a series of experiments were performed in anesthetized and ventilated rabbits which received defined numbers ( . x colony-furming units) of escherichia coli as a bolus injection. in unaffected control animals the intravenously injected bacteria are eliminated about . % within the first minutes and are totaiy cleared within minutes. % offue total cfu counted in the cultures of the organ homogenates were found in liver and spleen, whereas only very low numbers could be detected in the lungs and kidneys. systemic injury of the animals by hemorrhagic shock, endotoxinemia, hypoxia, coagulation disorder, systemic vasoconstriction by norepinephrine and other types of injury reduced the elimination rate of bacteria and changed the pattern and degree of their dissemination and tissue distribution. the bacterial clearance was delayed mostly in rabbits subjected to hypoxemic hypoxia in which about cfu of viable e.eoli per ml blood could still be counted hours following their injection. the number of viable bacteria was some ten powers higher in organs of hypoxic rabbits in comparison to control ardmais, and an excessive colonisation of the lungs and kidneys with % respectively % of the total cfu of the cultared organ homoganates was observed. unilateral iscbemia of the kidney prior to the intravenous injection of e.coli only moderately delayed the bacterial clearance, bowever, caused an intense eohinisation of the affected reperfused organ. in contrast to this, inhalation injury did not promote the accumulation of bacteria in the lungs. conclusion: shock, systemic and local affections reduce the clearance of bacteria from the blood circulation and enable their dissemination and accumulation in vital organs. the degree of this reduction and the organ pattern of the bacterial distribution varies with the type of injury. thus, these factors seem to be essentially involved whether or not bacterial translocation and multiple organ failure will follow the invasion of bacteria into the circulation as in the ease of gut barrier dysfunction. movement of enteric baaterla from gut to extralumeaal sites (bacterial tra~sloeation) m~y play a role ~. nraltipl~ orga~ failure. traumatic stress (shock, hffectiort, and im~lammation) and severe illness are common alateeedents. tnt~st~aal lleus is e common proximme causal factor. we have exanlined the hypothesis that bacterial ttanslecation from the gut in expe~me~tal paaerestitis is due to bacterial overgrowth as a cuas~ucnee of a deere~ae in intestinal transit. ne~rotit_.~g pancreatitls fbliowlng bile duct iigation in the opossum is associated with colonization of the pa,se ~re, aa by gut derived organisms or salmonella of biljary origin in infected animals (previously reported). to ti~rther define the mechanism of transloemdon in panereati* inflammation, pancteatitis was induced hy iigatlon of t~e lower bile duet distal to the pancreatic duets m the rat. intestinal transit, enteric bacteriology, and tromsloeatien of bacteria to mesanterie lymph nodes, blood stream and splanelmie organs wen deletmhaed at (n~ ), g (n ~ ), and (n~ ) hours with the fallowing results: ly~testinai,..transfi". geometric mean of fluorescent marker - % at hour~ with return to % of gut leugth (similar to ~m) at hour~. bacterial overgrowt_hff -increase in total bsctetia ~ad gram negative rod.~ at ,; hours with return to sham control at hours ( log cfu/g veraus log cfu/g ia ileum). translocation to mesenteric nodes - , , and percent at , , and fi hours compared to b in sham controls (n=l of ). conclusion -bacterial translocation following panetoatieobiliary duct ljgation induced panereatitls ha the rat is tighlly linked to intestinal trausit and bacterial overgrowth within the gut lumen. speclrjlation -the ilens in in/~arm~ation may be related to activation of eytokiaes and mediated by nitric oxide. preliminary evidence for this notion will be discussed. in a series of studies we investigated: a) the time course of bacterial translocation (bt), b) the kinetics of lps and cytokine appearance (tnf, il- , soluble tnf receptor [stnf-r] ) in the circulation, and c) the role of lps and/or tnf with regard to haemorrhagic shock (hs) related pathophysiologie alterations and mortality in baboons and/or rats. method: baboons were subjected to femur fracture, soft tissue trauma (acute experiment), and hs ( mmhg mean arterial pressure: map for - h terminated at an accumulated oxygen debt of - ml/kg followed by resuscitation). a chronic model of hs was set up by administration of zymosan activated plasma (zap) before and after hs but without trauma. hs was induced in rats by bleeding the animals to map of - mmhg - rain followed by resuscitation. results and conclusion: in rats, lps increased in the systemic circulation, plasma tnf levels were found to be significantly elevated at min and were still markedly increased at rain postshock. plasma tnf, il- , and stnf-r levels increased already during the shock period in baboons, while tnf was not detectable. our data suggest that haemorrhagic shock may lead to early bt in the intestinal wall (at min following resuscitation in rats subjected to hs for min, similarly at h after the end of oxygen debt period in baboons ) and transient access of gut-derived lps into the circulation (levels became significant at min, while in baboons higher levels up to pg/ml were found at the end of shock and h after reinfusion, partially accompanied by bacteremia). in addition, since the treatment of rats with anti lps measures or anti tnf therapy significantly improved the -hour survival rate it can be assumed that endogenous lps and lps-induced mediator(s), in particular tnf, may lead to organ injury and mortality following haemorrhagic shock. alteration of the mesenteric blood flow and the consequent ischemia / reperfusion injury to the intestine appear to be one of the earliest events in the systemic inflammatory response following severe thermal injuries. the causative relationship between the subsequent disruption of the intestinal integrity and the potentiation of the translocation of indigenous bacteria and/or endotoxins to remote body organs and the systemic circulation has been deeumented in several studies. among other effects, endotoxemia solely or acting synergistically with thermal injuries has been shown to promote bacterial translocation. as these sequences continue without adequate intervention, multiple organ failure and eventually death may become inevitable. hence, the crucial need of treatment modalities with the capacity of modulating the intestinal blood flow and preventing the manifestations of these pathological incidents. although the underlying mechanisms of this process have not yet been fully elucidated, there is accumulating evidence that various interacting vasomediators are involved. the actions of these mediators can probably be modulated by either nonspecific or selective agents. among the nonspecific agents, the composition, volume and timing of the resuscitation fluids appear to play an important role in this process. nitropmsside, a nonspecific vasodilator, has been shown to prevent the decrease of the postbum mesentefic blood flow when selectively infused in the mesenteric artery. the nonspecificity of various vasodialators with their possible undesirable systemic effects emphasizes the importance of the identification and modulation of selective vasomniiators. thromboxane a (txa ) and angiotensin ii (a-ii) appear to be the primary mediators of the postburn vasoconstriction. both mediators were found to be elevated following thermal injuries. in a previous study, pretreatment with oky- , a thromboxane synthetese inhibitor was found to attenuate the postbarn mesenteric vasoconstriction. in a bum/sepsis porcine model the efficacy of dup , an a- receptor antagonist as a posthum treatment modality was evaluated. treatment with dup prevented the early posthum and the late posteodotoxin elevation in the mesenteric vascular resistance and subsequently abrogated the fall in the mesenteric blood flow. the incidence of burn & endotoxin induced bacterial translocation was significantly reduced by dup from % to % (p< . , fisher's exact test). the indigenous flora of the gastrointestinal tract exerts a potent influence on the developmental maturation of normal systemic immunologic responsiveness. moreover, both oral and intraportal administration of experimental antigen is associated with a systemic state of immunologic hyporesponsiveness, known as oral tolerance. since trauma and critical illness are associated with changes in the flora of the gut and with altered systemic immune reactivity, we have hypothesized that the interactions of an altered gut flora with immune tissues in the gut and liver play a role in the pathogenesis of the immunologic derangements of critical illness. prolonged feeding of two clinically relevant killed organisms-pseudomonas and candida-to a rat results in significant impairment of cutaneous delayed hypersensitivity (dh) reactivity. conversely, measures directed against gram negative bacterial overgrowth in experimental peritonitis result in partial restoration of impaired dh reactivity. to ascertain the role of the liver in the pathogenesis of these alterations, we studied the differential immunologic sequelae of portal versus systemic (ivc) infusion of killed bacteria. experimental infusion of live or killed gram negative organisms into the portal vein produces dh suppression in rive, and profound suppression of mitogen-driven lymphocyte proliferation in vitro; systemic administration of the same organism has no effect on these phenomena. suppression is tgf -dependent, and mediated by a soluble factor released by fixed tissue macrophages of the lung and spleen. the suppressive influence appears to be mediated at the level of interactions between il- and its high affinity receptor. release of this factor can be induced by a second circulating factor present in the plasma of portally-, but not systemically-infused animals two hours after bacterial administration. these studies suggest that the release of inducible immunoregulatory factors from the liver, and possibly from the gut, may play a role in the pathogenesis of the profound derangements of systemic immune homeostasis that accompany trauma and critical illness. acad.hospital st. radboud,postbus , lib nijmegen introduction. the central question being tested in this study was whether liposome encapsulated dichloromethylene-diphosphonate (ci mdp) mediated elimination of liver and splenic maorophages would influence zymosan induced systemic toxicity (st) and bacterial lranslocation (bt). materia|s and methods. male swiss (icr) mice were used weighing - g elimination of liver and spleen macrophages was accomplished by intravenous injection of / suspension of ci mdp-liposome suspension. control mice received an i.v. injection with pt phosphate-buffered saline (pbs) . two days later all mice were challenged with an i.p. injection of zymosan suspended in paraffin (z) at a dosage of either mg/g, . mg/g or . mg/g body weight (n= in each group), signs of st and bacterial translocation bt were measured hours later the st was assessed by blindly grading the degree of lethargy, conjunctivitis, diarrhea, and ruffled fur of each mouse on a four point scale. bt to the mesenteric lymph nodes (mln) and systemic organs (liver, spleen, lung and blood) was tested by culturing on blood and macconkey's agar at the time of sacrifice sections of the distal ileum were taken for histology. an additional two control groups (n= in each group) were tested to verify that neither paraffin nor pbs or ci mdpqiposome suspension alone induced bt or st. furthermore survival over a -day period was assessed in a control and macrophage-depleted group with a dose of d mg/g z. results. neither the paraffin nor ci mdp-tiposome suspension induced bt or st the incidence of bacterial translocation to the mln was similar between macrophage depleted and control groups. however, macrophage depletion was associated with a significantly higher incidence of systemic spread of bacteria. data expressed as positive tissues/total tissues tested: / vs. / at . mg/g zymosan (p~o. ); vs. at mg/g zymosan (p~q ); / vs. / st . mg/g zymosan (p~o.o ).the magnitude of bt however did not show any differences. although systemic bt was greater in the macrophage depleted groups, the systemic toxic response was significantly less at doses of . mg/g zymosan ( . -+ . vs. . -+ , p~o. ) and . mg/g zymosan ( . -+ . vs. . -+ . , p<_.o. ) . the day mortality after . mg/g zymosan was % in the control group and % in the macrophage depleted group (p=o. ). histology did not show any differences between the control and macrophage depleted groups. conclusion. the lethal and toxic effects of zymosan in this model appear to be more related to the excessive activation of macrophages than to the systemic spread of bacteria. bacterial translocation (bt) in hemorrhagic shock was studied using a porcine model. in this study three groups were randomized: one control (n= ) and two experimental (n= each). a portal vein catheter was placed and remained in situ hrs. a femoral artery and vein catheter were in place hrs. the arterial eaanula was used for monitoring mean arterial pressure (map) in all animals and to bleed the experimental animals and the venous cannula to repelfuse with ringer's lactate (rl) or autologous blood (ab). baseline samples and values were taken in this period. control animals were observed for a sham shock period of . hrs., given more hours of anesthesia, and studied for further hrs. % of the estimated blood volume was withdrawn from each experimental animal over min. these animals were kept in shock for . hrs. at the end of the shock one group was perfused with rl and the other with ab. two hours later they were extubated and further studied for hrs. samples from portal blood for cultures and measurement of leukotriene b (ltb ), prostaglandin e (pge ), and nitric oxide (no) metabolites were taken from all animals at intervals beyond baseline up to hrs. after hrs. under general anesthesia a second laparotomy was performed and samples for culture from mesenteric lymph nodes (min), liver and spleen were taken; as well as samples for histologic study with light and scanning electron microscopy were taken from jejunum, ileum, and colon. animals were then euthanized. results: significant shock was induced as indicated by map and arterial blood gases. significant bt to min was observed in all groups. no significant bt was observed in cultures from liver and spleen in any of the groups. increased values for ltb , pge and no metabolites were found during the period of shock. these results suggest that the isehemic phenomenon triggers a significant inflammatory response, and that bt to min may be an epiphenomenon without apparent significant influence on the inflammatory response. objective: to study the potential effects and mechanisms of action of systemic administration of monoclonal antibodies anti-endotoxin (ha- a) in a animal model of gut-origin sepsis. materials and methods: exoeriment a. balb/c mice were transfused with allogeneic blood (from c hb-iej mice). five days post-transfusion the animals were gavaged with lxl viable escherichia coil and randomized into groups (n= /group) to receive a sham burn (sb group) or a % thermal injury immediately followed by the systemic administration, via a tail vein, of monoclonal antibodies ( mg/kg) (ha- a group) or a % burn injury and administration of equal volume of sterile saline (c group). all groups were resuscitated by intraperitoneal injection of . ml of saline. the animal survival rate was observed for days post-burn. experiment b, transfusion and burn procedures were identical to experiment a but the mice (n= /group) were gavaged with viable e.coli labeled with mmndium oxine. four hours after burn the mesenteric lymph nodes (mln), liver, lungs and blood were harvested to determine plasma endotoxin levels and the magnitude of transtocation of labeled bacteria as measured by the residual radioactivity (dpm) in the organs. circulating endotoxin levels were determined by limulus colorimetric assay. diamine xidae(dao) is an enzyme existing in the mucosa of small intestines, but its activity is low in the plasma. it is evoked in the blood with the intravenous injection of much heparin. it is well known that da declines under the chronic mueosal injury when the small intestines are cut off or the mucosae become atrophied. aim of this paper is to confirm that da goes up to the measureable level by the intravenous injection of a small amounts of low molecular heparin(lmh objectives: the aims of this study is to investigate the inhibitor" effect of the prolease inhibitor, urinastatin, on endotoxin induced bacterial transleeation in mice. materials and methods:lcr mice were divided in six groups as the fotlows, group i: control mice receiving intraperitoneal injections (ip) of saline . and hr prior to sacrifice, group ih treated mice receiving ip of utinastatin . hr and endotoxin ( mg/kg) hr prior to sacrifice,group ilk sham reated mice receiving ip of saline . hr and endotoxin ( mg/kg) hr prior to sacrifice,group iv: saline control mice receiving ip twice during rain intervals,group v: mice received ip of utinasmtin, and min later they were received ip of endotoxin ( mg/kg), group vi: mice received ip of saline,and min later they received ip of endotoxin ( mg/kg). in group l,ii and ill ,the mice were killed by cervical dislocation.using stetile techniques,a middle-line incision was made and the mesenteric lymph nodes were harvested in order to culture on selective agars for quantitation of bacterial trauslocation. in group iv, v and vi, survival was recorded for days. unnastatin pretreatment could rednce mortality significantly. first surgey, shiga university of medical science, seta ,ohtsu - ,japan increased gut permeability correlates with inflammatory response in multiple trauma aptients. pape, h.-c. dwenger, a. grotz, m. regel, g. purpose: disturbances of intestinal permeability have been advocated as a pathogenetic factor of posttranmatic multisystem organ failure (mof). a close relationship with impairment of the stationary reticulocndothelial system (res) and a systemic inflammatory response (sir) was discussed. these tactors were investigated prospectively in patients with multiple trauma showing posttraumatie complications (multiple organ failure, mof). methods: polytranmatized patients were studied prospectively. according to a mof-score (goris) those with posttrattmatic complications were selected (> points at days), others were excluded. every second day gut permeability according to the ratio of urine concentrations of lactulose and mannitol (l/m) was evaluated (enteral application). at parallel time points res clearance capacity (k-value, invasion constant, normal range . - . mind) was studied after i.v. injection of mbq rotehuman albumin. liver perfusion was calculated from these data, total serum bilirubin (/zmol/l) was documented. serum elastase (#g/l) levels were determined enzymatieally. results . + + liver perfusion did not ehangu, bilirubin showed progressive worsening indicating mof. a positive correlation was present between l/m and k (r= . ) and between l/m and ela (r= . ). conclusions: there is a positive correlation between the time pattern of intestinal permeability dysfunction and res hyperactivity as well as between intestinal permeability and the systemic intlammatory response (elastase levels). the results speak in favor of an interaction between intestinal and extraintestinal inflammatory systems, which in eombiuation are likely to be responsible for post~anmafic complications. endotoxemia, il- release and consecutive acute phase reaction are observed as a host response to surgical trauma. as well vasodilative prostaglandins (pg) and thromboxane (tx) are released after abdominal meaenteric traction (mt). the following hypotension and acute hypoxeraja are duo to prostacyelin (pgiz) arm can be avoided by perioperative cyclooxygenase inhibition. we therefore focused on the effect of pg and tx liberated following mt on the induction of endotoxemia. methods: in a prospective, randomized double-blinded protocol patients, who were scheduled for major abdominal surgery (pancreatic or infrarenal abdominal surgery), were studied. ibuprofen ( mg i.v.) or a placebo equivalent was administered minutes before skin incision. mt was applied in a uniform fashion. baseline values were obtained before induction of anesthesia. further measurements followed before the incision of the peri[onenm (tl) and , , , min, . the plasma concentrations (,pc) of -keto-pgft,, txb: and-ki- -pgf ~ (stable metabolites of pgi , txa and pge~) were determined by ria. we measured endotoxin pc by limulus-amoebocyte-lysate test and il- levels by elisa. data are given as mean+sem (* p< . placebo vs. [ibuprofen] ). results: endotoxin plasma levels increased before incision of the peritoneum tl both in the ibuprofen pretreated and in the placebo group. peak pc were observed minutes after mt. endotoxin pc were significantly higher in the ibuprufen treated group (t . + . e[ . + . ] eu/ml). il- pc demonstrated an increase continuously from t to t (t + [ + ] ng/l) in both groups. after intentional abdominal mesenteric traction we observed a marked increase of -keto-pgf~,, pc up to h after mt in untreated patients with a peak of *[ ] ng/ at tl. also txb: and kh pge pc showed a considerabe increase up to h after mt in the placebo group. in ibuprofen pretreated patients the pg and tx pc remained within the normal range. discussion: our data clearly indicate a significant endotoxemia and il- release following major surgical trauma which is not initiated either by prostaglandin or thromboxane release. moreover endotoxemia is accentuated by ibuprofen pretreatment. therefore we hypothesize that in major abdominal surgery prostacyclin release-after mt may play a crucial physiological role in maintaining splanclmic microcirculation and thus preserving gut mucosal barrier function. objectives of the study it has been shown recently that parenteral and certain euteral diets promote the translocation of gut flora to the mesenteric lymph nodes (mln) and systemic organs, a process termed bacterial translocation (bt). in chow fed rats bt usually does not occur without further promoting factors. the goals of the present study were to determine whether the provision of defined amounts of standard lab chow during iv-tpn administration wotfld redane the incidence of bt, materials und methods male spf spragnle-dawley rats were divided into groups. group received standard laboratory chow feeding ad lib. in group a central venous catheter was placed, ligated and secured by a spring coil tether attached to a swivel allowing free movement in the housing cage and chow was fed ad lib. in group % of the calculated daily required calory intake (drci) ( /kcal/kg) was given by iv-tpn ( % glucose, , % amino acids) and % by limited chow administration. groups and received % and % of the drci by i.v. tpn and % and % respectively by chow feeding. group received iv-tpn only. after days the rats were sacrificed and the mln, liver, spleen and cecum removed aseptically, homogenized and cultured for bt samples of distal ileum were taken for light microscopy. the group with the least amount of chow shown to be protective against bt received the amount of non-fermentable fiber of that chow regimen during iv-tpn feeding and bt was studied. , + , , - , , / + ~ " , -+ , , -+ ~ - , / +~ + _+ , + , , - , -+ + , ~ , , -+ ~ conclusions: the administration of % of drci by chow feeding during iv-tpn significantly reduced the incidence of bt and maintained gut barrier function. the addition of the respective amount of dietary fiber of this group did not prevent iv-tpn-indueed bt. dr. med. m naruhn., dep. of general surgery, eberhard-karls-university, hoppe-seyler-str. previous experimental studies have suggested that a disturbed ecology of the enteric bacterial population might contribute to the development of bacterial translocation from the gut in acute liver failure (alf). in the present study, the effect of oral administration of lactobacillus reuteri r lc and oat fiber on bacterial overgrowth and translocation was investigated in rats with acute liver failure induced by subtotal ( %) liver resection. the oatmeal soup base was anaerobically inoculated with lactobacillae and fermented for hours, after which the animals were fed with either fermented or unfermented oatmeal or saline daily for days prior to the operation. bacterial translocation to mesenteric lymph nodes (mln) and the systemic circulation was determined, as well as the intestinal bacterial flora and enterocyte protein content. the incidence of bacterial translocstion to the systemic circulation was nit in rats subjected to sham operation and saline treatment and % in animals subjected to % bepatectomy and lreatment with fermented oatmeal, while - % and - %, respectively, in rats subjected to hepatectomy and treatment with either saline or unfermented oatmeal. only one rat with fermented oatmeal demonstrated bacterial growth in mln (p < . vs hepatectomy and treatment with saline or unfermented oatmeal). the enterocyte protein content significantly decreased (p < . ) in salinetreated animals following % hepatectomy, while there was no significant difference between bepatectomized animals with oral administration of fermented or unfermented oatmeal. the number of anaerobic bacteria, gram-negative anaerobes and lactobacillus significantly decreased and the number of e.cnli increased in the distal small intestine and colon in hepatectomized animals with enteral saline or unfermented oatmeal as compared with animals subjected to sham operation or bepatectomy with fermented oatmeal. our results thus show that the occurrence of bacterial translocatiou from the gut in % hepatectomy-induced alf could be prevented by enteral administration of fermented oatmeal, maybe partly due to a positive effect on the enteric bacterial ecology. _+ " +_ " . " data=mean_+sd, * stats anova p< . vs control. l+air and lap groups, both exposed to exogenous i.ps shnwm:t m significant increase (p<. ) in lps gut translocation compared to control and l+co . this correlated with a significant increase in peritoneal inflammatory responses (o -,tnf) above that of the control and l+co groups, while mac- and cr opsonized phagocytosis were significantly impaired. the absence of significant differences between l+air and lap groups indicates that lps rather than wound factors is the principle mediator. thus, lps plays a significant role in regulating peritoneal responses in the early post-operative period dept of surgery, rcsi, beaumont hospital, dublin , ireland brlke e, berger d, staneseu a, buttenschsn k, vasilescu c, seidelmann m, beger hg in patients undergoing a colonoscopy, endotoxin, endotoxin neutralizing capacity (enc), thromboxane b o (stabile metabolite of tbmomboxane ~), -keto-prostaglansin, leueotriene c , interleukin and the incidence of bacteremia were determined before and then every five minutes during the procedure. twenty-one of patients showed a significant increase of endotoxin plasma levels during colonoscopy (p= . ), whereas only one patient had a positive blood culture with bacteria obviously derived from the gastro-intestinal tract. the enc decreased significantly five minutes after the beginning of eolonoscopy and was diminished further thereafter. the baseline values were reached after hours. ~hromboxane b o levels also increased after five min. from to pgyml peaking at min. with pg/ml. -keto-prostaglandin,leucotriene c , ii- and crp remained unchanged. a control group of i volunteers who were not subjected to endoscopy, were prepared for eolonoscopy by orthograde lavage. the blood sampling procedure remained identical. no differences were seen in all described parameters for the controls. these data show that the gut barrier can be compromised by mininml invasive procedures, at least, concerning bacterial products. living bacteria, on the contrary, do not pass the gastro-intestinal wall. endotoxin, when determined by enc, is more sensitive than the conventional limulus-amebocyte-lysate test. no acute-phase reaction was induceri by the observed endotoxin translocation. it can be speculated from the dramatically enhanced thromboxane b levels, together with its hemodynamie effects, that the thromboxane release may support translocation of bacterial products. sepsis is common after hemorrhagic shock. this study aims to demonstrate that hemorrhagic shock alone can promote translocation of gut bacteria from intestinal tract to its regional nodes and subsequently to blood. one hundred twenty mice, divided into groups were subjected to , and minutes of %, % and % of hemorrhagic shock. on the specified time, blood cultures were taken and mice were sacrificed. the intestinal tract were histologically examined for any changes which allows translocation and its regional nodes were quantitatively cultured for translocated bacteria. there was a direct relationship between duration and degree of hemorrhagic shock and incidence of translocation (p . ). there was a high incidence of gut bacterial translocation to the mesenteric and mesocolic nodes in all degrees of shock (p . ). bacterial growth in the regional intestinal nodes increased and blood cultures were positive in direct proportion to degree and duration of shock. histologic evaluation of segments of git showed submucosal congestion to allow bacteria normally contained within the gut to cause systemic infections. translocation of gut bacteria in untreated hemorrhagic shock is clearly shown in this study on animal models. in this study, guotobiotic rats with known species of bacteria were subjected to total parenteral nutrition(tpn) and subsequent hemorrhagic shock. the purpose of the study was to observe the impairment of gut barrier function following tpn and hemorrhagic shock and to study the mechanism of enterogenic infection induced by tpn and shock.the results were as follows: .long term( - days) tpn induced impairment of gut barrier function, evidenced by atrophy of intestinal mucosa, significant decrease in diamine oxidase activity of intestinal mucosa and blood, and marked microecologic imbalance of the intestinal mucosa flora with dorminant growth of aerobes and relative decrease in anaerobes. the degree of mucosal damage were proportional to the duration of tpn. .in tpn+shock groups, failure of gut barrier function was found. ri,~ere were further damage in the mucosa, with a large number of gramnegative organisms invading mucosa and submucosa and a significant decrease in dao activity as compared with each relative tpn groups. these changes were significantly correlated with enhanced bacterial translocation, elevation of lps and mda levels in the plasma. these findings suggested that long term standard tpn impaired the gut barrier function, precipitating posttraumatic gut barrier failure. thus infec. fion following shock might be oi'iginated from the gut and it was obviously related to the impaired gut defence resulted from antecedent tpn. the determination of plasma dao activity might provide a valuable tool for the ear. ly diagnosis of gut injut;y during tpn and after trauma. in our earlier studies we have investigated the dynamics of granuloayte infiltration of the ischemic/reperfused s~all intestine (g. illy~s, j. hamar int. j. exp. athol. . . .) . there was a increasing infiltration of the mucosa c m~nating at the d to th hours of reperfusion. in the present series we have studied sc~e of the conseqn/ences and the possible role of this cellular reaction. ~in isehemia was followed by a hour reperfusion in the anesthetized rat. arterial ~/ad mesenteric venous blood samples were collected at m_in, i, ~ , and hours of reperfusion. elastase and lactate concentrations were determined and hamoculture was carried out from the blood samples, and tissue pieces from the heart, lung, liver and kidney were collected for histological analyses at the above mentioned times of reperfusion. all blood samples were free of cell bacteria. staphylococci appeared only occasionally at the th hour in the arterial blood .and at the d and th hours in the venous blood, respectively. arterial and venous elastase activities were high throughout the reperfusion, venous concentrations being higher at all times. lactate concentrations of the arterial and mesenteric venous blood samples increased during shock. ~ranuloeyte infiltration of all organs studied appeared during the d hour and it increased at later times of reperfusion. it is concluded that heavy infiltration of the intestinal mucosa can block bacterial translocation in most of the cases during reperfusion. granulocytes activated either by the reperfused area or by the released cytokines infiltrate other organs contributing by this way to the mesenteric shock s!rndrc~e. intestinal motility plays an important role for maintaining nutrient transport and absorption and for balancing the enteric bacterial population. disturbances of intestinal motility may be one of the earliest notable changes in intestinal function. in the present study, we aimed at determining early alterations in intestinal transit time following ischemia-reperfusion injury induced by occlusion of the superior mesenteric artery in the rat. intestinal ischemia was induced for and minutes by applying a microvascular clip on the superior mesenteric artery followed by reperfusion , and hours after clip removal. intestinal transit time was measured by the propulsion of a radiolabelled solution (cr ). light microscopy was performed on intestinal samples. macroscopical pathological changes were not observed. however, microscopically, mucosal epithelial oedema, degeneration or slight ulceration occurred in rats hours after reperfusion in ischemia- rain group and and hours after reperfusion in the ischemia- rain group. delayed small intestinal transit time was seen from hours and on after intestinal ischemia for both and rain ischemia followed by reperfusion. the distribution of radioactivity demonstrated that most radioactivity was accumulated in the first two segments following intestinal ischemia and reperfusion, significantly differing from what was seen in animals subjected to sham operation (p < . ). the distribution of radioactivity in segments and in the group with repeffusion hours after intestinal iscbemia for rain was significantly higher than that noted in the group with repeffusion hours after intestinal ischemia for min (p < . ). q'he results indicate that a delayed intestinal transit time may be one of the earliest pathophysiological alterations noted, associated with duration of gut ischemia, and a potential factor for the development of bacterial overgrowth, gut barrier failure and bacterial translocation, in hypovolemic conditions. bacterial infections still constitute a major cause of morbidity and mortality in patients with acute liver failure. the present study aimed at evaluating the effect of ethylhydroxyethyl cellulose (ehec) on bacterial translocation following surgically induced acute liver failure. acute liver failure was induced by subtotal hepatectomy ( %) in the rat. water-soluble ehec was administered orally and hours prior to hepatectomy. the incidence of bacterial translocation from the gut to mesenteric lymph nodes (mlns) and systemic and portal circulation was evaluated and the number of isolated bacteria from these samples and from intestinal content were determined. intestinal transit time, bacterial adherence onto the intestinal surface, intestinal mucosal mass, bacterial growth and dna synthesis, bacterial surface characteristics (hydrobiology: hydrophobicity, hydrophilicity and neutrality; surface charges: positive, negative and neutral) were also determined. hepatectomized animals showed a - % translocation rate to mlns or blood and hours after operation, while only - % of rats subjected to sham operation or animals with % hepatectomy and pre-treatment with ehec (p < . ). bacterial overgrowth, increased bacterial adherence onto the intestinal surface as well as decreased intestinal mucosal masses were observed in animals with subtotal liver resection alone, alterations that were prevented by enteral ehec treatment. a delay in intestinal -hour transit time occurred in both groups with subtotal liver resection, with or without enteral ehec. ehec inhibited bacterial growth and dna synthesis, and altered bacterial surface properties following hour incubation with bacteria. in conclusion, the findings in the present study imply that ehec alters enterobacterial capacities for metabolism, proliferation and invasion by effects on e.g. bacterial surface characteristics. furthermore, ehec seems to possess a trophic action on the intestine, rather than exerting its effect by enhancing intestinal motility. department of surgery, lund university hospital, s- lund, sweden disturbances in intracellular calcium signalling can potentially result in impairments of cellular responses vital to the functional integrity of both immune and non-immune cells, and thus contribute to a decrease in host resistance against infection and to multiple organ system failure during sepsis. studies in our laboratory have focused on assessments of intracellular ca ÷ regulation and ca~+-depended cellular responses in the liver, skeletal muscle and splenic tlymphocytes harvested from rats subjected to gram-negative intraabdominal sepsis. cytosolic ca + concentration, [ca *]i, and ca + fluxes were measured by the use of fluorescent ca + chelating dyes (fura- or indo- ) and ca respectively. to assess sepsis-related changes in ca + dependent cellular responses, we measured the acute phase protein response in the liver, the regulation of protein and sugar metabolism in the skeletal muscle, and the proliferation response in the splenic tlymphocytes. altered ca + i signalling with sepsis was correlated with an exaggerated inappropriate acute phase protein response ( % ¢) in the liver, and a blunted insulin mediated sugar utilization ( % ) and increased proteolysis ( % ~) in the skeletal muscle. in t-lymphocytes, a decrease in mitogen induced elevation of [ca +]i by - % was correlated with a significant depression in their proliferative capacity. these studies clearly suggest that altered calcium signalling is correlated with disturbances in cellular responses in both immune and non-immune cells during sepsis. the altered cellular responses adversely effect the outcome of the septic injury. (supported by nih grant gm ). alfred ayala, ping wang and irshad h. chaudry. changes in macrophage capacity to respond to foreign pathogens are thought to be central to the developing immunosuppression associated with traumatic injury. in this respect, the suppression seen in m~ functions following hen (a common component of traumatic injury) may be mediated by the direct or indirect inhibition of their capacity to perceive external stimuli (e.g., opsonized & non-opsonized bacteria, and their cellular components, etc.} due to the breakdown of the receptormediated signal transduction system. results of a number of studies by our laboratory and others indicate that this inability to respond to external stimuli is in part due to the loss of cell surface receptors. decreases have been documented for not only la antigen, but also c b, fc, and tnf receptors following hem in mice. furthermore, studies which have examined second messenger generation in these cells indicate that m~ derived from the peritoneum and spleen exhibit a decreased capacity to mobilize ca + from intracellular stores. this protein kinase dependent process of [ca+ ] i mobilization appears to be linked to the inability to synthesize inositol triphosphate. of interest, the depression in ca + signal generation appears to be inversely related to presence of elevated levels of camp in m~ from hen mice. we have reported that m~ priming agents, such as ifn- (which exhibits salutary effects on m~ function following hem), appear to restore cell signal transductive capacity while reducing the levels of camp. nonetheless, the extent to which depressed receptor signal transduction in hem, is due to receptor loss~dysfunction or elevated antagonistic second messenger levels remains to be determined. conclusions: significant impairment of calcium signaling occurs at all time-points prior to and following pha stimulation in trauma patients. tcell activation failure can, in part, be explained by the inadequacy of this essential intracellular second messenger system. restoration of immunocompetence following trauma will have to address strategies to better assess and restore this vital step in the activation sequence leading to proliferation during the antigen recognition process. patrick a. bseuerle institute biochemistry, albert-ludwigs-university, hermann-herder-str. , d- freiburg, germany the active form of the transcriptional activator nf-~b is a heteredimer composed of a and kda polypeptide. in this form, nf-'<b can bind with high affinity to decameric sequence motifs (consensus: "-gggpunnf'ypycc- ") found in enhancers and promoters of many genes activated upon a wide variety of pathogenic conditions, including viral and bactedai infections, acute phase response, oxidative stress and uv and gamma irradation. clinically important target genes for nf-k:b encode inflammatory cytokines (il- b, tnf, [l- , il- , gm-csf etc), cell adhesion molecules (icam- , elam- , vcam- ), acute phase proteins and immunoregulatory ceil surface receptors. in most cell types, nf-~:b is sequestered in the cytoplasm and, therefore, unable to initiate transcription of these genes. the cytoplasmic form of nf-~:b contains one additionai subunit, referred to as h,;:b. i~b can reversibly suppress dna binding and nuclear uptake of nf-~b by virtue of its association with p . upon stimulation of cells, ikb is proteolytically destroyed, allowing nf-kb to enter the nucleus and activate genes upon binding to transcriptional enhancers. we have demonstrated that various antioxidative compounds inhibit the activation of nf-~b in response to many inducers. moreover, nf-~:b was shown to be activated upon treatment of cell cultures with p.m-amounts of hydrogen peroxide. these data suggested that nf-~b prinicipaliy is an oxidative stress-responsive transcnption factor. the notion is supported by numerous reports on the induction of oxidative stress by many nf-nb-inducing agents. nf-~b activition can likewise be suppressed by protease inhibitors. these drugs apparently inhibit a yet unidentified protease responsible for the inducible decay of inb. we propose to use nf-nb inhibifors as novel drugs with a very broad application under acute phases el inflammation, injury and infection. northern blot experiments revealed that expression of the recently discovered lipopolysaccharide binding protein (lbp), a / kd glycoprotein, in the liver rises substantially during the acute phase response. experiments with an in-vivo acute phase model using new-zealand-white rabbits and also in-vitro experiments employing stimulated hep-g cells showed that lbp transcripts could be induced to ford within hours after induction with cytokines. by using a newly established nonradioactive nuclear run-on technique we show that induction of lbp during the acute phase is transcriptionally regulated. furthermore we screened a human genomic library and were able to clone the lbp gone, containing the promoter . kb upstream. several liver-specific and "acute-phase-typical" potential binding sites were found fn the promoter region and reporter gone assays were set up. several caat-boxes, the il- responsive elements hstf-hsp . and h-apf- rs as well as the transcription factor hnf- and the glucocrticoid-responsive elements oct- -d and gcre were found, which correlates with the induction pattern of lbp mrna in hep-g cells by il- , il- and dexamethasone. pcr-based analysis of the exon-intron pattern of the lbp gene revealed similarities with the genes of two other lps binding proteins, namely bpi and cetp. further analysis of this novel acute phase protein, that also has an important role in endotoxin recognition and immunomodulation will help in understanding the complex acute phase mechanism and potentially lead the way to new therapeutic strategies. lps activation of nucle?/r fa-ctor:~b " (nf:~bj"in cd .transfected fi'broblasts does not appear to require tyrosine kinase activity d. t. golenbock, r. delude, r. savedra, s. vogel and m. j. fenton lipopolysaccharide (lps) is the major constituent of the outer leaflet of gram-negative bacteria. during the course of serious infection, shock may occur as a result of the interaction of lps with macrophage lps receptors. cd , a kda glycosyl phosphatidylinositol (gpi)-linked protein, functions as an lps receptor. a critical issue in lps activation concerns the mechanism by which cd , which has no transmernbrane domain, transduces a sig,nal after lps binding. evidence exists which suggests that cd may signal cells after lps binding by interacting with an lps signal transducer with tyrosine kinase (tk) activity. wild-type chinese hamster ovary fibroblasts (cho) normally do not respond to lps, but can be activated following transfection with cd (cho/cd ). stimulation of cho/cdi with as little as ng of lps/ml resulted in the release of h-arachidonic acid ( h- : ) into the culture supernatant. in addition to h- : release, we examined lps-imiuced activation (transl cation) of the transcription factor nf-~b. similar to lps-induced h- : release, these responses were observed only in cho cells lransfected with cd closely resembling the same response in the marine macrophage cell line raw . . maximum nf-~cb expression occurred at minutes. in contrast to lps-induced h- : release, dexamethasone, cycloheximide, and actinomycin d had no effect on activation of nf-r,.b in cho/cd , suggesting that nf-r,b activation begins early after lps binding to cd and does not require transcription or translation. we then examined cells for lps-induced tk activity by western blotting cellular ly~ates with anti-phcsphot-'rosin:~ anl',bodie~" although tk activity was seen in lps-stimulated raw cells and phorbol ester stimulated cho/cd , lps-induced tk activity in cho/cd was not observed. although the tk inhibitor herbimycin inhibited the release of h- : in cho/cd and raw cells, neither herbimycin nor genestein effectively blocked nf-r,b activation in either cell type. these results suggest that tk activity is involved in a portion of the signaling pathway that is distal to initial signal transduction. the absence of observable lps-induced phosphotyrosine residues in cho/cd cells as well as the failure of tk antagonists to inhibit lps-induced nf-~cb activation suggest that the proposed cd -related lps signal transducer in cho/cd is not a tymsine ldnase. dimished cardiac inotropic function and response to -adrenergic receptor ( -ar) stimulation are frequently seen in septic patients, these cardiac defects are also seen in animal models of entoxemia. to determine the characteristics of the decreased transmembrane signal associated with the decreased beta adrenergic response we measured the force and rate of contraction of atria harvested from sprague-dawley rats exposed to endotoxin ( : gm/kg). to stimulate various components of the transmembrane signal cascade of -ar was isoproterenol (i -ar), acetylcholine (m ach receptor), naf(gs and gi proteins), forskolin (adenylate cyclase), and calcium (intracellular contracttile signal) were used. to eliminate the transmembrane control of calcium and test the intrinsic contractile response, hypothermia ( °c) was used the results showed alterations in the inotropic function with no significant difference in chronotropic response. the inotropic reponse for the endotoxin exposed atria and controls is shown below these results show that there is a transmembrane signal defect both for the i~-ar signal and for ca +. these data indicate that the level of the defect appears to be at the g proteins. ischemia-reperfusion of the rat intestine produces an injmry both to the intestine and to distal organs, notably the lungs and liver. prior studies have shown that h of intestinal ischemia leads to a nemtrophil independent reperfusion injury of the gut. thus, rats rendered neutropenic by pl~l antiserum have been shown to express a severe local gut injury when subjected to ischemia and reperfusion. this gut injury is postulated to he mediated at least in part by the complement system. the soluble (s) cri receptor which binds to c b and cdb was given to rats at a dose of mg/kg by intravenous bolus, min before reperfusion of the ischemic gut. a control group was given pbs buffer. at h of rmperfmsion the animals were sacrificed. pbs treatment led to a significant activation of both classical and alternate complement pathways while scri inhibited both pathways (fall to zero of chbo ). intestinal mucosal injury score, assessed by histological grading was reduced by scri ( . ± . to . _+ . ,p< . ) . intestinal neutrophil sequestration estimated by assay of myeleperoxidase was also reduced ( . ± . to . ± . u/g). c was detected in the gut hy i~unohistochemistry. remote organ injury was modified that is lung permeability (ration of concentration of radiolabelled albumin in broncho-alveolar lavage fluid to that in blood) was reduced ( . ± . x i to . ± . x , p<o. ). however, neutrophil sequestration by the lungs was unaffected. this remote protection is thougth to be related to prevention of ic b deposition on imng andotheli~ which activates adherent neutrophils. these findings support the hypothesis of complement mediated local and remote injury. we postulate that complement fragments may be deposited either as a result of the ischemia induced loss of membrane bound complement regulatory proteins, such as decay accelerating factor or membrane cofactor protein, which allow complement fragments to accumulate on the endothelial cell surface. alternatively, increased expression of p-selectin on the endothelial cell surface may, by means of its complement binding domains, act as a lattice for complement deposition. indeed, p-selectin has been detected on the surface of endothelial cells ans platelet-neutrophil aggregates recovered from the intestine of these animals. ischemia ( hr) followed by reperfusion (dhr) of rat hind limbs resuits in local (muscle) injury as well as in remote (lung) injury, which is characterized by increased vascular permeability (leakage of j sl labeled albumin) and neutrophil accumulation (tissue content of myeloperoxidase, mpo). within minutes of reperfusion following ischemia, tumor necrosis factor-o~ (tnfc , interleukin-i ( l-i) and il- plasma levels increased significantly, reaching maximum levels after hours ofreperfusion. polyclonal antibodies to tnfet and l-i provided significant protection against muscle and lung injury. muscle and lung vascular permeability decreased in anti-tnfct treated rats by % and % respectively and mpo was reduced by % and %. antml- yielded a protection in muscle and lung vascular permeability of . °, and . % respectively whereas muscle mpo was reduced by . % and lung mpo by . °, . these results were confirmed by the use of soluble tnf~ receptor and il-i receptor antagonist (il-ira). when icam-i expression in vivo was examined using mabeled antmcam-i, constititive expression of icam- was evident only in lung but not in muscle. during reperfusion icam- expression increased by . %. treatment with anti-tnfcx or il-ira reduced icam-i upregulation by . °, and . % respectively. frozen sections of normal rat lung revealed no evidence of e-selectin expression, whereas lung sections obtained after ischemia and reperfusion immunhistochemically demonstrated expression of e-sdectin. lungs from rats pretreated with anti-tnfct were negative for e-selectin staining. our data indicate a role for cytokines in the upregulation of adhesion molecules in ischemia/reperfusion injury. adherence of neutrophils to the coronary endothelium is associated with significant myocardial injury following min of ischemia (mi) and . h of reperfusion (r). p-selectin is expressed by activated endothelial ceils and platelets within min and tethers polymorphonuclear leukocytes (pmns) to the endothelium. we examined the cardioprotective effects of a monoclonal antibody (mab) designated pb . to p-selectin in a feline model of mi+r. pb . ( mg/kg) administered rain post-occlusion ( min prior to reperfusion) significantly attenuated myocardial necrosis compared to a non-blocking mab (nbp . ) for p-selectin ( + vs + % of area-at-risk, p< . ). endothelial dependent relaxation to acetylcholine was also significantly preserved in ischemic-reperfused coronary arteries isolated from cats treated with pb . compared to nbp . ( + vs + , p< . ). furthermore, pmn adherence to ischemic-reperfused coronary endothelium was significantly attenuated in pb . treated cats ( + vs + pmns/mm z, p< . ). also, normal coronary endothelium activated with thrombin ( u/mt) had increased pmn adherence under conditions of shear stress, an effect which was significantly (p< . ) blocked by pb . , but not by nbp . . furthermore, p-selectin is markedly upregulated - min post-reperfusion in coronary arterial and venous endothelinm. similar results were obtained in a rat model of mesenteric ischemia/reperfusion, including upregulation of p-selectin on mesenteric vascular endothelium. these results demonstrate that tethering of neutrophils to endethelium by p-selectin is an important early consequence of reperfusien injury, and a specific monoclonal antibody to p-selectin exerts significant endothelial preservation and cardioprotection in ischemia and reperfusion states. as recent interest has increased in the role of extracellular matrix proteins in inflammation, we examined the role and relationship of laminin and fibronectin to the processes of cell infiltration in a rat model of heart isografts. changes occurring in this system are on a nonimmunological basis and may be an effect of the initial surgical manipulation and the warm and cold ischemic times of transplantation. lewis (lew) donor hearts were transplanted into lew recipients, naive lew acted as naive controls (nc). grafts were harvested , , , , , , , and h after transplantation (n= /time point) . snap frozen sections of organs were stained for cd- (w / ), cd- (ox ), t-lymphecytes (tl) (ox- ), macrophages (ed , ed ), neutrophils (pmn) (mom), icam-i (iap ), laminin and fibrinogen. results were evaluated visually by counting cells/field of view (cf) for w / , ox , ox , ed , ed and mom, staining for icam , lain and fib was assessed visually using a scale (ve= - ). as early as h after transplantation, fibrinogen and laminin expression increased in i, peaking h after transplantation (ve= . ; nc: ve=i. ) . at and h in i, on both vessels and interstitial cells laminin and fibrinogen expression had declined to baseline (ve=i. ) but rose again at h, peaking at h (ve= ) and remaining elevated thereafter (ve= ). the high expression at h correlated well with the maximal pmn infiltration at that time (cf= ) in i returning to baseline at h (cf= . ) and thereafter. the second peak at h correlated with the onset of macrophage and t-lymphocyte infiltration. thus, laminin and fibrinogen seem to guide leucocyte infiltration following graft ischemia during the time of reperfusion. background. reperfusion of ischemic kidneys with xenogeneic blood leads to activation of endothelial cells and circulating leucocytes with the final consequence of microvascular thrombosis. in concordant systems, the mechanisms of rejection can be studied due to cross-reactivity of mediators with anti-human monoclona~ antibodies. aim of the study. to obtain information about the kinetics of proinflammatory cytokines and production of soluble adhesion molecules in the acute phase of reperfusion, eight kidneys from rhesus monkeys were perfused ex-vivo with human blood (group b/o) for one hour in a closed system. blood levels of il-lb, il- , tnf-a, soluble icam and e-selectin were measured in elisa-technique under steady-state conditions. results. cytokine levels rose significantly within the minute interval (il-lb: , __+ , to , __+ , pg/ml; il- : . - , to , __+ , pg/ml; tnf-a: , __+ , to , + , pg/ml; p< . ). immediately after the beginning of reperfusion, soluble icam- and selectin levels were abnormally high and constantly rising throughout the observation period, reaching significance at minutes. discussion. high levels of proinflammatory cytokines may lead to an induction of adhesion molecules, thus upregulating the leukocyte-endothelial interaction in an complement-independent mechanism. specific pretreatment with monoclonal antibodies against icam- , lfa- or other soluble mediators may be useful in downregulating hyperacute rejection in transspecies transplantation. prolonged ischemia has been associated with later dysfunction of solid organs as it may cause upregulation of adhesion molecules, production of cytokines on vascular endothelium and migration of host cells into the graft. these early events may lead to irreversible organ injury. this study evaluates the effects of global ischemia on early immunohistological changes in cardiac grafts transplanted in rats. isografted hearts (lewis->lewis) were were divided into ischemic and non-ischemic groups (n= /group). all donor hearts were flushed immediately with cold saline. non-ischemic hearts were then transplanted within rain, ischemic hearts were stored in cold ringer's solution for hours before revascularization. representative grafts were removed after . , hrs, and days, and evaluated immunohistologically (cells/field of view=c/f). restitution of ventricular activity was significantly delayed in ischemic grafts ( vs rain). after hrs, all ischemic grafts exhibited an extensive interstitial edema, declining slowly thereafter. at the same time, numbers of pmn peaked ( vs c/f in non-ischemic grafts), whereas edl+macrophages ( vs c/f) and tnfe expression peaked by hrs. by hrs t-lymphocytes began to enter ischemic myocardium and icam- was moderately increased. after days cellular infiltration had returned to baseline, and no differences were seen among both groups after days. global myocardial ischemia inhibits initial graft function, and engenders a brisk inflammatory reponse, primarily pmn and macrophages, with increased mhc class ii and cytokine expression. leukocyte -endothelial interactions are the result of endothelial activation, leukocyte activation or combination of both, which are accompanied by nee-expression, upregulation or shedding of adhesion molecules (selectins, inlegrins). such interactions differ with regard to the stimulus (e.g. thrombin or histamine for p-selectin, endotoxin or tnf/il- for e-selectin), the time course of response (minutes versus hours) and the localisation in different organs. recently assays are available for circulating soluble fragments of the cell bound adhesion molecules e.g. se-seleetin was found to be increased in plasma concurrent with high circulating endoloxin and cytokine levels. the importance of adhesion molecules for the sepsis event is evident, while effectiveness of anti-adhesion inolecu]e therapy is controversial e.g. beneficial anti-e-selectin therapy in baboon bacleremia but deleterious effects of amti-cd treatment in the same model. in other species similar controversial results with anti-cd therapy in sepsis were reported. steven l. kunkel,theodore standiford* and robert m. stricter. the migration of leukocytes to the lung during endotoxemia is dependent upon the coordinated expression of lung vascular adhesion molecules and the subsequent production of appropriate leukocyte chemotactic proteins. in experimental animals, neutrophils accumulate within the lung soon after the administration of endotoxin, while mononuclear cell infiltration occurs in a more distal manner. a kinetic analysis of lung leukocyte levels revealed a -fold increase in neutrophil numbers associated with dispersed lullg tissues hours after lps treatment, while macrophage levels increased by -fold at the hour time point. thus, the recruitment of different leukocyte populations to the lungs during endotoxemia is likely directed by different mechanisms. recent studies have identified a supergene family of small inducible chemotactic cytokines (chemukines) which possesses chemotactic and activating properties for neutrophils. the prototype of this family is interleukin- (il- ). interestingly, a related supergene family has been identified which possesses activity for recruiting mononuclear cells. examples of this group of inflammatory chemukines are monocyte chemotactic protein-i (mcp-i) and macrophage inflammatory protein-i alpha (mip-i). in initial in viva studies we examined whether mip-i was expressed systemically or in a compartmentalized fashion post lps challenge. assessment of plasma cytokine levels revealed maximal tnf levels occurred i hour post lps administration, returning to baseline by hours, while mip-i levels were maximal at hours ( , ng/ml), with a second peak at hours after lps challenge. interestingly, aqueous extracts of liver homogenates from lps treated animals demonstrated no mip-i levels, while aqueous extracts of lung revealed a -fold increase in mip-i levels over control lungs. immunohistochemical analysis of the lungs from hour lps treated animals demonstrated the alveolar macrophage was a rich source of mip-i protein. cell-associated mip-i was also expressed by blood monocytes adherent to the pulmonary vascular endotheliun, however the expression of monocyte-mip-i was observed by hours post lps administration. immunohistochemical analysis also demonstrated that mip-i antigen is associated with the extracellular matrix on the interstitial side of the endothelium. this suggests that the extracellular matrix, which is produced during inflammation, can bind mip-i and this may serve as a depot for the prolonged presence of nip- . in additional studies we have demonstrated that the intratracheal instillation of rmui [ip-l(loong) activation of polymorphonuclear leukocytes by inflammatory stimuli may contribute to the development of multiple organ failure in septic patients. thereby pmnl are proposed to avidly adhere to vascular endothelium causing damage by the subsequent release of toxic agents. as cellular adhesion is primarily mediated by -integrins and lselectins, the present study compares the expression of these adhesionmolecules on pmnl in septic patients and healthy volunteers. methods: expression of -integrins and l-selectins on pmnl was measured in whole blood by flow cytometry using the monoclonal antibodies ib and dreg , baseline values were determined immediatley after drawing blood. in addition cells were incubated min at °c to allow for spontaneous regulation of adhesion molecules. blood specimens from septic patients were obtained during the course of their illness. control values were determined in healthy volunteers. results: baseline expression of -integrins and l-selectins was not signifcantly different in septic and in healthy subjects. in contrast, there was a significant upregulation of g -integrins and shedding of l-selectins of pmnl in septic patients (sp) compared to healthy volunteers (hv). the local or systemic production of inflammatory cytokines, such as tumor necrosis factor alpha (tnfc~), can serve to modulate multiple aspects of neutrophil function. the ability of neutrophils to leave the circulation and migrate to areas of infection is one essential component of host defense. l-selectin, a leucocyte-associated adhesion molecule, is responsible for the initial reversible contact between neutrophils and endothelium and the subsequent roiling action of neutrophils along the vessel wall. in contrast to other adhesion molecules, l-selectin expression is rapidly down-regulated after neutrophil activation. the loss of l-seleclin may thus be a critical determinant of how neutrophils become unbound from their endothelial attachments and enabled to proceed towards an underlying extravascular area of infection. we hypothesize that the shedding of l-selectin is a strictly controlled process, occurring primarily at localized sites of inflammation, which may be modulated by tnf~, a flow cytometric method of staining neutrophhs by monoclonal antibodies in whole blood is described whereby the kinetics of l-selectin shedding may be followed in real time. the dose response and time course of in-vitro l-selectin shedding by neutrophils from normal human subjects was assayed after exposure to n-formyl-methionylleucyl-phenylalanine (fmlp) and tnfc~. either singly or in combination, our results show that l-selectin shedding can be reliably followed over time. a significant percentage of cells shed l-selectin after exposure to pg/ml tnfc~ or nm fmlp (but not at pg/ml tnfc~ or nm fmlp). greater numbers of cells were able to shed their l-selectin when fmlp and tnf~x were presented in combination rather than alone. high levels of tnfc~ did not appear to alter the threshold concentration of fmlp required to induce shedding, we conclude that the extent and rapidity of l-selectin shedding may be modified by different combinations of ligands and that shedding, by vidue of the high concentrations of cytokines or chemotactic factors required, is a process localized to sites of infection or inflammation. we prospectively studied patients with severe sepsis syndrome; group a : septic shock with or without adult respiratory distress syndrome lards) (n = , bacteremia = ); group b : sepsis syndrome without septic shock (n = , bacteremia = ). serial plasma samples obtained on day , , , , and , were assayed using elisas method (british biotechnology), normal control levels of soluble icam- and e-selectin, obtained from healthy volunteers, were respectively ± . ng/ml and ± . ng/ml (mean _+ se), acute lung injury was quantified dally on a tour-point score system (murray, am rev respir dis, ) . compared to control mean values, initial levels of groups a and b were significantly higher for icam- (p < - ) and e-selectin (p < - ). comparisons of group a and [] (* = p< . ; ** = p< . t) soluble icam- levels of group a enhanced significantly (p< . ) during the first hours, and a sustained high levels was of bad prognosis ( % of survivors at day ). the evolution of soluble icam- and e-selectin levels were significantly correlated with murray's score (spearman test : p < . ). conclusion: these results suggest that endothelial adhesion molecules are released into the plasma of patients with severe sepsis syndrome. soluble icam- and e-selectin are correlated with endothelial lung damage, and loam- seems to be a better indicator of the severity of endothelial injury. introductory remarks to anti-adhesion molecule strategies as a therapeutic modality ch wortel, repligen corporation, one kendall square, building , cambridge, ma , usa. the development of antimicrobial therapy represented a major breakthrough in the struggle against disease. it strengthened the notion that disease could be overcome by eliminating foreign invaders threatening the host. this paradigm has proven to be very successful, the threat of many infectious diseases has significantly changed, some have even been eradicated. nevertheless, sepsis has remained a severe condition, increasing in incidence while mortality remained very high. more recently, it has become increasingly clear that besides the nature and treatment of an exogenous agent, the reaction of the host defense itself plays a pivotal role in the outcome of the event. endogenous mediators, such as tnf, il-i, il- and il- , govem many of the actions of the host defense system. while the expression of these cytokines more often than not benefit the host, (over)-expression can cause severe damage. based on this hypothesis,anticytokine strategies, such as those targeted against tnf or il- , have been evaluated for the treatment of sepsis. results of these early studies have not yet indicated success in improving the outcome of the disease. it has been difficult to define a patient population where a benefit could be reproducibly shown. furthermore, it has been documented that synergy between cytokines occurs, but detailed knowledge of the cytokine network is not yet available. it is conceivable, that neutralization of one cytokine prompts the induction of another which will evoke the intended response in the host. recent data obtained in human endotoxemic volunteer models seem to confirm this. if this turns out to be the case, neutralizing a single cytokine may not be a successful approach. cytokines in tum, induce various adhesion molecules, such as icam- . such molecules regulate for instance the neutrophil-endothelial cell interactions, which are thought to play an important role in the pathogenesis of systemic organ injury. the potential for monoclonal antibodies to adhesion proteins to reduce vascular and tissue damage has been studied in a large number of experimental models. protective effects have been observed in a wide variety of inflammatory, immune, and ischemia-reperfusion injuries. thus, altering the host response by modulating the function of adhesion molecules may attenuate the inadvertent injury caused by inappropriate behavior of host defense cells. targeting cellular surface interactions has been added to the efforts to change the outcome of disease. modulation oftheseprocesses seems very promising, but may temporarily leave the host without effective defense mechanism. great care therefore, must be exerted when studying this powerful two-edged sword in a clinical setting. our knowledge of the role of adhesion molecules in the intlammatory response has increased rapidly due to the availability of new reagents and mice geneticly deficient in adhesion molecules. these molecules are important in interactions of leukocytes with endothelial cells, other leukocytes, platelets, and epithelial cells. when these molecules are engaged, they can also play a role in activating leukocytes and their effector functions. in the venules of the systemic circulation, adhesion often occurs through a series of sequential interactions. initial interactions are mediated by members of the selectin family to loosely associate the leukocytes with the endothelium and are followed by firm adhesion requiring members of the integrin and immunoglobulin family. later interactions with endothelium may require pecam. adhesion molecules are usually required for leukocyte emigration in response to extravascular stimuli and for neutrophil-mediated endothelial cell injury. they are critical for host response in many diseases including infections. however, when the inflammatory response results in damage to host tissues, patients may benefit from blocking the leukocyte response. anti-adhesion molecule agents are an important potential antiinflammatory therapy. the focus of anti-adhesion therapy may be at any step of the sequence. diseases where anti-adhesion molecule therapy may benefit patients include ischemia/reperfusion injury in many organs, ards and mof, and transplantation, both to protect the donor organ from ischemia/reperfusion injury and to inhibit graft vs host disease. many strategies have been considered and include: ) blocking the ability of adhesion molecules to recognize their ligand using antibodies that have been humanized or soluble receptors linked to igg to prolong their circulating halflife, ) blocking the ligands for adhesion molecules using soluble adhesion molecules, peptide analogues, or oligosaccharides, and ) blocking the production of the adhesion molecule using anti-sense oligonucleotides. because the synthesis of adhesion molecules is usually regulated by cytokines, inhibiting the action of cytokines is another potential site for interrupting the adhesion process. although important issues of safety must be evaluated, the potential for modulating the inflammatory response make this an exciting area of improvement in health care delivery. claire m. doerschuk, m.d.; riley hospital for children, room ; barnhill drive; indianapolis, in usa. modulation of neutrophil-endothelial cell adhesion with anti-cdl i/cd monoclonal antibodies as a therapeutic modality. ch wortel, repligen corporation, one kendall square, building , cambridge, ma , usa. the central role of inflammatory cells in the pathogenesis of lung and systemic organ injury is well recognized. binding of neutrophils to endothelial cells and migration into the parenchyma are largely regulated by complementary adhesion molecules. the leukocyte integrins are glycoproteins expressed on the neutrophil surface and in the cytoplasmic granules. integrins consist of a common beta or cluster differentiation (cd) chain covalently linked to one of three different alpha chains (cdlla, cdllb, cdilc) and exist on the cell surface as three distinct heterodimers. cdlla/cd is expressed on all leukocytes, whereas cd b/cd and cd c/cd . are restricted to cells of myeloid origin. cd i / cd interacts with intracellular adhesion molecule- (icam-i), its ligand on endothelial cells. the potential for monoclonal antibodies to adhesion proteins to reduce vascular and tissue damage has been studied in a large number of experimental models. protective effects with anti-cd antibodies have been observed in a wide variety of inflammatory, immune, and isehemia-reperfusion injuries, such as arthritis, burns, endotoxic shock, bacterial meningitis, autoimmune diabetes, nerve degenemrion, allograft rejection, allergic asthma, acute lung inflammation, skin lesions, and ischemia-reperfusion models of the intestine, myocardium, lung, skeletal muscle, and central nervous system. protective effects have also been observed in animals resuscitated following hemorrhagic shock. blockage of cd , however, would affect all leukocytes, as would antibodies to cdlla/cdi . targeting cdllb/cd would affect cells of the myeloid lineage only, which could prove to be beneficial. cd b/cd is not only involved in transendothelial migration, but is also implicated in adherencedependent formation of reactive oxygen species. blocking cd lb/cd may therefore not only reduce the numbe r of leukocytes accumulating in the tissue, but also attenuate the oxidant stress of infiltrated neutrophils. anti-cd b treatment has been used effectively to reduce tissue injury initiated by ischemia-reperfusion, complement activation and endotoxemia. altering the host response by modulating the function of adhesion molecules may attenuate the inadvertent injury caused by leukocytes, but may also temporarily leave the host without effective defense machinery. overall, animal studies suggest that it may be safe to inhibit neutrophil adhesion for a limited period of rime. these observations will have to be confirmed in carefully designed clinical trials. c, arbobydrams are ubiquizom constir~uts of cell sv.rfaees, and possess many c~xssfies ttm~ m~,e ~em ide~. canaidates for r~ognifioa mole~ule& in m~y systems whe,~ cer udhesioa ~lays a critical ro~ car~hydram l:~dtag ~otegas have been shown to b~ad tocell surfa~ earbohydzaxes ~nd pzrl~pate in cell-ceil lumtaefion& such sys,.ems include ~rti~za~io=, deveaopmeat, l~thoge~-hcet reeog--ition ~d i~zmmadon_ in particular, tb.z recent di%~ve~ of lhe selec~ and th~ impo.~a~c~ in teukccy~udo~lelium adh~ion has -~f~m av.c~on ok l~in m~ted cell adhe~on. s~vere/poten~s/cs.rbohydr~ l~ga~s hrve ~e~l ~u~ilied for ~he s~lcc~ins. the,~ c~u be broadly di,,sded la~o ~wo m'oups -sibyl l~wis x m~ mh~.~l oligo~chadd~s, ~d sf/~ ca~ohydmma, all ~:~ ~l~dns bind m siflyl l~wis x (sie$ o!igos~ccb.e.rkms, zlthou~ w~ differing avi~re~. 'we have i~¢n~ed the functional g~oups a s~ex ~n~ med/a~ ~he b~u ~di~g of ~h~ c~b hydmm = e-se/sedm we have used ~hat iv.formation to sya~esize sle ~ '~mt gs r.he, t focus on replacing slslic ~sd ~nd fuc s¢ wi~ simpler, more stable strunt~es. a[~ou~a ~ proeer~ is ongoing, we hve been ~ucee,.~ful a~ rep~aein t.ke si~ic a~id. residue wi~ std.fzte. ~ce~ or la~c amd groupa we t'we ex aninad &e ten, bunion of ezed~ hydroxyl group of the fizeose residue ~ billding of e-, l-~nd p-selees..u. we have also found m~fi~fio~ of the reducing end ~¢.cha'i~ ~z increase mtagovsst activity. the, m¢ond. group of figs,rids a.r eontzin su~a~ u a ea.rbohydr~t¢ support,, und seem to bi~.d to t~e sele~ti~s wi~ dlf:ferem characteristics c .an does sle:, s=h compounds are m ogniz~d by l-selects. md p-selectia, bur., in genera/, not e, selecti~ these dam may mdicam r.hat l-and p-s~ ¢at~ h~d via o, second ~te thaz operates lu~.ead of, or in conjunction with ~tc sle" b~ding ~iite. dam rela~&~g to ±e, se two types of ,ml~ liga~ds have beam t~ed to desig~ potential the ~peutics for i~fi~anmat ry disease. lr:rng maimai models of acute lung lu ury we can demo~trate that eompmmds that inhibit seleetiu birding ~ ~i~o hzve ber~ficial effects when uc~d in rive. progressive microvascular damage in the tissue adjacent to a cutaneous burn injury results in extension of burn size. the role of leukocytes in the pathogenesis of microvascular injury was investigated by inhibition of their adherence to the microvascular endothelium using monoclonal antibodies directed to leukocyte cdi or its endothelial ligaud, intercellular adhesion molecule- (icam- , cd ). a model of thermal injury was developed using new zealand white rabbits. two sets of three full-thickness burns separated by two x -mm zones were produced by applying brass probes heated to °c to the animals' backs for sec. cutaneous blood flow determinations carried out with a laser doppler blood flowmeter were obtained for hours. there were five experimental groups: controls given saline alone; animals given monoelonal antibody to the cd r . prior to burn injury (pre-r . ); animals given r . min after burn injury (post-r . ); animals given a monoclonal antibody to icam-i, r . prior to burn (pre-r . ); and animals given the r . min postburn injury (post-r . ). blood flow in the marginal "zone of stasis" between burn contact sites was significantly higher in the antibody-treated animals. administration of the antibodies min after injury was as effective as preburn administration in preserving blood flow. at hr post-burn all antibody -treated animals had blood flow in the areas at risk for progression (i.e., the zone of stasis) at or above baseline levels while the control animals had levels equal to . _+ % of baseline (p < . by analysis of variance and mann-whitney u test). these results indicate that leukocytes play an important role in the pathogenesis of burn wound progression, and that this progression can be attenuated by moduiating adherence to endothelial cells. a wealth of information now supports the hypothesis that inhibition of cell adhesive mechanisms will nter the course of immunologicand inflammatory processes. what remains unclear is whether inhibition of specific mechanisms wfl[ be of therapeutic benefit in any specific human disease. current data derived from animal models are not inconsistent with the hope of therapeutic benefit, but techniques for inhibition (e.g., antibodies, antisense oligonucleotides, inhibitory peptides, inhibitory carbohydrates, smaii synthetic inhibitors, etc), tissue and species differences in the relative contributions of adhesion molecules to the inflammatory process, and the cascade model of adhesive interactions are all confounding issues, making predictions of therapeutic benefit in any specific human disease process very difficult. additional concerns involve the potential roles of adhesive mechanisms in host resistance to infection. as human therapeutictdals are initiated, more exact information on the roles qf specific adhesion molecules in human disease should emerge. inhibition of leukocyte adherence to endothelial cells can represent a novel therapeutic approach to septic shock. we performed a pilot study to evaluate the safety and tolerability to cy- , a monoclonal antibody against human e-selectin, in patients with septic shock. septic shock was defined by clinical signs of sepsis, a documented source of infection, and fluid-resistant hypotension requiring the use of vasopressors. eleven patients entered the study, but patients who died during the first hours were excluded, as this was part of the protocol. cy- was administered as a single intravenous bolus of . mg/kg (n= ), . mg/kg (n= ) or i mg/kg (n= ) mg/kg. the antibody was well tolerated. none of the patients died during the day follow-up period. organ failure was assessed for organs (cns, lungs, liver, kidneys and coagulation). the mean number of organs failing, which was initially . ± . , decreased to . ± . at the end of the study (p<o.o ). these results are therefore encouraging. administration of an antibody to e-selectin in patients with septic shock requires further study. the importance of cytotoxic t lymphocytes (ctl) in the host defense mechanism against viral as well as parasitic and bacterial diseases is becoming increasingly appreciated. the design of vaccines to generate cytotoxic t ceils from nonviable or subunit constructs, however, poses challenges due to the unique characteristics of antigen processing and presentation by class i major histocompatibility complex (mhc) molecules. since the final antigen recognized by ctl are short peptides capable of high affinity binding to class i mhc molecules, we have designed strategies: a) to define the structural characteristics of peptides that are required for their high affinity binding to mhc; and b) to formulate these peptides into immunogenic vaccines that are capable of generating cytotoxic t lymphocytes. the strategy and results to accomplish these two goals will be discussed. amnon altman and erich gulbins ras proteins represent essential intermediates in receptor-mediated growth and differentiation pathways. they couple signals initiated by receptor or nonreceptor protein tyrosine kinases (ptks) at the cell surface to cytoplasmic targets which coordinate signal transduciion to the nucleus. ras also participates in t lymphocyte activation initiated by the antigen-specific t cell receptor (tcr)/cd complex, which leads to lymphokine production and proliferation. receptor ligation causes activation of associated ptks of the src and syk families as the earliest identifiable event in this pathway. the importance of ras in t cell activation is indicated by the findings that an oncogenic ras protein activates the interleukin- (il- ) gene promoter; conversely, a transdominant inhibitory ras mutant inhibits this event and the activation of map kinases. the rate-limiting step in ras activation is the exchange of bound gdp for gtp, which is catalysed by guanine nucleotide exchange factors (gefs). we identified the sh /sh domain-containing vav protein, which is selectively expressed in hematopoietic cells, as a ras-specific gef coupled to several hematopoietic receptors. vav can be activated by two pathways, i.e., by ptk-mediated phosphorylation or by binding of diglyceride second messengers to a cysteine-rich, protein kinase c (pkc)homologous vav domain. these pathways are independent as demonstrated by structure/function analysis and the use of pharmacological inhibitors. the two activation pathways may enable vav to integrate signals from distinct hematopoietic cell receptors, and couple them to ras. t cells express another, ubiquitous ras gef, i.e., sos, which is known to be coupled to activated tpk receptors. t cell activation leads to membrane association of a signaling complex consisting of sos and two other signaling proteins, grb- and shc, via direct binding of the shc sh domain to the tyrosine-phosphorylated chain of the tcr/cd complex. thus, multiple receptors, ptks and ras activators participate in signaling pathways that lead to hematopoieitc cell growth and differentiation. the interactions and function of these various signal transducers will be reviewed. phagocytes. immunity is mediated by specific t lymphocytes, cytokines produced by these specific t cells activate antimicrobial capacities in mononuclear phagocytes, thus contributing to protection. other immune mechanisms also participate in the acquisition of resistance. on the other hand, t cells are also crucial for many pathologic sequelae of intracellular bacterial infections. although ifn-y is central to macrophage activation, synergistic and antagonistic effects with other cytokines occur. the cd/ t cells, representing the major t cell population in experimental mice, are the main mediators of antibacterial immunity; an auxiliary role for y/~ t cells appears likely. the c~// t cell population further segregates into cd t cells which recognize microbial peptides in the context of gene products of the major histocompatibility complex (mhc) and cd t cells which see their peptide in the context of mhc class i. the -y/~ t cells are generally double-negative. knock-out mice in which the genes for various t cell receptor chains, for mhc class i or mhc class ii molecules, for cytokines or cytokine receptors had been deleted, have provided extremely helpful tools for analyzing the role of t cell subsets and cytokines in antimicrobial immunity. using these mutant mice, the role of distinct t cell subsets and cytokines in bacterial elimination and granuloma formation was analyzed in detail. these studies underline the central role of a// t cells and ifn-y in antibacterial immunity and, furthermore, show a distinct function of /$ t cells. moreover, these studies show that the relative contribution of cd or cd t cells to antimicrobial immunity varies in response to different pathogens. apoptosis is an active form of cell death in which the cell participates in its own demise, providing the biochemical pathways that trigger and mediate the complex events of the process. although this phenomenon has been studied for many years, it is only recently that significant progress has been made towards the elucidation of the molecular mechanisms that control apoptosis. once such mechanism came as something of a surprise: in a number of eases, apoptosis can be promoted by the action of the c-myc protein, a protooncogene product that had previously been associated only with cell proliferation (and presumably, survival) . expression of c.myc in cells can cause them to enter an apoptotic pathway or proliferate, mad this "decision" depends upon additional signals, such as growth factors that inhibit apoptosis and allow the ceils to proliferate. thus, c-myc directs cells out of rest and the choice of proliferation or death depends upon the presence or absence of survival signals. other survival signals are generated by oncogene products that can cooperate with my¢, including bcl- and abl there are implications of this interplay between apoptotie and anti-apoptorlc signals in cell iransformation and the resistance of some tumor ceils to therapeutic agents capable of inducing apoptosis. oncogene interactions therefore control the life or death of transformed ceils but also have important roles in normal, development processes. in the immune system, developing t ceils are "screened" for potential self-reactivity by a process of negative selection, in which activation via the t cell receptor (tcr) induces apoptosis. this process can be mimicked in t cell hybridomas, and appears to depend upon the expression of the c-mye protein. evidence that this represents a requirement for the myc/max heterodimer will be presented. as above, these cells are presented with the "choice" to proliferate or die and this depends not only upon myc but also other signals. thus, expression of functional v-an kinase in these ceils can render them resistant to the activation of apoptosis via tcr ligation, surprisingly, bcl- does not appear to be capable of blocking this form of apoptosis, and the reasons for this will provide new insights into the development of the immune system and the process of apoptosis. although the oncogene products discussed here probably do not directly participate in the biochemical process of apoptosis, they represent molecular controls on this complex mechanism. as such, they gave us new ways to look at the life and death of a cell recent attention has focused on macrophage release of cytokines, such as il- , il- and tnf as important mediators of septic shock. however, serum cytokine levels have correlated poorly with outcome of septic shock. the purpose of this study was to compare the functional status of macrophages to serum cytokine levels in early sepsis by an analysis of splenic macrophage protein synthesis during abdominal sepsis. macrophage total protein distribution and biosynthetic activity was assessed by large format -d page, autoradiography of s-labeled proteins and computer assisted densitometric analysis. sepsis was induced in sprague dawley mts by cecal ligation and puncture (clp). untreated and sham operated rats served as controls. splenic macrophages were harvested at and hrs. following clp. serum il- levels were determined at , , and hours by the tdi bioassay. by hrs. % of the clp mls exhibited multi-microbiaj bacteremia. control or sham operated rats did not show bacteremia. clp resulted in a significant % elevation (p < . ) in serum il- levels at hrs. there was no difference in il- at and hrs. when compared to the control groups. d page studies examined splenic macrophage total protein distribution and biosynthetic activity at and hrs. post-clp. at hrs. macrophages from clp rats showed a substantial decrease in total protein pattern ( protein spots vs protein spots) when compared to non-septic control macrophages. a decrease in the number of lower molecular weight proteins (< kd) was observed. at hrs. post-clp, splenic macrophages from clp rats showed a substantial increase in the synthesis of low molecular weight (< kd) proteins, when compared to non-septic controls. we conclude that: l) fulminate abdominal sepsis induces an early ( hrs.) staining with cd and cd mabs will identify two monocyte subpopulations in human blood: a major population of regular monocytes, which strongly expresses the cd antigen (cd ++) and a minor population with weak expression of cd and expression of the cd antigen lcd +/ cd + cells). in healthy control donors(n= ) the latter cells account for + cells/mm and %+ % of the monocytes. in sepsis patients, the cd] +/cd + cells can become a major population with more than % of all monocytes in of patients and with more than cells/mm in of cases. there was no correlation of cd +/ cd + cells to any clinical parameter except for cd +/cd + percentage and body temperature (p= . ). the cd ++ monocytes showed a substanttial decrease in cd antigen density in of patients. three-color-if shows that the cd +/ cd + cells in sepsis patients when compared with the cd ++ monocytes exhibit a higher level of class ii antigen and a lower level of cdiib and cd antigens, consistent with a more mature nature of the cd +/cd + cells. levels of il- were increased in sepsis patients: of patients with high numbers of cdi +/cd + cells ( /mm ) had high levels of il- ( u/ml). these data suggest that septicemia may lead to substantial changes in blood monocyte composition and this may be related to elevated levels of cytokines such as il- . human peritoneal macrophages were exposed to increasing doses of lipopolysaccharide (lps) or a synthetic lipid a analogue (mrl ) and production of the cytokines il-lb, il- , tnf-a and g-csf was assessed at the protein-and mrnalevel. cells were also stimulated with low doses of lps and mrl to study their "adaptation" to a secondary challenge with high doses of lps. tnf-a production after stimulation with lps could be almost completely relieved by preincubation of cells with low doses of lps and similarly, il- production was suppressed. surprisingly, however, "adapted" cells were able to synthesize even larger quantities of of g-csf and il-lb when exposed to a secondary lps challenge. the changes in tnf-a, il- and g-csf protein synthesis could a/so be detected on the mrna level, whereas transcript levels for il-lb remained unaltered as assessed by northern blot analysis. high doses of the synthetic lipid a analogue mrl were also able to "adapt" macrophages for a secondary lps challenge by downregulating tnfa-and il- -production, while priming secretion of g-csfand il-lb as well. taken together, here we describe for the first time the discordant adaptation of human peritoneal macrophages to a secondary lps stimulus in vitro. these findings appear to bear ramifications for the in-vivo endotoxin response during inflammation and gramnegative septicemia. shock states with inadequate cellular oxygen delivery may contribute to macrophage (mo) activation or dysregulation. in this study we compared the effect of transient hypoxia and endotoxin pretreatment (lps ) on mo mediator release with a second endotoxin stimulus (lps ). methods: in vitro cultures of marine peritoneal exudate mo were exposed to hr. of hypoxic or normoxic conditions, then incubated hr under identical normoxic conditions _+ ng/ml of lps pretreatment. during the final hours all m~l were exposed to a range of lps concentrations. m~i supernatants were assayed for tnf, il- , il- , pge , nitric oxide (no), and superoxide release. results: lps markedly inhibited mo tnf release by lps but hypoxia had no effect on lps -triggered tnf release. hypoxia increased mo il- production in the absence of lps , but inhibited lps augmentation seen under normoxic conditions. pretreatment with lps increased no production from lps under normoxic conditions, but bypoxiainhibited this effect. pretreatment with lps signifcantly augmented mo release of il-i and pge , but hypoxia had no significant effect (data not shown) superoxide production was increased by lps under normoxic conditions, but hypoxia significantly inhibited superoxide release (not shown a. lepape, c. docile, f. arpin, m. c. gutowski, v. banssillon and j. bienvenu. i aim of the study. increased levels of tnf are inconsistently correlated with the severity of sepsis. one possible explanation is a decrease ability of ceils to produce eytokines. the objectives of this study were m compare at different levels of of clinical severity the responsiveness of cytokine producing cells. this was evaluated by the response to a stimulation by lps as well as to the inhibitory effect of ptx. the technic used is a whole blood ex-vivo model, as described by desch et al. ( ) . h materials and methods. different groups of icu patients, postoperative (n= ), sepsis (n= ), septick shock (n= ), and healthy control (n= ), were studied. blood was drawn in endotoxio free heparinized robes. stimulation was achieved by addition nf pl oflps ( ng/ml) to id of whole blood in presence of various concentrations of ptx ( , " , - , " , i " m). after hrs incubation at °c, the tubes were centrifuged and supematants frozen at - °c. tnfa and/l were measured by elisa (medgenix r and immunotech r respectively). monocytes were quantified on a technicon h . the results are expressed as median values. non parametric tests are used for testing differences between groups. hi results, tnftx and , , corrected for monocytes count, are given as % of their initial value, the baseline before stimulation or inhibition being %, ) stimulation by lps. the control group is much more stimulated (> % for il , > % for tnfa). blood samples taken postoperatively and in patients with simple sepsis are significantly less stimulated (> % for il , > % for tnfa ). the lowest stimulation was observed in patients with septic shock (median = %), some patients being not stimulated at all. )effects of ptx.the inhibitory effect of ptx on tnftx production is effective in all groups at - m (reduction to less than '¼ of the median values), and is almost complete at " m. the septic shock group has a decreased sensitivity to ptx. il production exhibits a lesser reduction at - m (~ 'a to ½ of the median values), further increased at - m. the septic shock group is again less sensitive to ptx. iv conclusion: the reduced ability of circulating monocytes to produce cytokines during severe infections is confirmed here. ptx is able to reduce significantly tnfc~ at - m and the inhibition is nearly complete at - m. surprisingly, there is a lesser, but significant suppressive action of ptx on il , not found in experiments using purified monocytes. one possible explination could be the interplay between cytokines production. ( ) lymphokine research ( ) cdna sequencing constitutes a powerful method of measuring steady-state mrna levels for all genes transcribed in a given cell or tissue at a particular stage of differentiation. by comparing transcript abundance both prior to and following differentiation, individual genes can be identified whose transcription is regulated both positively and negatively. in order to examine monocyte activation, the human monocyte line thp- was induced with phorbol ester ( h) and activated for h with lipopolysaccharide (lps) after which polya + rna was purified. the rna from control and lps-treated cells were each used to construct a cdna library under identical conditions, and all resulting clones were selected for cdna sequence analysis. each clone sequence was evaluated by matching with both genbank and our own gene databases. very different patterns of gene expression were seen in the two libraries, the latter reflecting very high levels of known inflammatory mediators such as il- and tnf. a second set of libraries were made from umbilical vein endothelial cells (huvec), both with and without lps stimulation, and were analyzed in a similar fashion. the effects of lps induction on specific gene transcription in both cell types will be discussed. t. tadros, md, th wobbes, me) phd, rja goris, md phd to investigate whether the preactivation of regional macrophuges by liposomes containing muramyl tripeptide (mtp-pe) can counteract the detrimental effect of blood transfusions on both anastomotic repair and host susceptibility to infections. methods eighty lewis rats received lmg/kg of either empty or mtp-pe encapsulated liposomes, intraperitoneally (ip). twenty-four hours thereafter, the animals underwent resection and anastomosis of both ileum and colon, and received ml of either saline or blood from brown norway donors,iv. the animals were killed or days after surgery and examined for septic complications and anastomotic repair. the average anastomotic strength, as assessed by bursting pressure (+sd), was significantly diminished in the transfused animals, as compared to the non-transfused animals (ileum;day ; -+ vs + , p< . ). transfused animals pretreated with mtp-pe encapsulated liposomes showed a significant improvement of their anastomotic bursting pressure ( + , p< . vs transfusion). pretreatment with mtp-pe encapsulated liposomes decreased significantly the incidence of anastomotic abscesses in transfused animals ( from % in ileum on day to %, p< . ). conclusions preactivation of regional macrophges by intraperitoneal administration of mtp-pe encapsulated liposomes prevents the detrimental effects of transfusions on anastomotic repair and reduces the incidence of intraabdominal sepsis. academic hospital nijmegen, dept of general surgery, pb i, hb nijmegen, the netherlands. leukemia cell line, teip- . robin s. wa, gner*, perry v. halushka "~, and james a. cook*, departments of physiology , pharmacology "l" and medicine "t, medical university of south carolina, charleston, s.c. . adherence of monoeytes to endothelium and extracella/ar matrix proteins is essential for accumulation at sites of inflammation. txa , an arachidonic acid metabolite, inhibits human monocyte chemotactic responses suggesting that txa may alter monocyte adhesiveness. we selected the thp- cell line, a human monocytic leukemia cell line to further investigate the effect of txa on adhesion. we tested the hypothesis that txa alters lpsinduced adhesion of thp- cells and that txa exerts its effect on adhesion via a camp dependent mechanism. thp-i cells were exposed to s. enteritidis endotoxin (lp.g/ml) _+ the cyelooxygenase inhibitor lndomethacin (in), the txa mimetic i-bop ( . .tm,) or txa receptor antagonists bms and l ( ~m). cells were allowed to adhere for hours and adherent protein/well was determined. lps-induced a significant (p< . ;n= ) increase in adherence of thp- cells (basal, . + . gg protein/well; lps, . +_ . p.g protein/well). the amino acid glutamine is an essential compound for synthesis of purine and pyrimidine basis and therefore necessary for rna-and dna synthesis. in human plasma the concentration of glutamine is between . - . mm, and is reduced in septic patients up to % ( . - . mm). monocytes play a central part in the inunune system and it was of interest, whether glutamine is involved in the modulation of cell surface markers and phagocytosis of these cells. human peripheral blood mononuclear ceils were obtained from ml heparinized blood of apparently healthy donors by ficoll-paque density gradient and isolated by counterflow elutriation. the puritiy was more than %. subsequently cells were cultured in phenolred-free rpmi medium with various concentrations of glutamine ( . , . , . , . , . , , mm) in teflon-fluorinated ethylene propylene bottles to exclude cell adhesion and possible cell activation. aider seven days culture, cell viabilty was determined by trepan blue exclusion and varied between and %, independent of glutamine concentrations. cell surface markers were detected by flow cytometry, noaspecifie phagoeytosis was measured with latex beads and specific phagocytosis with opsonizied e.eoli using a facscan. lower concentrations of glutamine decreased the expression of hla-dr and icam- /cd on monocytes in a dose-dependent manner. the receptor for fc'/rucd as well as the receptors for complement cr /cdllb and cr /cdllc were down-regulated. cr /cd which is only slightly expressed on monocytes was not influenced. furthermore, no effects on the expression of cdi , the receptor for transferrin cd and fc'friii/cd were seen. our data indicate, that lower concentrations of glutamme influence the phenotype of monocytes. we are now interested to study whether glutmnine influences non-specific phagocytosis, or whether specific phagocytosis correlates with the decreased expression of fc'/r and complement receptors. we investigated immunologically more than patients who were admitted to icu because septic syndrom during the last four years. patients were immunologically followed up - times per week until release from icu. the expression of hla-dr antigen on monocytes turned out to be the best prognostic parameter. the persistence (> days) of low hla-dr expression (< %) predicts fatal outcome (mortality > %). the altered phenotype was associated with a functional deactivation of monocytes (diminished apc, ros formation, cytokine secretion). we called this phenomenon "immunoparalysis". ifn-gamma and gm-csf were able to restore the altered phenotype and function in vitro. however, addition of autologous plasma from septic patients with "immunoparalysis" to these cultures prevented the cytokine-induced restitution. the inhibitory activity could not be removed by dialysis. therefore, we started a study to prove the therapeutic efficacy of plasmapheresis. indeed, [ of patients recovered from "immunoparalysis" following repeated plasmapheres; of them survived ( %). patients recovered temporarely and patients did not respond (all died). the survival rate in the control group of septic patients with persistent "immunoparalysis" was of ( %; p< , ). in summary, plasmapheresis in association with immune monitoring may be an alternative strategy to improve survival rate in severe sepsis. taurolidine, a synthetic taurine-formaldehyde derivative has antiadherent, bactericidal and anti-lps properties functioning primarily through binding of the lipid a region of the lps molecule. the active derivative of taurolidine, taurine, modulates calcium channel activity, critical to the initiation of a number of immunostimulatory pathways. we hypothesised that taurolidine may have direct immunostimulatory activity. the aim of this study was to investigate the immune effects of taurolidine on peritoneal macrophage (pmo) function and then determine the role of taurine in this response. study : in vivo stimulation:cd- mice (n= ) were randomized to receive taurolidine ( mg/kg bw/i.p.) or saline cor~trol. peritoneai cells were harvested after hours and were assessed for pm function [superoxide anion generation (o -), nitric oxide (no), tumor necrosis factor (tnf), fc/cr -mediated phagocytic function (phago) study : control pm were harvested and cultured in vitro with taurine ( . mg/ml for hrs), after which time they were assayed for -and tnf release. in vivo stimulation with taurolidine taurolidine has specific immunological effects on m . release of the inflammatory mediators -and tnf, and fc/cr -mediated phagocytosis were significantly increased, while release of the endothelial relaxing factor no was significantly reduced. in addition, the amino acid taurine, which is released as a byproduct of taurolidines breakdown has an immunostimulatory effect on pmo and may be the active moeity of the compound tanrolidine. in sepsis, a number of mediators which affect vasomotor tone and cardiovascular function are produced. inasmuch as sepsis causes decrease in systemic vascular resistance (svr), attention is usually focussed on vasodilators such as lactate, tumor necrosis factor, interleukin-i & , and nitric oxide. but injury and inflammation als cause production of several vasoconstrictors whose effect may not be evident in changed svr, but may significantly affect organ blood flow or function in the paracrine environment. endothelin (et) is a amino acid peptide vasoconstrictor produced by ischemic or injured endothelial cells (ec's). et is also a potent constrictor for renal mesangial and coronary vessels, an endocrine regulator, and a negative cardiac inotrope. systemic et levels increase significantly in hypoperfusion and ischemia. while et is principally produced by ec's, we asked if human monocytes might also produce et and thereby regulate vasomotor tone in areas of inflammation. monocytes from healthy donors were separated on ficoll, resuspended in rpmi + % fetal calf serum and stimulated with i ug/ml endotoxin (lps). et was measured by radioimmunoassay. lps-stimulated monocytes produced ! fm of et/ cells (vs. unstimulated controls of < ). this calculates to - % of the amount of et observed in patients with low cardiac output, sepsis or ischemia. we conclude that et is a cytokine produced by both ec's and monocytes with potent effects on numerous cells and organs in the critically ill. wuppertal , germany we and other authors showed that fatal outcome in septic disease is associated with a decreased capacity of peripheral blood monocytes for the in vitro production of proinflammatory cytokines, especially tnf-alpha. we found that this monocytic deactivation is completed by a persistent and marked decrease of hla-dr expression on monocytes (< % hla-dr+ monocytes) and a diminished antigen presenting activity whereas the capacity to form the antiinflammatory il- receptor antagonist remains high. in order to evaluate the in vivo situation and to determine at which level tnfproduction/secretion is altered we assessed the tnf-alpha mrna expression in freshly isolated peripheral blood mononuclear cells (pbmnc) from septic patients. tnf-mrna was onty rarely detected by semiqaantitative polymerase chain reaction in pbmnc's from septic patients with monocyte deactivation. meanwhile, it was found in almost all pbmncs from septic patients without monocytic deactivation. we wondered, whether il-i , which ,is known to depress monocytic proinflammatoly response and mhc class ii expression, could be one of the mediators in fatal sepsis. in fact, we found that il- message in pbmncs of septic patients peaked in the beginning phase of monocytic deactivation. in further investigations we found that tnf-administration can induce monocytic deactivation in a murine model/n vivo and provoke il- message in human pbmncs in vitro. these results support our hypothesis that an excessive delivery of proinflammatory cytokines in a first phase can induce an overwheiming inhibitory feedback, mediated by immuninhibitory mediators like il-l , which leads to often fatal monocytic deactivation in a second phase. interferon-gamma which is known to counteract il- production and the effects of il- on monocytes restores the function and phenotype of monocytes from septic patients with monoq, te deactivation in vitro and could be a possible therapeutic agent in otherwise fatal sepsis. our laboratory previously reported that lps dependent macrophagederived tnf-a production can be enhanced by pretreatment with lps at substimulatory lps priming doses coincident with a suppression of lps dependent nitric oxide (no) production (zhang and morrison, j. exp. med : , ) . in order to extend the characterization of these lps priming effects in mouse macrophages, we examined the capacity of substimulatory lps to modify lps dependent il- production. macrophages were obtained from peritoneal exudate of thioglycollate treated c heb/fej mice and cultured in rpmi medium containing % fetal bovine serum. macrophages were pretreated with various subthreshold stimulatory concentrations of lps (olll:b ) for hours, washed three times, and then stimulated with the effective stimulatory concentration of lps for hours. the amount of il- in the supernatant was measured by il- dependent cell line (b and td ) proliferation assay. il- was produced by macrophages at lower threshold doses of lps than those required for tnf-o~ or no production. subthreshold doses of lps modulated il- production in a biphasic manner characterized by an initial suppression and then potentiation. higher doses resulted in secretion of il- during the initial incubation with lps and subsequent desensitization. il- , like tnf-~ and no, is, therefore, also affected by lps pretreatment. moreover, tnf-a and il- shared the similar potentiational pathway, but differed by the fact that only il- was inhibited. (supported by r ai and po a .) department of microbiology, molecular genetics and immunology and the cancer center, wahl east, university of kansas medical center, kansas city, ks - . korolenko t.,urazgaliev k.,and arkhipov s. the role of macrophage (mph) stimulation in mechanism of protective effect of new immunomodulators yeast polysaccharides -heteropolysaccharide cryelan and homopolysaccharide mannan rhodexman (both produced by petersburg chem.-pharm. inst.) was studied. in vitro according to nst test incubation of murine peritoneal mphs with cryelan or rhodexman, ~g/ml, min was followed by increase of potencial microbicidic activity of mphs. in vivo mph stimulation by immunomodulators studied included increase rate of carbon particles phagocytosis during single i.v. or i.p. mode of administration to mice - days after (peak at nd day for i.v. and th day for i.p. mode of administration of the same dose of mg/ g b.w.).the preliminary injection of cryelan ( mg/ g, or h before) to mice with acute cold stress (- ° c, h) revealed protective effect restorating the value of depressed phagocytosis up to the normal level;the positive effect on ultrastructure of hepatocytes was noted also.there was no changes of plasma corticosterone level between group with acute cold stress and mice with cryelan + acute cold stress (several fold increase comparatively to the control mice).as was suggested, the mechanism of protection can include mph stimulation and secretion of some acute phase proteins responsible for positive effect of immunomodulators. new yeast polysaccharides cryelan and rhodexman can be used for macrophage stimulation,especially in pathological states. immunomodulators were shown to increase production and secretion of lysosomal enzymes (like zymosan). secreted enzymes,especially cysteine proteinasescathepsins b and l -involve in the process of inflammation;however, excessive release of these enzymes may lead to noncontrolled proteolysis followed by tissue degradation (assfalg-machleidt et al., ) .the effect of zymosan,bcg and new immunomodulator carboxymethylglucan (cmg), second fraction on secretion of lysosomal enzymes by murine peritoneal macrophages was studied. zymosan increased the secretion of n-acetyl-~-d-glucosaminidase and ~-galactosidase into the culture medium ( - fold); bcg possessed similar effect.cmg in the same concentrations ( /~g/ml) increased release of these enzymes only saightly ( . times).it's known that zymosan-induced secretion reflects the enzyme release from formed lysosomes (warren, ) .it was suggested that cmg activated macrophages via interaction with scavenger-receptors,followed by weak secretion of lysosomal enzymes and as a result decrease of tissue damage. in vivo zymosan induced stimulation of mononuclear system of phagocytes followed by increase of cysteine proteinases activity in liver at the th day. in the same time in blood n-acetyl-~-d-glucosaminidase and n-acetyl-~-d-galactosidase activity increased - fold. it was concluded that in drug design it's possible to select such immunomodulators,e.g. cmg,which can activate mononuclear system of phagocytes and do not damage tissue. endothelin-i (et-i) is produced by injured/ ischemic endothelium, mobilizes intracellular ca ++ and is a potent vasoconstrictor. it is also a ca ++ agonist for anterior pituitary or renal mesangial cells and monocytes. et-i causes monocytes to produce interleukin-l, , , prostaglandin e , and substances which trigger neutrophil superoxide production. et-i levels increase in shock and et may play a role in activating leukocytes post shock causing reperfusion injury. but blood flow experiments suggest splanchnic circulation changes more profoundly in shock than peripheral circulation. we therefore asked if et- (or vic), the et which predominates in splanchnic vessels, had any effect on monocyte cytokine production. human monocytes from health~ blood donors were separated on ficoll. . x ucells/ ml in rpmi + % fcs were incubated i min., & hrs. with - m et-i, - m vic or i ug/ml of lps. supernatants were assayed by elisa. we have shown that low dose endotoxin pretreatment (lps ) for hrs markedly inhibits the macrophage (mo) release of tumor necrosis factor (tnf) and increases interleukin- (il-i) in response to a subsequent endotoxin stimulus (lps ). in this study we examined the kinetics of lps inhibition of tnf and augmentation ofil- . methods: murine peritoneal exudate mo from balbc mice were exposed in vitro to medium or ng/ml of lps for intervals of to hours. culture medium was then replaced with , or ng/ml of lps for hrs. tnf and il- in mo supernatants were measured by specific bioassays. during sepsis endotoxin (lps) activates macrophages (mo) to release mediators such as tumor necrosis factor (tnf), interleukin- (il- ), interleukin-i (il-i) and prostaglandin e (pge ). we showed that preexposure to lps (lps ) alters the response of murine m~i to subsequent lps stimulation (lps ). we hypothesized that in vitro cytokine release by lps in human monocytes (mo) is also be altered by preexposure to lpsi. methods: human peripheral blood mo were obtained from healthy volunteers (n= ), cultured in vitro hrs, then pretreated hr _+ lps -cultures were then stimulated with lps and mediators in mo supernatant measured: tnf, il-i, and il- by specific bioassays, pge by immunoassay kit. serum cytokine levels (specific elisa kits) were compared to in vitro supernatant levels. data is expressed as % control_+sem, lps = ng/mh the table shows that all mediators were increased, in the absence of lps . pretreatment with lps resulted in complete inhibition of lps -triggered tnf release. in contrast, lps significantly increased mo secretion of il- , il- and pge (data not shown). serum cytokine levels were as follows: tnf _+ , il-i + , and il- . -+ . ng/ml. these serum levels were low, showed an extremely wide variation, and did not correlate with in vitro lps -triggered mediator production. conclusion: human monoeyte mediator production is differentially regulated by preexposure to lps . provocative in vitro testing of monocytes may ultimately be clinically useful to identify prior in vivo lps exposure or mo macrophages release numerous secretory products involved in host defense and inflammation. activated macrophages with cytokines produced have been implicated in tissue damage in sepsis and multiple organ dysfunction. aimed to elucidate the organ-association phenomena,this study is to compare peritoneal macrophage(pm),alveolar macrophage(am), and kupffer cells(kc) during sepsis in terms of cellular protein contents as symbol of activation by flow cytometry analysis. sepsis were produced by cecal ligatien and perforation (clp) in wistar rats weighing - g.pm were obtained by peritoneal lavage,am by bronchial lavage and kc by incubating the collegenase digested liver with pronase-e. leukocytes have been implicated as a mediator of the microvascular dysfunction associated with reperfasion of ischemic tissues. a role for ieukocytes is largely based on observations that rendering animals anutropenic with anti-neutrophil serum or preventing leukocyte adhesion with monoclonal antibodies attenuates the increased fluid and protein leakage from the vaseulature that is normally observed in postischemic tissues. we have recently undertaken studies designed to determine the relationship between leukocyte-endothelial cell adhesion and albumin leakage ia rat mesenterlc venules exposed ~o ischemia-reperfusion (i/r). leukocyte adherence and emigration as well as albumin extravasafion were monitored in single postcapillary venules using iatravital fluorescence microscopy, lschemia was induced by complete occ!usion of the superior mesenteric artery and ~dl parameters were monitored at various intervals following reperfusion. the magnitude of the leukocyte adherence and emigration, and albumin leakage elicited by i/r was positively con-elated with the duration of ischemia. the albumin leakage response was also highly correlated with the number of adherent and emigrated leukocytes. monoclonal antibodies against the adhesion glycoproteins cd , cdllb, icam- and l-selectin, but not p-or e-selecdn, reduced i/r-induced leukocyte adherence and emigration as well as albumin leakage. phauoidln, an f-aetin stabilizer, largely prevented the emigration (but not adherence) of leukocytes and greatly reduced, the raicrovascular protein leakage. plateletleukocyte aggregates were formed in postischemic vemdes; the number of aggregates was reduced by antibodies against p-selecdh, cdilb, cd , and icam- , but not e-selectin or lselectin. a significant fraction of the mast ceils surrounding the posteapillary venules degranulated in response to ischemia/repeffusion, but mast cell stabilizers did not afford protection against the albumin leakage elicited by i/r. these results indicate that reperfusloninduced albumin leakage is tightly coupled to the adherence and emigration of leukocytes in posteapillary venules. this adhesiomdependent injury response is primarily mediated by cdllb/cdi on activated neutrophils and icam- on venular endothellum, and appears to require l-selecda dependent leukocyte rolling. mast cell degranulation does not appear to conwibate to the vascular pathology associated with i/r. m.d. rod=iek, boston, ma, usa the polymorphonuclear neutrophil (pmn) has long been known to pa~tlcipats in the inflammatory rebpons~ as a phagocyte and killer of invading organisms, but little attention has been given to its potential as a participant in the in~une interaction of lymphocytes and macrophages. we and others have shown that the pmn may have i~m~/nomcdulatory effects both in vitro and in vlvo. more recently it has been proven that the pmn can make mrna for and secrete the proinflammatory oytokines illa, il-ib, tnfs, il- and il- as does the other major circulating phagocyte, the monocyte/macrophags. furthermore it has been shown to make the potentially autoregulatory oytokines gcsf and gmcsf. these functional capabilities suggest that the pmn is not an wend cell ~, but one which has a potential role in regulation cf ~he immune response and that this potential ~cle should no longer be ignored when considering the immune abnormalities existing in patients following majo~ injury or surgery. we have investigated the proinflaznmatory oytokine secretion patter~ by pmn in patients following major ~hermal or tra~matic injury and in volunteers fellowinq endotoxemia. ?ollowing major injury there is variable pmn secretion of these cytokines when stimulated in vlero. following endotoxemia in a group of human volunteers pmn showed a hypo=esponsivenesa to lps hrs following endotoxin infusion followed at hre by an overshoot. pretreatment with steroids modulated this overshoot phenomenon, suggesting that receptors for steroids are involved in the regulation of cytokin® secretlon by fmn. these results sugges~ that the pmn, the most numerous cell in the circulation and the first to respond to an ins~l~ may be a so~rce of the prolnflammatory cytokine cascade following injury that has been recognized as significant in the process which often leads to multiple o;gan failure, the immunosuppresslon which occurs following major thermal injury may predispose these individuals to infection and sepsis, which remain a significant cause of morbidity and mortality. included among the many immune aheratlons are the p integrln (cdlla, b,c/cd ) dependent activities of adhesion, chemotaxls, diapodesls, and phagocytosls. our investigations indicate that, following major thermal injuries, the expression of the [~ integrlns, but not cd , is significantly decreased on neutrophlls (pmns). it remains unclear if pmns from thermally injured patients respond normally to lps, the effects of treatment in vitro with lps and f-met-leu-phe (fmlp) on the expression of cdtlb was examlned on pmns from the peripheral blood of healthy volunteers and non-septic burn patients (> ~; total body surface area, >ls~ full thickness), the pmns were incubated with lps (]ng- p.g/ml) or f'mlp ( " to " m) et oc for mln, in ~; human ab serum, the expression of the ]ntegrins was detected using monoclonat antibodies and flow cytometry. lps and f'mlp resulted in a slight increase ( fold) in the expression of cd b on pmns from burned patients compared to an and fold increase, respectively, on pmns from healthy individuals. this inability of lps or fmlp to increase cd b expression was not due to the amount of lps bound to the two cell populations. because the same defect is seen after either lps or fmlp stimulation, it is speculated that the defect must be in the amount of preformed cd ] b or its transport to the plasma membrane. platelet-activating factor (paf) and neutrophils have been implicated in the patbophysiology of ischemia-repeffusion injury, in addition, paf stimulates neutrophi[ (pmn) oxidative metabolism in vitro. the present study examined the potential role of paf in repeffusion injury in an in viva rabbit model. eight anesthetized rabbi~s underwent retroperitoneal exposure of the infrarenal abdominal aorta after percutaneous insertion of a catheter through the jugular vein into the infrahepatic inferior vena cava. doppler flow probes were placed around the abdominal aorta and the right common femoral artery to assess flow through these vessels. an occlusive ligature was placed around the abdominal aorta (superior to the flow probe) at t = and total occlusion of blood flow to the lower extremities was maintained for g mins., after which the ligature was released allowing for reperfusion of the ischemic lower limbs. effluent blood from the ischemic hind-limbs was collected through the ivc catheter at the times indicated below and assayed for paf by a direct radioimmunoassay. in addition, neutrophil h production was determined by a previously described ' '-dichlorofluorescein flowcytametric assay. _+ amean _+ s.e.m, pg/ml blood; brelative fluoresenee (% of baseline); caortic and femoral artery flow (% of baseline); *p < . vs. baseline; "p < . vs. baseline. a significant elevation of paf was observed in ischemic hind-limb effluent blood at min. after release of the aortic ligature during the repeffusion phase, as compared to baseline levels. in addition, pmn h production was increased by . -fold above baseline values by hour after ligature release during the reperfusion phase. both of these elevations were transient and returned toward baseline by hours post-isehemia. tatar occlusion of hind-limb flow was achieved as evidenced by the absence of aortic or femorat flow at rain. post-ischemia, however after release the ligature a significant reactive hyperemia was observed by mln. into the rapeffusion phase. histolog[c examination of reper[used gastrocnemius muscle revealed moderate pmn infiltration into the interstitium. in conclusion, these data indicate that paf is released into the circulation during repeffusion, and is likely involved as a mediator in the observed pmn oxidative burst activity, thereby contributing to reperfusien injury. following thermal injury and infection granulocyte function ts abnormal. to elucidate the mechanism by which thermal injury and infection affect the granulocyte's ability to polymerize and depolymedze actin, we serially measured f-actin levels in granulocytes from burned patients (mean age , +_ . years, mean burn size . % _+ . %) during the first s weeks post injury. six of the patients had infections during the course of the study, (septicemia, wound invasion and pneumonia). actin levels in granulocytes from eleven healthy volunteers (mean age years) were measured repeatedly and served as controls. lysecl white blood cell preparations were brought to c and incubated with n-formyl-met-leu-phe (stim) or with dulbecco's phosphate unbuffered sellne (unstim). the cells were concomitantly stained and fixed with formaldehyde, lysoleclthln and fiuoresceln phafioidin. actin depolymedzation (depol) was measured by incubating stimulated cells at °c before the stain-fixative was added. baseline (base) f-actln levels were assessed by adding stsln-fixatlve to icecold unstimulated cells. fluorescence was estimated in a facscan and expressed as ilnesr mean channel fluorescence_+ sem (mcf). figure displays granulecyle fectln levels in infected and uninfected patients as compared to controls. f-actln levels were consistently lower in control cells than in those from burned or burn-infected patients under all measured conditions. granulocytes from infected burned patients demonstrated a significant decrement in their ability to depofymerlze f.actin compared to both uninfected burned patients and controls, while there were no significant differences between infected and ,~ uninfected patients in the baseline, unstlmuleted and stimulated conditions. those results indicate la that grsnulocytas from burned and bum-infected patients contain higher levels of polymerized actln than ~ , s control cells. in order to study tumor necrosis factor (tnf) receptor sensitivity in septic critically ill patients we investigated blood samples of such people in reaction of leucocyte migration inhibition. migration of their polymorphonuclear leucocytes (pmns) was studied with stimulation with human recombinant tnf in concentration of . u/ml (recommended by manufacturer is the range of - o/ml) and without such. ten healthy blood donors formed control group. the results obtained showed diminished pmn reactivity to tnf in patients (migration inhibition was absent) oscaring with significantly increased migration ability of their pmns ( . % of that in control group). at the same time normal pmns in control group did show migration changes upon tnf stimulation. considering all the above we come to a conclusion that externally added tnf fails to activate pmns in critically ill patients more than they are by their endogenous tnf. moreover, this tnf no longer serves a positive chemotactic factor for such pmns. these findings may suggest that in critically ill septic patients reactivity of pmns to tnf is deeply altered. tnf receptors of pmns are either exhausted as such by excessive stimulation with endogenous tnf or further transmission of their message is impossible due to "fatigue" of the cell's activation mechanisms. we express our gratitude to reanal factory of laboratory chemicals for generously providing us with a tnf com~rcial sample. ~-sanguis medical, ekaterineburg russia; s-urals med.lnst. activated neutrophils infiltrating the local site of inflammation following trauma release high amounts of destructive lysosomal enzymes into the extracellular space. cytokines were discussed to be involved in regulation of this early process. the task of this investigation was to evaluate the possible regulatory role of interleukin- (il- ) and its potential immunosupressive opponent, the transforming growth factor-&, in regulation of neutrophil degranulation. we analysed the concentration of the al-proteinase-inhibitor complex of the lysosomal elastase as marker for the degranulation of neutrophils as well as the levels of il- and tgf- in the plasma probes of patients undergoing multiple trauma and severe surgeries. the time courses of il- and elastase were found to be highly correlated, wheras the concentrations of the cytokine tgf-e~ were found to be not significantly altered in comparison to the control group. this close temporal correlationship was confirmed by investigation of fluids derived from sites of inflammation. interstingly, the inhibitory potential (~zcproteinase inhibitor, antithrombin iii) was dramatically reduced in the early inflammatory phase. to prove this in vivo findings, the effects of il- and tgf-i~ on the degranulation of isolated human neutrophils of healthy donors was investigated in vitro. pathological high concentrations of rhll- up to u/ml (as detected in fluids derived from local inflammatory site) were found to be capable to induce a significant release of lysosomal elastase in a concentration-dependent manner, whereas the degranulation of neutrophils was uneffected by tgf- . in conclusion, these data suggest a contribution of il- in regulation of neutrophil activation at sides of inflammation. the immunosuppressive cytokine tgf-i&~ seems to have no direct regulatory effect beside its described chemotactic function on neutrephils. postirradiation chan~es of adhesive properties arid supercoiled nucleoid dna structure of blood leukocytes were studied in macaca nemestrina andrats. the dynamics of membrane chan~es after nonlethal irradiation of rats demonstrated the temporary increase of the leukocyte adherence at h followed by return of this parameter to normal levels at h. after lethal irradiation of both animal species the increase in adhesive leukooytes fraction was detected as early as at h. this hi~her index persisted until the end of experiments ( days). the early ( - h) temporary loosin~ of supercoiled dna structure was demonstrated in the leukocytes of nonlethally irradiated animals. this phenomenon seems to be connected with the lymphocyte fraction chan~es. this process was not dependent on altered adhesive properties of leukocyte membranes. the membrane chan~es of leukocytes preceded decondensation of supercoiled dna after lethal irradiation of animals, in this case loosin~ of supercoiled dna pro-~ressively increased at h and at the later terms of postirradiation period. the systemic inflammatory response syndrome (sirs) involves many inanunological reactions of the host including acfivatinn of inflammatory mediator cascades and depression of cellular reactivity in t-lymphecytes ( ). there are reports of nentrophil dysfunction in inflammatory disorders of the skin ( ), are there dysfunctions concerning the unspecific host defense in sirs, as well? in this study, we examined the reactivity of neutrophil granolocytes from patients suffering from sirs. twenty-one patients (apache ii-score ± ) with diagnosis of sirs entered the study. granulocytes were prepared as reported previously ( ) . in parallel, granulocytes from healthy individuals were tested. two granulocyte functians were studied in vitro: . migration of the ceils in a boyden chamber through a filter matrix following stimulation with different receptor dependent stimuli (c a, intefleukin- , platelet-activating-factor, leukotrien b , fmlp). . release of glucuronidase following stimulation with the aforementioned activators. the results demonstrate, that the release of -glucuronidase in patients suffering from sirs was comparable to the enzyme release of granulocytes prepared from healthy individuals. each stimulant induced release of p-glucuronidase in a characteristic dose dependent fashion. all granulocyte preparations from the healthy donors showed a positive chemotaxis response in the migration-assay. in contrast, only ten out of twenty-one patients had granulocytes migrating after stimulation. the two groups of patients displaying reactive or non-reactive granulocytes differed clinically: the nonreactive group consisted of patients with multiple organ failure ( / ) and nonsurvivors ( / ), whereas / patients in the reactive group survived. thus, the in vitro chemotaxis of granulocytes is impaired in a subgroup of patients with sirs. this defect of the non-specific host defense may contribute to poor prognosis and outcome of these patients. dermatol. : - , klinik ffir an~isthesiologie und operative intensivmedizin der cau kiel, schwanenweg , kiel, germany. objectives of the study: major emphasis has been given to the analysis of interactions of antibiotics with microorganisms. effects of antibiotics on cells of primary host defense mechanisms, such as the neutrophils, are less well known. therefore, attention has been focused on clindamycin, a member of the lincoseamide family. materials and methods: the effect of clindamycin (i -i ~g/ml) on granulocyte functions (healthy volunteers) such as random migration, chemotaxis (agarose method), ingestion (radiometric assay), superoxide (cytochrom c reduction) and hydrogen peroxide production (phenol red oxidation), lucigenin-and luminol-amplified chemiluminescence (luminometry) and degranulation (turbidometry with micrococcus lysodeicticus) were investigated in vitro. results: motility and degranulation were inhibited, ingestion of saccharomyces cerevisiae, zymosan-induced lucigenin-and luminol-amplified chemiluminescence, superoxide and hydrogen peroxide production were stimulated in a dose dependent fashion. conclusion: clindamycin has granulocyte function modulating properties. recognition of immunomodulating effects of antibiotics may have therapeutic significance, especially in patients with long-term antibiotic therapy or immune deficiencies. the intense muscle activity (ea) of rats resulted in increase of neutrophil influx in muscles during the recovery. we investigated neutrophil proteinases involvement in neutral proteinases balance of skeletal muscles by na. the rats were submited to swim with the load ( % of body mass) till exhaustion. immediately after na the neutrophil antiserum was injected i.p. to rats of experimental group. saline was injected to control animals° injections were repeated in h of the recovery and cytosol proteolytic activity (ph . ; fitc-casein) was determined. isolated soleus muscles were incubated also in vitro and proteolytic activity of incubation media was measured. it was found that there was - -fold proteinases activity increase in cytosols of all investigated muscles (soleus, white and red portions of quadriceps) of control animals by h of the recovery (the comparison was done with the sedentary rats). in h cytosol proteolytic activity decreased and then increased again by h of the fast. antiserum injections resulted in relible decrease of the proteolytic activities at every investigated time. when incubating m. soleus in vitro the activities of proteinases in incubation media turned out reliably less if soleus muscles were isolated from the animals to which antiserum was injected. the conclusion is that neutrophil proteinases can be involved in the balance of rat skeletal muscle neutral proteinases after ~a. a lot and new clinical problems complicating the outcome of polytrauma, burn and septic patients in surgical intensive care units, have arisen as the care improvement prolonged the patient's survival: a progressive degradation of organ and system functions often develops, usually making its first clinical appearance by ards, followed by the other organ failure (mof) and sepsis symptoms. the clinical picture is polymorphic, the end result of a complex systemic pathophysiological reaction trigg~ed off by trauma consequences (tissues disruption, hypo~xygenatiun and necrosis). nowadays there is not a preventi~ or specific therapy to lower the mortality rate ( - %) and-'mdy-a~ early, aggressive surgical approach .-evacuating haematomas, stopping bleeding, toileting all septic, necrotic foci and restoring anatomic continuity-, seems to be of some help this complex clinical entity has not an univocal denomination yet. the proper labelling of an illness should come from the full understanding of its pathopysiology and suggest the proper treatment choice. clinical and experimental studies demonstrated that pathophysiologic mechanisms involved in the past-traumatic illness, share the same anatomo-pathological elemem: the interstitial edema, due to a generalised endothelial micro circulatory injury. this alteration, as constantly seen in polytrauma patients, develops in a few hours after trauma as a consequence of the deregulation of the homoeostatic and immune mechanisms. in fact the overproduced oxygen free radicals and r~ombinam cytokines (il ,tnf), together with the complement degradation fragments, the proteolytic enzymes and many other mediators are all strongly h~l ~ ,_he e,,j,yheha! ceils. our~osect, atim~,-bnsed on examination of autopsical specimens from polytraanm patients, showed that such endothelial damage, supporting the interstitial edema, is widely and simultaneensly distributed, ensues shortly arer trauma and shows its effects in different organs at different times, only because each apparatus has different fimctienal reserves: the lung is the first organ to fail just because its ah, celocapillary membrane is one of the most delicate bodily structure, and its function is irroplace~le. we think it will be of a great help, in planning a preventive therapy, to chose a denomination focusing the physician's attention on the earl)" generalized endothelial injury and its effects, as in trauma patients it is present -even if latenflysince the first few hours. we would like to see the generalised endothelial microcircolatory injury properly highlighted when considering the best definition and the optimal nomenclature for the post-traumatic s mdrome. the presence of interleukin (il)- in bronchoalveolar lavage fluid of critically ill patients correlates clinically with the development of the adult respiratory distress syndrome lards), and inhibition of il- in animal models can attenuate lung injury. collectively, evidence to date suggests that il- attracts and activates neutrophiis (pmn), which are then responsible for the capillary leak of ards. however, an alternative explanation is that il- is directly toxic to the endothelial cell (ec). in this study, we have hypothesized that il- can disrupt endothelial integrity independent of pmn. meth ods: human umbilical vein (huv) ec monolayers were cultured to confluency on collagen-coated micropore filters. to assess ec integrity, .albumi n leak was quantitated by measuring the counts which crossed the monolayer, using a gamma counter. il- (lpg/ml) was incubated in the culture medium with .albumi n for hrs. the il- dose was not cytotoxic. to determine the involvement of protein synthesis in this process, selected monolayers were pretreated with cycloheximide (ch) prior to .- addition. statistical analysis was performed using anovmfisher plsd. we have previously shown that platelet activating factor (paf) enhances cdt expression and primes pmn's for subsequent generation. both are important steps in pmn mediated injury and are assumed to occur in concert. following major trauma non-specific pmn inflammation is activated, however, unbridled systemic pmn activity needs to be minimized. since circulating catecholamines are high early post-injury, we hypothesised that they downregu/ate cd expression and pmn priming via the [ adrenergic signal transduction pathway. methods: normal human pmns were primed with paf ( ng/ml for min) or pre-treated with - m of isoproterenol (i) or forskoklin (f) for rain and then primed with paf. cd expression was measured by flow cytometry (fig.l) and -generation in response to -rm fmlp was determined as sod inhibitable reduction of cytochrome c ( fig. holler** and georg w. bornkamm* lymphocyte-endothelial interactions are crucial for various immune responses, including cytokine driven inflammatory processes. protein kinase c (pkc)-inhibitors on the other hand are discussed as potential cytokine antagonists. in the present study we investigated the influence of the pkc-inhibitor gf x on cytokine-and endotoxin induced expression of intercellular adhesion molecule (icam- ) and on adhesion of lymphocytes to cytokine activated endothelial cells. we found that tumor necrosis factor alpha (tnfo -and lipopolysaccharide (lps)-induced icam- expression on human endothelioma celts (eahy ) were unaffected by the pkc-inhibitor and thus appeared to be independent of pkc activation. in contrast, gf x significantly reduced icam- expression induced by interferon-y (ifn-?) and interleukin- (il- ). the functional relevance of these findings was evaluated in an adhesion assay using human umbilical vene endothelial cells (huvec) and peripheral blood mononuclear cells (pbmc). in fact, the ifn-? and il- induced adhesion of pbmc to cytokine treated huvec could be downregulated by the pkc-inhibitor, whereas tnfc~-and lps-mediated adhesion was not influenced. additionally, the il- driven icam- expression on eahy cells as well as the il- induced adhesion of pbmc to huvec was found to be tnf-dependent, since both effects could be inhibited by an anti-tnf monoclonal antibody ( f) . these in vitro data further support the idea of examining pkc-inhibitors, such as gf x, for their biological relevance in cytokine related dysregulations. seiffge, d., bissinger, t., laux, v., during inflammation there are some key processes, which occur in the microcirculation: the release of mediators from various cell types, the migration of inflammatory cells towards a chemotactic stimulus in the tissue, the expression of adhesion molecules on different cells, and the extravasation of plasma proteins. the aim of the present study was to elucidate the mediator induced interaction of leukocyte adhesion and plasma leakage in postcapillary venules. using an analogous video-image analysing system we have studied the effect of different mediators on leukocyte adhesion and macromolecular permeability in the mesentery of the rat. the increase in permeability was measured as changes in optical density. we found that topical administration of leneotriene b (ltb , x " tool/l) or intravenous injection of interleuldn- (il- , - iu/kg b.w.) and lipopolysaccharide (lps, mg/kg b.w.) resulted in a significant extravasation of fitc-labelled rat serum albumin (fitc-rsa) in venules but not in arterioles. we could correlate the changes in vascular permeability with a locally increased number of rolling and sticking leukocytes in venules. both effects were dose dependently inhibited by different drugs. pentoxlfylline inhibits lps-indueed fitc-rsa extravasation and leukocyte adhesion at a dose of mg/kg b.w., superoxid-dismutase (sod, . iu/kg b.w.) was able to decrease the ltb effect, and the immuumodulating drug leflunomide (hwa ) exerted inhibitory effects on il- -induced permeability at a dose of mg/kg b.w.i.v. the obtained results demonstrate that lps, ltb or il- induced extravasation of fitc-rsa is mediated by activated leukocytes and can be deminished following administration of different drugs. platelet-endothelial cell adhesion molecule-i (pecam-i), a member of the immunoglobulin superfamily, is constitutively expressed at high levels on the endothelial cell surface. in vitro data have suggested that pecam-i functions as a vascular adhesion molecule, specifically in neutrophil transmigration across the endothelium. this current work is the first demonstrating the in vivo role of pecam- in neutrophil migration. blocking antibodies to human pecam- , in which the antibodies are crossreactive with rat pecam- , were able to block the movement of neutrophils into the rat lungs after igg immune complex deposition. furthermore, when human foreskin was transplanted into mice with severe combined immunodeficiency and the site injected with tnf-alpha, anti-pecam-i blocked neutrophil emigration into the dermal interstitium. it has already been established that neutrophil recruitment is dependent upon selectin mediated rolling, followed by firm adherence that is icam- / integrin mediated. these data suggest, for the first time, that a third endothelial adhesion molecule (pecam-i) is involved in the coordinated recruitment of neutrophils in vivo. to test whether trauma causes generalized activation or priming of pmns, cdi adherence receptors were measured with iinmunomonitoring in whole blood after lps stimulation ex vivo. anesthetized (fentanyl) mongrel pigs ( - kg) were subjected to % arterial hemorrhage + soft tissue injury and after liar, resuscitated with all the shed blood + supplemental fluid. blood was collected at hr intervals from unanesthetized animals with indwelling catheters, pmns were counted, and lps was added ( , , , i.tg/ml) ex vivo. after hr incubation at - °c, %cd (+) pmns were determined with fitc-ib and flow cytometry from mean channel fluorescence histograms. ± # p< . vs baseline * p< . vs sham $p< . vs no anesthesia these observations provide direct evidence for time-dependent changes in pmn priming following major injury because cd expression was depressed for at ]east hr after trauma relative to sham but by hr, was enhanced, relative to sham, and because fentanyl anesthesia at hr had a greater effect on cd expression in trauma vs sham. neutrophil (pmn) adhesion to vascular endothelial cells (•c) is a key element in the inflammatory response and tissue injury. inflammatory mediators such as lps (exogenous) and tnf (endogenous) can promote pmn-ec interaction which is believed to be responsible for capillary leakage and subsequent organ injury. however, the mechanism of this injury remains unclear.we hypothesised that the mechanism of tissue injury is due to ec necrosis with release of toxic products and that activated pmn are responsible. human pmn were obtained from healthy donors, separated by density gradient, and activated with lps ( ng/ml), tnf( ng/ml), and lps/tnf( ng/ ng/ml). cultures of the human ec tine(ecv- ) were used as surrogates of the microvasculature, were exposed to either lps, tnf, lps/tnf and pmn activated with lps, tnf, lps/tnf and incubated for , , , and hrs. ec necrosis was assessed by a cr release cytotoxicity assay. pmn activation was assessed by cd lb receptor expression and respiratory burst activity hr _+ . -+ -+ . _+ _+ . _+ _+ . _+ . hr + . _ _+ . _+ _+ _+ " +_ +-- . " lghr - . _+ +_ - " o:fo , " ~ +- . * hr _+ . - -+ +_ * _+ _+ * _+ _+ " data = ec % necrosis mean_+sd stats: student's t-test with significance (*) set at p< . vs control. ( our previous studies have indicated that despite the increased cardiac output and maintenance of tissue perfusion, hepatoceliular dysfunction occurs during early sepsis. nonetheless, it remains unknown whether vascular endothelial cell function (i.e., the release of endothelium-derived relaxing factor/nitric oxide) is depressed under such conditions and, if so, whether endothelial cell dysfunction also occurs at the microcirculatory level. to determine this, rats were subjected to sepsis by cecal ligation and puncture (clp), following which these and corresponding shams received ml/ g bw normal saline. at hr after clp (hyperdynamic sepsis) or sham operation, the thoracic aorta was isolated, cut into rings, and placed in organ chambers. norepinephrine (ne, xi - m) was used to achieve near-maximal contraction. responses for an endothelium-dependeut vasodilator, acetylcholine (ach, via nitric oxide), were determined. in additional studies, the small gut was isolated at hr post-clp. after pre-contraction of blood vessels in the isolated gut with xl m ne, vascular responses to ach ( x m) and an endotheliumindependent vasodiiator, nitroglycerine (ntg, xl - m), were determined. total vascular resistance (tvr, mmhg/mi/min/ g) was then calculated as pressure/ perfusinn rate. ach-induced relaxation (%, n= /group) in the aortic rings were: ach lxl i~s, st-in ~ ~ significantly at hr post-clp (i.e., increased *p(o vs. sham; n- per group. tvr) in the absence of any changes in ntginduced relaxation (fig. a) . thus, the vascular endothelial cell dysfunction observed in the aorta in early sepsis also occurs at the microcirculatory level. introduction: the cytokine-mediated adherence of leulcooytes to vascular endothelium is considered as an early step in the cascade of pathologic reactions culminating in the "systemic inflammatory response syndrome" (sirs); the purpose of this study was to evaluate the influence of interleakin- on leukooyteendothelial cell-interactions and microoirculation in the liver after hemorrhagic shock by means of intravital microscopy. methods: in anesthetized female sprdrats co.w. - g) shook was induced by fractionated withdrawl of arterial blood within rain and maintained for h (map at mm hg, cardiac output % of baseline). rats were adequately resuscitated with % of shed blood and twice the volume in ringer's solution additionally. following h of reperfusinn (map > mm hg, co > % of baseline) the microcirculation in liver lobules was examined by intravital fluorescence microscopy after labelling of leukocytes. continuous administration of il-lra (synergen, boulder, colorado, mg/kg/h) was started at different time points in a randomized and blinded manner. the animals in group p (n= ) received the il-lra as pretreatment beginning min prior to shock induction. in the group t (n= ) the application of il-lm started at the beginning of the reperfusion period with a bolus injection of mg/kg and was followed by continuons administration of mg/kg/h. the control group c (n= ) received equal volumes in nac , %, the sham-operated group s (n= ) was not exposed to shock. results: macrohemodynamics were comparable in all shook groups. the increased percentage of permanendy adherent leukocytes after hemorrhagic shook (s: , % + , %; c: , % _+ , %) was significantly reduced by pretreatment or treatment with il-lra (p: , % -+ , %; p< . , t: , % -+ , %, p< . , anova). temporary adhesion of leukocytes was unaffected by application of il-lra. liver microcirculation measured by volumetric blood flow in liver sinusoids and sinusoidal diameters was impaired after hemorrhagic shock in all groups and was not affected (c: iam /s + um /s, p: llm /s + }am /s, t: ams/s -+ lam /s, s: am /s -+ am /s). di.seu~sinn: the results demonstrate that permanent adherence of leukocytes to endothelium is in part regulated by il- . pathological adherence could be reduced by application of illra, even given at die time of resuscitation. the effect of ll-lm on permanent adhesion is a specific event and might be caused by reduced expression of specific receptors on sinusoidal endothelial cens and leukocytes. objectives of the study. the adhesion of activated neutrophils (pmn) to endothelial ceils (ec) and the concomitant production of reactive oxygen metabolites (rom) initiates organ damage after trauma, sepsis, shock and organ reperfusion. aien of this study was to investigate the effect on adhesion and rom production of the highly water-soluble, membrane-permeable and physiological ascorbic acid (asc). materials and methods. adhesion of pmn to nylon fiber (cell count) and simultaneous rom production (chemiluminescence-cl-response) were measured up to retool/ asc as well as adhesion, rom production and ec damage (lllln-release from labeled ec) of endotoxin-activated pmn to cultered ec moanlayers. in an in vivo animal model (sheep with lung lymph fistulas) the effect of asc ( g/kg bw bolus, followed by . g/ kg-h infusion) on the endotoxin-induced ( . ixg/kg bw) neutropenia (cell count), lung capillary permeability damage (lung lymph protein clearance) and rom production of neutrophils (zymosan-induced cl response) was measured. results. asc scavenged rom dose-dependently during adhesion of pmn to nylon fiber (p< . at mmol/l asc), adhesion itself was unchanged. during the activated pmn/ec interaction asc scavenged rom (p< . at mmol/l asc) and reduced the adhesion dose-dependently (p< . at mmol/l asc); ec damage was also reduced (p< . at retool/ asc). in the in rive model asc increased the endotoxin-induced blood pmn decrease (p< . ), decreased the protein clearance (p< . ) as well as the zymosan-induced rom production (p< . ), indicating the asc-mediated reduction of adhesion, rom production and lung tissue damage processes. conclusions. by in vitro and in rive experiments ascorbic acid reduced the adhesion-and rom production-initiated tissue damage. therefore, i.v. administration of ascorbic acid is recommended for oxidative stress-associated states after trauma, sepsis, shock and organ reperfusion. for neut rophi l-accumulat ion and activation. we investigated the influence of or to the activation and the expression of lecam-i and cdiib,cdi on neutrophils and lymphocytes. methods: from blood samples (n= ) all white blood cells (wbc) and neutrophils (nc) were isolated and cultured. or were produced via the xanthine oxidase/hypoxanthine system. after , , , , and minutes a giemsa-staining to determine the granulation of neutrophils (n: normal, r : reduced ) and a facs-analysis with monoclonal antibodies detecting cdiib,cdi and lecam-i was performed. results: under the influence of or a degranulation of neutrophils starting at min was observed in wbc-cultures (n/r: min / , min / , min / , min / , min / ). these data were confirmed in the dot-plots of facs-analysis. only in wbc-cultures or induced a significant increase of lecam-i expression on neutrophils up to min followed by a decrease to normal values at min. lecam-i on lymphocytes disappeared totally during the observed period. cdllb,cdl -expression was not altered. conclusion:increased lecam-i expression on neutrophils due to or could enhance the 'rolling' of neutrophils along the endothelium which is a prerequisite for neutrophil sticking and migration. further or are able to activate neutrophils without endothelium. these changes seem to be mediated by other wbc. introduction. multiple organ failure (mof) has been hypothesized to be the result of an excessive uncontrolled autedestructive inflammatory response. since the complement system is an important mediator and initiator of the inflammatory response, interruption of this cascade could theoretically lead to an attenuation of mof. in order to test this hypothesis we evaluated the response of c -delicient mice in a model of zymesan indt~ed mof. materials and methods. c -deficient b d /oid and c -sufficient b d /new mice were used in this study. on day all mice received an intraperitoneal injection with zymosan suspended in paraffin in a dose of mg/g body weight. between day and , biological parameters (temperature, body weight and clinical condition) were measured daily and mortality was monitored. clinical condition was assessed by blindly grading the degree of lethargy, conjunctivitis, diarrhea, and ruffled fur of each mouse on a two point scale (maximum score= ). on day all surviving mice were sacrificed and relative organ weights of lungs, liver, spleen and kidneys (relative organ weight= (organ weight/body weight)x ) wore calculated. earlier experiments with our model have shown a good correlation between histological organ damage and relative organ weights. statistical analysis of biological parameter was performed using the koziol curve analysis. analysis was divided in an acute phase (day - ) and a late phase (day - ). relative organ weights were analyzed using wilcoxon's test and mortality rate using fischor's exact test. results. all zymosan injected mice showed a typical triphesic illness. deterioration of the clinical condition as indicated by the symptom score and the decrease in temperature and body weight in the acute phase were all significantly lass severe in c deficient mice (all p< . ). in the late phase no differences could be noticed in the courses of biological parameters. overall mortality was / ( %) in c deficient mice and / ( %) jn c sufficient mice (p= . ), a difference mainly due to a difference in the acute phase. organ damage assessed as the relative organ weights did not show any statistical differences for any organ between both strains. conclusion. complement factor c appears to play an important role in the acute hyperdynamic septic response in this model but deficiency of c could not prevent organ damage in the late mof phase. this suggests that other factors could be more important in the development of the inflammatory response leading to mof. proinflammatory cytokines are thought to play a critical role in the pathophysiology of multiple organ failure (mof). in mice, zymosan-lnduced generalized inflammation (ztgi) leads to mof. therefore we performed a sequential study into plasma levels of, and macrophage production capacity for, four cytokines during the development of mof in the zigi model. male young-adult c bl/ mice received zymosan ( mg/g body weight) intraperitoneally. groups of animals were killed after , , , and h and subsequently at each day until day . plasma was collected and peritoneal macrophages were isolated and cultured overnight with or without lipopolysaccharide (lps). interleukin -ct, and - (il-lc~,~,), and tumour necrosis factor-o~ (tnf-c were measured in plasma and culture fluid by means of a ria (detection limit . ng/ml). interleukin- (il~) levels were assayed using the b hybddoma cell proliferation assay. zymosan induces a three-phase disease in mice. after an acute phase the animals recover. around day , they start to develop clinical signs which resemble mof. plasma tnf-~ peaked within h after zymosan injection and disappeared within h. from day onwards, tnf levels started to rise again. plasma il- behaved almost similarly in the acute phase, but in the mof phase plasma il- remained low. no circulating il- could be detected at any time point. macrophage lps-stimulated production of il-lcq il- ~ and tnf--c~ was suppressed immediately after zymosan injection. production of il- and tnf-~ was normalized within h, while production of il-lc~ remained lower than that in macrophages from untreated control mice. only at day did production of il-i~ reach control values. il- production was higher than control values from day onwards. il production was similar to that of ili-il the production of tnf-ct was strongly elevated between days and and again during days to . the development of mof-like symptoms during zlgi in mice is accompanied by increased plasma levels of tnf-ct without enhanced il- or il- . also, the ability of macrophages to produce excessive amounts of il- and tnf--~, as well as the suppressed capacity to produce il-lcq could be important mechanisms in the pathophysiology of mof. when conjugated to an asialoglycoprotein, dna and oligonucleotides are specifically taken up by the hepatocytes via the asialoglyccprotein receptor which is unique to the liver. human asialoglycoprotein (~ -acid, asgp) was derivatized with low molecular weight poly(l)lysine(pll) and complexed with antisense dna's (as) complementary to the ' region of the il- gpl receptor. the antisense were '-agtttagggatgagg- ' (asl), '-atcttcatcttctgaat- ' (as ), '-aagtgaatgattaaaacact- ' (as ), '-aaacctttataggcg- ' (as ), and '-cgttctacaactgcaacgt- ' (as ). using hepg , the biological effects of these antisense complexes on the high affinity il- receptor were evaluated by scatchard analysis, cellular proliferation, and acute phase protein expression by radioimmunoprecipitation and two dimensional gel electrophoresis. scatchard analysis demonstrated that high affinity receptor expression was inhibited by incubation of cells with asgp-pll-asi for h. underivatized asl was less effective and the complex, asgp-pll-as , had minimal effects on high affinity binding. when the cells were treated with the conjugates and stimulated with il- (i units) asgp-pll-asi alone showed a dose dependent ( .i- . ~m) inhibition of ss fibrinogen synthesis. two dimensional gel electrophoresis showed that expression of other acute phase proteins was also blocked. these results indicate that the targeted delivery of antisense molecules via conjugates recognized by the asialoglycoprotein receptor can block the cytokine stimulated acute phase protein response in hepatocytes, this approach may be relevant to the therapeutic management of patients with severe injury and sepsis. it has been established that immune cells are able to express neuropeptide genes and to release products that were considered to be of neuroendocrine origin. we have shown that proenkephalin (penk), a neuropeptide encoding gene, is expressed in lymphoid cells in culture. to study the physiological significance of these observations we have used the model of experimental endotoxemia. in this model, a disease state is induced by bacterial lipopolysaccharide (lps), that activates the immune system, the adrenocortical axis and the nervous system. we found that the expression of penkmrna is markedly enhanced in vivo immediately after lps injection both in the adrenal glands and in the lymph nodes. in situ hybridization analysis combined with immunohisto-chemistry indicated that the induced penk expression is confined to macrephages within the lymph nodes and chromaffin cells in the adrenal medulla. furthermore, this expression in lymph nodes is modulated by ligands of the adrenergic system. our results strongly support the notion that immune derived opioids participate in the bidirectional communication between the nervous and immune systems. of neurology hadassah university hospital, jerusalem , israel. objectives of the study: multiple-organ-failure is recognized as the most severe, and often lethal, complication after multiple trauma. however there is no adeqate animal model available. our goal was to develop an animal model, in which reproducable irreversible failure of parenchymal organs is achieved in the late phase after insults in the early phase (trauma). materials and methods: l female merino-sheep were included (mean weight: kg). day : hemorrhagic shock (mean arterial pressure (map) mmhg for hrs.), closed femoral nailing (ao-technique), day - : bolusinjection of endotoxin (et) ( , ~tg/kgbw) und zymosan-activated plasma (zap) ( ml) every hrs., day - : observation. bronchoalveolar lavage (bal): day , , . the course of representative parameters of organ function was documented: cocardiac output (i/min), svr -systemic vascular resistence (dyn ~ s cm- ), pap -putm.art.pressure (mmhg), pap -arterial oxygen pressure (mmhg), bill -bilirubin (;xmov ), crci -creatinin clearence (ml/min) statistics: data as means+sem, *significant from baseline (wileoxon test; p< ) results: baseline day day day day heart: co , _+ , , _+ , , _+ , , _+ , * , _+ , * svr _+ + _+ +_ " +- " lung: pap , _- , , _+ , " , +- , " , + , " , +- , ' pap , + , , +- , , _+ , , +- , , +_ , * liver: bill , _+ , , _+ , ' , _+ , ' , _+ , " , _+ , " kidney:crcl , +_ , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , _+ , , + , , + , histologic specimens showed all signs of fulminant mof. combination of hemorrhagic shock, femoral nailing, et und zap (insults in the early phase) lead to an irreversible organ failure in the late phase. prostaglandin e (pge) levels are elevated by trauma, shock or sepsis and can profoundly affect the immune response. pge is produced by many cell types including fibroblasts, macrophages, monoeytes, follicular dendritic cells, and epithelial cells and is induced by il-i, bacterial lps, components of the complement cascade, tnf, il- and crosslinking of surface fc receptors for igg, iga and ige. our research has shown that pge inhibits b cell activation (specifically enlargement, class ii ~c and fc~ rii expression), proliferation, igm and igg responses, t cell proliferation, and il- synthesis in the mouse model. in contrast, pge greatly promotes class switching to ige,the isotype responsible for type i allergic hypersensitivity. thus, our model mirrors th~ general immunosuppression and elevated ige titers of the trauma or sepsis patient. pge increases the number of cells secreting ige and iggl, acts on surface igm positive b cells, synergizes with il- and lp$ to induce preswitch germline transcripts, and induces more rapid expression of mature vdj~ mp~a than in eontro~ pge intracellular signalling occurs through cyclic adenosine monophosphate (camp) levels and can be mimicked by camp-inducing agents and blocl~ed by an inhibitor of campdependent protein kinase a. pge action requires de novo protein synthesis and candidate pge-inducible regulatory proteins have been identified by d gel eleetrophoresis. thus, pge inhibits a number of immune mechanisms while promoting ige production. a deeper understanding of pge immune regulation may lead to more effective treatment of immune perturbations as sequelae of trauma, shock or sepsis. during infrarenai aortic surgery mesetueric traction (re.t.) results in prostacyclin (pgi:) release and consecutively in hemodynamic disturbances (decreased systemic vascular resisteace, mean arterial pressure; increased cardiac output, heartrate). these symptomes are bypassed by cyclooxygenase inhibition. hemodynamic symptoms vanish after - rain even without cyclooxygenase inhibition although pgi levels remain elevated. to study the endocrine vasopressor system in a prospective double blinded protocol, we investigated patients undergoing major abdominal surgery as compared to ibuprofen ( rag, i.v.) pretreated (ibu) patients. the surgeon applied m.t. in a uniform fashion. we chose a general anesthesia combined with a supplemental thoracic epidural anesthesia. at the points in time , , , , , , , rain after and before (to) mesentzrie traction we determined the plasma concentrations (pc) of -keto-pgf~o~pr~, epinephrine, norepinephrine, dopamine, renin, aldosterone, adh and cortisol. pc of -k-pgf~,tp~, peaked minutes after m.t. ( _+ , ibu: _+ , to: +i ng/l) and declined monotonously over h ( +_ , ibu: _+ ng/ ). catecholamine pc "s did not exceed the reference range during the observation period. reninpc peaked after rain ( _+ , ibu: + , to: -+ /~u/ml); aldosteronc also presented a maximum after rain ( + , ibu: -+ , to: +- pg/ml), whereas cortisol demonstrated irrespectively of circadian rhythms a maximum h after m.t. ( +_ , ibu: -+ , to: +_ ~g/ ). adh pc peaked min after m.t. ( + , ibu: -+ , to: +_ pg/ml) and showed analogously to -k-pgft~j~ pc a monotone decline over the observation period. our data demonstrate a counteractive reaction to pgiz mediated vasodilation via adh secretion. the second regulative is the renin-angiotensin-aldosterone system (raas), which is activated min after m.t., the aldosterone pc does not paratlel the cortisol pc, which peaked post operafionem in both groups, probably due to the end of anaesthesia. a regulative release of catecholamines could not be documented. the activation of adh and raas after mt is not a hormonal response primaryly related to surgical trauma and/or stress but a counterregulation to systemic vasoditafion induced by prostacyclin. although adh and raas support systemic circulation, angiotensin and vasopressin may compromise local organ blood flow (e.g. splancimic vascular bed). insfitut f. klin. chemic, anaesthesiologie ~, chirurgie l*, univ. ulm, elm, expression of c-fos protein in rat brain following occlusion of superior mesenterie artery. takanobu there is general agreement that neurologic abnormalities are seen in sepsis. the aim of this study is to examine what effect does the brain receive in case of sma occlusion by immunohistochemistry using antibody to c-fos, an immediate early gene, which is recently recognized as a genetic marker of activated neurons. moreover, we investigated the correlation between c-fos induction in the brain and plasma endotoxiu level. rats of them received sma clipping and others wee used as control. control and treated rats at , , , hours were perfused and fixed. the brain were sectioned at pm and stained by abc method using c-fos antibody. plasma endotoxin level of rats were measured at , , , , hours after the treatment by chromogenic limulus method. immunohistochemical study showed scarcely no immunoreactivity in control rat brain. in treated rat brain, the significant expression of c-los was detected in specific nuclei including the habenula, some hypothalamie nuclei, amygdala, locus ceruleus and nucleus tractus solitarii. such immunoreactivities were increased in time curse, which well corresponded plasma endotoxin levels. the mean plasma endotoxin level of , , , , hours after the treatment were . ± . , . _- - . , . _+ . , . ± . and . ± . pg/ml, respectively. the results indicate that limbic and hypothalamic-brainstem systems are involved in sma occlusion, and suggest that such neuronal actival.jon may precede the elevation of plasma endotoxin icy.el. systemic vascular resistance and increased cardiac output accompanied presumingly by a increased pulmonary shunt (qs/qt). this response is induced by prostacyclin (pgi ). we examined oxygen transport after traction on the mesentery root and the transpulmonary prostacyclin levels in a prospective placebo controlled study with intravenous ibuprofen. methods: with approval of the human [nvestigadon review board we studied patients in a prospective, randomized double-blinded protocol who were scheduled for major abdominal surgery. ibuprofen ( mg i.v.) or a placebo equivalent was administered minutes before skin incision. pulmonary artery thermodilution and radial artery catheters were placed after induction of anesthesia. mt was applied in a uniform fashion. baseline values preceded the incision of the peritoneum (to). fulther assessments followed , , , , . tile plasma concentrations (pc) of -keto-pgft, (stable metabolite of pgi ) were determined in arterial and mixed venous blood by radioimmunoassay. at all points in time we measured arterial and mixed venous blood gases. qs/qt was calculated by standard formula. data are given as median (p < . placebo vs. [ibuprofen] [ ] mmhg (*p< . i). these changes were accompanied by a marked increase of -keto-pgf~ pc up to rain after mt in arterial and mixed venous blood of untreated patients with a peak of *[ ] ng/l tl (*p< . ol). there was no difference between arterial and mixed venous pc. ibuprofen pretreated patients (n=zr) demonstrated stabile qs/qt and pao while -keto-pgf~ pc remained within the normal range. discussion: our data clearly indicate that mesenteric traction response includes a critical rise in qs/qt followed by significant decrease of paov stable oxygen transport determinants following cyclooxygenase inhibition signify an action mediated by prostacyclin. an indicative transpulmonary gradient for -keto-pgft~ was not detectable. a splanchnic vascular source for pgi release seems to be likely, but could not be proved by our current data. department of anesthesiology, cliu. chemistry * and surgery*; university clinics uim, prittwitzstral]e , ulm, germany it is unclear whether injuries like bums, in general, directly result in alterations of cell-mediated immunity that, in turn, promote endotoxic and bacterial translocation or, alternatively, whether these conditions allow increased bacterial invasion that, in turn, inhibits cmi. aim: to determine whether infectious challenge, as clp alone or combined with ti causes further immune abnormalities in the days following clp. study plan: on day , two groups of n= week old aj mice were subjected to either a % scold burn (ti), or were untreated (c) n= . on day , mice (ti+clp) and mice (clp) were subjected to clp. the two other groups (ti and c) were untreated. at days , and after thermal injury splenocytes (sp) were harvested and cultured with cona for an assay of il- and adherent splenocytes (as) were cultured with lps for il- , tnf, il- and pge . results: either ti + clp or clp alone result in significantly decreased secretion of all cytokines tested. in the ti group almost every cytokine production determined was elevated in comparison to ti + clp and prosmcyclin (pgi ) has been implicated in the pathophysiology of septic shock. however, pgi~'s role in the inflammatory response to sepsis is not well-defined. the purpose of this study was to identify which acute septic events are mediated by pgi during graded bacteremia. methods: eleven ~nesrhetized, hemodynamically monitored adult swine were infused iv with aeromonas h. ( /ml) at rates increased incrementally from . to . mi/kg/hr over hours. animals were studied in two groups: septic control (sc), graded bacteremia only (n= ); pga (n= ), graded bacteremta plus anti-pgiz antibody, ml/hr iv, beginning at hours. mean systemic (map) and pulmonary arterial (pap) pressures and arterial po , mmhg, cardiac index (ci), l/min/m , oxygen delivery index (do i) and consumption index (vozi), ml/min/m , and oxygen extraction (er), %, )latelet aggregometry (plt), %max., plasma pg -keto f alpha ; in the first instance~ peak values of lt ~ after i~ hrs post infarction were times higher than in the controls and excess leucocyte infiltration was noted at the infarction zone. in second instance two levels of lt b led to weak infiltration of the infarction zone by leucocytes. a. mo~e~o, in~.~p~siolo~,d~t.e~.cardiolo~,bogotsolets , ~ev , ukrmne systemic lesion$of erythron in traumatic disease and possibilities of their regulation by opioid peptides. redkin y. v., fominih s. g. using clinical ( patients) and experimental material( rats and dogs) we revealed general regularities of erythron lesions after hard mechanical trauma of various genesis as well as some mechanisms of development of posttraumatic anemia and possibilities of its correction with preparations of opioid peptides. the condition of central and peripheral compartments of erythron was studied with unified morphologic, immunogematological, biochemical and radiological methods. it was revealed that irrespective of the experimental animal species (dogs, rats) or in clinical experiments (patients) and irrespective of the injuring factor type (skeletal trauma, craniocerebral trauma, loss of blood) in erythron can be observed one-directed unspecific reaction realized by the considerable lowering of hemoglobin concentration, erythrocytes number and hematocrit. in the initial period ( - days) in the system of erythron prevail processes of distraction and elimination of er~zthrocytes relatively to the general production of stimulated erythropoiesis. the primary alterating factor is the prolonged intensification of peroxydation of membrane iipids of erythrocytes with simultaneous lowering of reserves of reduced glutathione. the distraction of erythrocytes is supported by the developing phenomena of autoallergization of organism that becomes apparent by the appearance of sensitized t cells and antierythrocyte antibodies. the intensified production of erythropoietin rules to the realization of he program of fetal and terminal (reserved) erythropoiesis. failure of erythropoiesis function is supported by disturbances of the processes of the injuring of cell metabolic apparatus. using of dalargin ( microgram per kilogram of body mass intrap'eritoneally within days after the trauma) showed the precise pharmacotherapeutic effect revealed by the diminishing of anemia of experimental rats, more . fiberbronohoscopic procedures are known to produce "peep-like" effects and to increase pulmonary artery (pa) resistance [ ] . peep can affect rv function by reducing preload and ejection fraction (ef) [ ] . since changes of rv function during bronchoscopy in septic patients are not reported, we measured rv parameters before, during and after fiberoptic bronchoalveolar lavage (bal). method: this -year-old patient (apache-ii: ) developed a hyperdynanlic septic state due to staphylococcus aureus (blood culture). we inserted a "fast response" thermistor pa-catheter (baxter-edwards) to evaluate rv performance [ ] . the therapeutic procedure included volume replacement, vasopressors (dopamine , dobutamine gg/kg/min. iv) and analgosedatior/. before bronchoscopy (olympus bf- , od= mm) the patient received pancmonium for muscle relaxation. ventilation was not changed during the procedure (endotracheal tube: id= ram, bennett a, pressure controlled mode, pm~x= mbar, peep= mbar, i:e=i:i, fio = . ). we measured rv enddiastolic volume (edv), stroke volume (sv), ef, heart rate (hr), cardiac index (ci) and mean pa pressure (mpap gerlach h, gerlach m, clauss m, falke kj renal hypoxia and/or ischemia initiates the development of a deteriorated medullary perfusion based on fibrin deposition in the peritubular capillaries, vasoconstriction, and perivascular edema, which is followed by a swelling of the tubular epithelial ceils, intraluminal tubular obstruction, and a backleak of fluid through the injured tubules into the renal interstitium, finally leading to an acute tubular necrosis (atn) [ ], clinically diagnosed as acute renal failure (arf). one important pathway for induction of enhanced vascular procoagulant activity and permeability is based on the synthesis and expression of macrophage-derived cytokines, which bind to specific endothelial cell surface receptors. we recently described the identification and purification .of a new , dalton polypeptide, which is synthesized and expressed by murine macrophages after stimulation with lipopolysaccharide, and exerts procoagulant activity on cultured endothelial cells [ ] . in the presented study, we demonstrate that the new polypeptid is also synthesized by macrophages under hypoxic conditions. the protein binds to specific receptors, which are expressed by endothelial cells dependent on the environmental oxygen tension. animal studies were performed after approval by the local committee for animal safety; the animals were anesthetized, treated and supervised in accordance with the guidelines of this committee. in contrast to other authors, who performed long-term hypoxia experiments in awake animals, we preferred to implement the studies under anesthesia for ethical reasons, although regulatory functions for ventilation might be influenced. animal studies demonstrated that the intravenous injection of the polypeptide initiates fibrin formation in the peritubular vessels. keeping the animals under hypoxic conditions induces similar effects, which are reduced by a rabbit-antiserum against the new protein. in conclusion, the new polypeptide obviously contributes to the pathogenesis of acute renal failure by tubular necrosis during and after hypoxic events. the use of verapamil as cardioprotective agents for management of patients with acute ischemic/reperfused heart is based on the assumption that the increased intracellular ca+ level is a key factor in causing cell death. our in vitro study was designed to focus on effects of verapamil on the metabolic potential of cardiac slices after reversible ischemia in rats. the material consisted of two main groups : group a (non ischemia/reperfusion group) and group b (ischemia/reperfusion group), each is subdivided into two subgroups (a and b). each subgroup included rat hearts. group aa is the control group, group ab is verapami] added group. group ba is ischemia group without verapamil. group bb is verapamil added group. ischemic cardiac slices were obtained from rats subjected to min. haemorrhage to induce reversible global ischemia. both nonischemic and ischemic cardiac slices were placed in well oxygenated krebs ringer phosphate buffer containing mg% glucose & gm% bovine albumin and incubated in dubnoff shaking water bath for min at °c the results revealed that there was an enhancement in release of free fatty acids (ffa) ( %) and lactate ( %) and in glucose uptake ( %) in group ba as compared with group aa. these metabolic alternations produced by ischemic cardiac slices were reversed by verapamil addition ( ml%) but in group ab verpamil did not alter the release of ffa & lactate from non-ischemic cardiac slices, whereas it inhibited glucose uptake from these slices by %. the improvement of the metabolic intervention of ischemic myocardium indicates that verapamil may be of importance in reducing the extent and severity of acute myocardial ischemic injury in acute haemorrhage. severe endothelial dysfunction occurs following injury to carotid arteries which is characterized by a decreased ability of these arteries to dilate when challenged with ach or a , but not with a direct vasodilator (nano ). this failure to relax to ach and a reflects an inability of endothelium to generate edrf, but relaxation recovers gradually to control values by weeks. exogenous no donors (e.g., c - or spm- ), accelerate the recovery of the injured endothelium in rat carotid arteries. intravenous infusion of an no donor ( p.g/day) with an implanted osmotic pump significantly accelerated the recovery of regenerated endothelium to produce edrf at days. rat carotid artery rings relaxed only + % and + % to gm ach in vehicle treated rats and in inactive no donor treated rats respectively days following injury compared with + % in no donor rats (p< . ). relaxation to gm nan was normal in all groups indicating that the differences in relaxation were not the result of damage to vascular smooth muscle. contraction to l-name ( mm) was markedly reduced by injury, but was protected by no donors (p< . ). thus, exogenous no donors enhance the ability of the endothelium to regenerate and to release edrf in response to endothelium-dependent vasodilators. this may be due to an anti-proliferative and anti-mitogenic effect of no on vascular smooth muscle cells, allowing the endothelium to regenerate without intimal thickening. no also has been shown to inhibit platelet aggregation, and to attenuate neutrophil adherence and activation. the superoxide scavenging effect of no is not the basis for these effects since hsod is inactive in preserving endothelial function in injured arteries. thus, no exerts a variety of cytoprotective effects which may be of importance in protecting against vascular injury. much evidence has now accumulated to show that the excess production of the vasodilator nitric oxide (no) in sepsis is an important contributor to the hypotension and multiorgan failure characteristic of this condition. various cytokines play an important role in this process through their ability to induce the production of one of the enzymes responsible for no synthesis, the inducible no synthase (inos). we have studied the effects of cytokines on the induction of this enzyme both in vitro using vascular smooth muscle cells, and in a murine model of gram-negative sepsis. tn smooth muscle ceils, the cytokines il- , ifnq', and tnf-oc show strong synergy with one another in the production of inos. in order to define the molecular basis for this synergic effect, we have linked the promoter of the inos gene to a "reporter" gene, chloramphenicol acetyl transferase (cat), and transfected these constructs into vascular smooth muscle cells. assays of cat activity reflect the activity of the promoter in this system, and by generating sets of deletion mutants of the promoter sequence we have been able to define the area within the promoter which mediates the synergic effect of these cytokines. in addition to stimufatory effects on inos production, certain cytokines are able to down-regulate the production of inos in vascular smooth muscle cells, and the effects of these counterregulatory cytokines will be discussed. the interaction of these cytokine effects in the whole organism has been studied in a murine model of gramnegative sepsis. widespread induction of inos occurs in this model as assayed by enzyme activity and through use of specific antisera to inos. neutralizing antibodies to tnf-~ and tfn-y are both able to prevent death in this model, but it is only the anti-ifn-y which attenuates the induction of inos assayed in the liver. clearly there is some redundancy in the effects of cytokines on the production of inos in sepsis, and greater understanding of the most important factors in inos production is required in order to target anti-cytokine therapy most appropriately. effects of nitric oxide on hepatocyte metabolism in inflammation. j. stadler, department of surgery, tu mqnchen, frg hepatocellular nitric oxide (no) synthesis is induced by proinflammatory mediators such as tumor necrosis factor, interleukin- and interferon gamma or by bacterial toxins such as lipopolysaccharide. stimulation of the hepatocytes (hc) with a combination of these agents leads to an output of no in quantities which are not seen in any other celltype. it has been demonstrated by various investigators that important effects of these cytokines and bacterial toxins on hc metabolism can be attributed to the action of no. in contrast to other celltypes hc seem to be relatively resistant to suppression of basic metabolic functions such as energy metabolism by no. therefore, cell damage has not been described to a significant extent following exposure to no. however, no does inhibit total protein synthesis. the exact biochemical mechanism of this phenomenon has not been uncovered yet, but it has been demonstrated for some specific proteins that their production is inhibited at a posttransscriptional level. as in many other celltypes cgmp generation is elevated in hc by no through activation of the soluble guanylate cyclase. cyclic gmp may possibly exert a plethora of metabolic functions, but it is interesting to note that most of the cgmp seems to be transported out of the cell. some very specific effects of no on hc metabolism include the inhibition of the glyceraldehyde- -phosphate dehydrogenase (gapdh) and the cytochrome p (cyp) enzymes. inhibition of gapdh activity is mediated through nitrosylation of critical domains of the enzymes by no which enhances auto-adpribosylation. this effect on gapdh activity might be responsible for the inhibition of gluconeogenesis by no, which has been described recently. finally, no-mediated inhibition of cyps may help to explain the suppression of hiotransformation processes which is a characteristic featur,'~ r ~ "~flamed liver. nitric oxide (no) is an endogenous inhibitor of polymorphonuclear leukocyte (pmn) adhesion which limits pmn-endothelial cell interactions under normal conditions. we have previously demonstrated that following ischemia, no production by the vascular endothelinm is dramatically reduced. accordingly, we investigated the effects of no-donors on pmn accumulation and tissue injury following hemorrhagic shock and ischemia. hemorrhagic shock was induced in anesthetized rats by bleeding to mmhg for hours followed by reperfusion. segments of superior mesenteric artery (sma) were isolated and suspended in organ baths. in rats receiving saline sma relaxation to acetylcholine (ach, nm) was reduced by % compared to control sma segments (p< . ) while relaxation to sodium nitrite ( gm) was unaffected. in addition, mesenteric tissue pmn accumulation as determined by myeloperoxidase (mpo) activity was significantly elevated compared to controls (p< . l). interestingly, treatment with the no-donating agent, s-nitroso-n-acetylpenicillamine (snap) significantly preserved sma relaxation (p< . ), attenuated mesenteric mpo (p< . ) activity, and significantly improved survival compared to saline vehicle. in anesthetized, open-chest dogs we investigated the cardioprotective actions of a novel no-donor, spm- (schwarz pharma), following regional myocardial ischemia ( hour) and reperfusion ( . hours) . treatment with spm- ( rim) significantly reduced myocardial necrosis by % (p< . ) compared to an no-deficient analog of spm- , spm- . furthermore, mpo activity within the ischemic-reperfused zone was also significantly (p< . ) reduced following treatment with spm- compared to spm- ( . + . vs. . + . u/ mg tissue). these data strongly suggest that no is a potent inhibitor of pmn-mediated tissue injury following hemorrhagic shock as well as in acute myocardial ischemia-reperfusion injury. overproduction of nitdc oxide (no') may contribute to sepsis-induced hypotension. during septic shock, excess no" is produced by an isoform of nitric oxide synthase (nos) which is induced by inflammatory mediators. nonselective nos inhibitors have been proposed as a new therapeutic approach to treating hypotension in septic shock. we studied the differential hemodynamic effects of n~-methyi-l-arginine (l-nma), a nos inhibitor, in normal canines versus those challenged with endotexin (lps) and compared the activity of this drug across the venous, pulmonary and systemic vascular beds. awake canines were challenged with lps ( mg/kg, n= : mg/kg, n= ; or mg/kg, n= ) and treated with l-nma ( , , , , mg/kg/hr) for hours following a , , or mg/kg loading dose. animals were resuscitated with iv ringers solution ( ml/kg/hr). hemodynamic data were collected at , , , , , and hours using intravascular catheters and radionuclide heart scans and analyzed by anova. in both normal and endotoxemic animals, l-nma at all doses studied similarly increased mean arterial pressure (p= . ), and systemic vascular resistance index (p= .ol) and decreased cardiac index (p= . ) and oxygen delivery index (p= . ). in contrast, the effect of l-nma on mean pulmonary artery pressure, central venous pressure, pulmonary capillary wedge pressure, and pulmonary vascular resistance index was greater in lps-challenged canines compared to normal animals (p< . ), but this differential effect on the venous and pulmonary circulation occurred, > hours after lps challenge. l-nma did not significantly increase survival rates or times at any of the doses studied ( , , , or mg/kg/h) in either the low ( mg/kg) or high dose ( mg/kg) lps-challenge groups. a nonsignificant (p> . ) trend toward a beneficial effect on survival ol low dose l-nma ( mg/kg/h) in animals given the mg/kg lps-cha[lenge was not enhanced by increasing the lethality of the model or by administering higher l-nma doses. at the highest l-nma dose used in this study ( mg/kg/h), survival time decreased significantly for both the low and high dose lps-challenge animals (p< . ). this increased mortality was not explained by changes in plasma concentrations of either lps or tnfc~. thus, l-nma did not have a greater effect on the systemic arterial circulation in endotoxemic compared to normal canines. however, in the venous and pulmonary vascular beds, the effect of l-nma increased with time after endotoxin-challenge these data suggest the induction of nos activity by endotoxin in canines may be relatively greater in venous and pulmonary vessels compared to systernic arteries. l-nma, a nonselective nos inhibitor, did not decrease mortality in endoloxemic canines and the highest dose studied was harmful. pulmonary hypertension (ph) and arterial hypoxemia are characteristic features of the adult respiratory distress syndrome (ards). reducing pulmonary vascular pressures may promote the resolution of pulmonary edema. intravenously infused vasodilators lower ph in ards, but, as a result of their general vasodilatatory effects, systemic mean arterial pressure may also decrease. furthermore, blood flow may be increased to non-ventilated or poorly ventilated lung areas resulting in a rise of intrapulmonary shunt, thus causing a further fall in pad . recently, short term inhalation of low concentrations of the gas nitric oxide (no), an endogenous endothelium derived relaxing factor, which is rapidly inactivated in blood by hemoglobin, was reported to decrease ph without causing systemic vasodilation in sheep [ ]. similar changes have been observed in patients with severe ards during repeated short term inhalation of no ( and ppm), which rapidly and selectively decreased the mean pulmonary artery pressure (pap) and, in contrast to intravenously infused prostacyclin, induced a remarkable increase of pad [ ] . this improvement in oxygenation was caused by a redistribution in blood flow away from intrapulmonary shunt areas to normal ventilated lung regions. continuous no inhalation ( - ppm) consistently lowered the pap and augmented the pao /f.o for up to days. no negative side effects were observed during the whole time span examined. in particular methemoglobin levels always remained below . %. following these investigations, it could be shown that these effects may also occur using concentrations in the parts per billion range [ ] , which may reduce possible toxic side effects. however, in the same study it was demonstrated that the dose-response curves for pa and pap have different patterns. whereas pap presented a continuous dose-dependent downward tendency with an eds o of approximately - ppm, the improvement of oxygenation had a maximum at ppm and, at higher doses, drifted back towards the baseline data. the ed~o was estimated at approximately ppb, i.e. more than ten times lower than for the reduction of pap. in conclusion, inhalation of no by patients with severe ards may result in persistent and reproducible decreases in pap associated with an evident improvement in pad , thus allowing reduction of the f.o . no inhalation should be performed using low concentrations which are less toxic, although any possible risks still have to be considered carefully. dose-response studies for the individual patients are recommended urgently. finally, controlled randomized studies are required to demonstrate that additional no inhalation is able to reduce mortality of ards. inhibition of the activity of glyceraldehyd- -phosphate dehydrogenase (gapdh), an enzyme of the glycolysis/gluconeogenetic pathway, through adp-ribosylation is promoted by nitric oxide (no). since no is produced in the septic liver and hypoglycemia is a major problem of late sepsis, it was investigated whether no interferes with gluconeogenesis of hepatocytes. hepatocytes (hc) were isolated from sprague-dawley rats using a collagenase perfusion technique and differential centrifugation. exogenous no was applied by incubation with the no-donors s-nitrosyl-acetylpenicillamine and sodium-nitroprusside. endogenous no synthesis was induced by incubation with cytokines (tnfcq il- , ifnj and lipopolysacchafide (lps). hrs later the incubation medium was changed to a solution containing lactate, ornithine, lysine, ammoniumchloride and glucagon for optimal conditions of gluconeogenesis. after more hrs glucose and nitrite levels were determined spectrophotometrically. gapdh activity was measured by the nadh-dependent conversion of , -diphosphoglycerate to glyceraldehyde- -phosphate. incubation of hc with no-donors led to a concentrationdependent inhibition of gluconeogenesis and gapdh activity. however, gapdh activity was about times more sensitive to the inhibitory effect of exogenous no. incubation of hc with cytokines and lps induced nq synthesis as measured by an increase in nitrite concentrations. endogenously produced no suppressed gluconeogenesis by _+ %. in contrast to exogenously applied no, the effect of endogenous no synthesis was less on gapdh activity resulting in an inhibition of only _+ %. in conclusion, exogenous and endogenous no inhibited gluconeogenesis as well as gapdh activity. however, there was no correlation between the extent of inhibition of these two parameters of hepatocellular glucose metabolism. we have shown that inhibition of hepatocyte (hep) synthesis of nitric oxide (no) potentiates cell injury in a model of acetaminopheninduced oxidative stress and the extent of damage was paralleled by depletion of reduced glutathione (gsh) stores. to clarify the role of no in modulating the redox state of hep, we studied the effect of inhibition of cytokine-mediated no production on hep gsh stores, in a system of isolated rat hep in primary culture, no synthesis was induced (stim) by exposure to il- , tnf, ifn, and lps for hours. , , and ~m of n-monomethyi-l-arginine (nmma), a specific inhibitor of no synthesis, was added. cells incubated in media alone served as controls (cont). the no metabolite (no ); aspartate aminotransferase (ast), an indicator of cell injury; and gsh were assayed. (data presented as mean + sem; n= .) gsh (nmovma orotein) ..~ (nmol/ma orotein) cont . + . + . # stim . + . + stim+ o tzm nmma . + . + . # stim+ ~m nmma . _..+ . * + . # stim+ pm nmma . + . * + . # stim+ )lm nmma . + . * + . # anova , . (* p < . versus stim, # p < . versus stim; anova with neuman-keuls) gsh in cont+ i~m l-nmma was equivalent to that of cont ( . vs. . ). ast release was equivalent in all treatment groups. these data show that inhibition of hep synthesis of no depletes intracellular stores of reduced gsh. we conclude that hepatocyte no production modulates cellular gsh homeostasis and as a result, may be hepatoprotective in oxidative injury. nitric oxide (no) is a modulator of immune response and may be involved in the changes in immune reactivity after major trauma and operations. we investigated no-generation in rat and mice spleen cells (sc) after partial hepatectomy (ph). c bl/ mice and lew rats underwent a % and % ph, respectively. sc were prepared - days after ph and plated at to x ecells per well. after h incubation at °c, no-production was measured as nitrite levels (griess reagent). normal mouse sc did not produce no, neither basal nor in response to lps or con a starting at the second day after ph, we found a substantial production of no. in rats, also sc from control animals were able to generate no; both basal and stimulated no-generation were further enhanced after ph (table, values expressed as mean --se). after shame operation, there was only a modest elevation of noproduction in rat and mouse sc. in first experiments we could demonstrate no-production also in phagocytes from a patient days aider liver partial resection ( . nmol nitrite/ cells) enhanced no-production in macrophages may contribute to the changes of immune reactivity after partial hepatectomy. nitric oxide (no) is recognized as an important mediator in endotoxemia and sepsis. increased synthesis of no has been demonstrated in septic humans and animals, and no inhibitors have been used in the treatment of septic shock. recent reports have, however, suggested that this form of therapy may cause serious organ damage. in the present investigation circulatory and metabolic changes in the liver were studied during treatment with the no-synthase inhibitor n-nitro-l-arginine-methyl ester (l-name) in endotoxemia. methods: juvenile pigs were randomized to one of the following treatment groups: ) encletoxin and l-name, ) endotoxin, ) naci and l-name, ) nach preliminary results from groups (n= ) and (n= ) are presented. catheters for pressure measurement were introduced into the aorta, hepatic and portal veins and ultrasonic transit time flow probes were placed on the hepatic artery and portal vein. a catheter was introduced into the pulmonary artery. endotoxin ( . gg/kg/h) was given as a continous portal infusion over the entire observation period of hrs. l-name ( mg/kg) was given as a bolus after hrs. of endotoxemia. results: endotoxin transiently reduced portal vein flow (pvf) by %* and hepatic artery flow (hal e) by %*, while l-name caused a further and lasting reduction in flow (pvf %, haf %)*. transhepatic (portal-hepatic vein) vascular resistance increased to times baseline value during endotoxemia while l-name caused a further marked increase in resistance to times initial value. portal oxygen saturation (so ) decreased by %* during endotoxemia. l-name caused a reduction in portal so by %*. arterial so was unchanged in both groups. hepatic oxygen uptake was not changed by endotoxin, but was markedly reduced after addition of l-name. endotoxin caused a % reduction in cardiac output (co). the addition of l-name reduced co by a total of %*. *: p < . . conclusion: is the present model of endotoxemia treatment with the nitric oxide synthase inhibitor l-name markedly reduced liver perfusion and portal oxygen supply. this might explain the increased liver damage reported in previous studies using no-inhibitors. the increase in transhepatic resistance found after l-name treatment will tend to cause pooling of blood in the splanchnic veins, resulting in reduced filling of the heart and thus contribute to the observed reduction in cardiac output. institute for surgical research, rikshospitalet, the national hospital, university of oslo, oslo, norway. we have investigated the role of tumour necrosis factor (tnf) and interleukin-i (il-i) in the induction of nitric oxide synthase (nos) by bacterial endotoxin (lipopolysaccharide; lps; mg kg -i i.v.) in vivo. in anaesthetized rats, pretreatment with a monoclonal antibody for tnf (tnfab; mg kg -i s.c., at h prior to lps) or with an il-i receptor antagonist (il-ira; mg/kg bolus and . mg/kg/h infusion) ameliorated the fall in mean arterial blood pressure (map) at - min after lps. for instance, endotoxaemia for min resulted in a fall in map from -+ (control) to -+ mmhg (p< . ; n= ). in contrast, animals pretreated with tnfab or il-ira prior to lps injection maintained significantly higher map at min when compared to lps-control: -+ mmeg (n= ) and -+ mmhg (n= ), respectively (p< . ). three hours of endotoxaemia significantly reduced the contractile effects of noradrenaline (na) in the thoracic aorta ex vivo. the hyporeactivity to na was partially restored by in vitro treatment of the vessels with ng-nitro-l-arginine methyl ester (l-name, min, x - m). pretreatment of rats with tnfab or il-ira significantly (p< . ) prevented the lps-induced hyporeactivity of rat aortic rings ex vivo. l-name did not alter or only slightly enhanced the contractions of aortic rings obtained from tnfab or il-ira treated lps-rats, respectively. at min after lps there was an induction of calcium-independent nos activity in the lung ( . -+ . pmol citrulline/mg/min, n= ), which was attenuated by tnfab and !l-ira by -+ % and -+ %, respectively (n= ; p< . ). thus, the production of both tnf and il-i contributes to the induction of nos by lps in vivo. the protective effect of agents which inhibit the release or action of tnf or il-i in shock may be, in part, due to inhibition of nos induction. neal garrison, md objective: sepsis is often accompanied by organ dysfunction, in part due to impaired microvascular perfusion. recently, nitric oxide (no) has been described as an important mediator of the hemodynamic changes of sepsis, and no synthase (no-s) inhibitors have been advocated for treatment of septic shock, but their visceral microcirculatory effects are inadequately characterized. we postulated that no-s inhibition would exacerbate the impaired organ perfusion of sepsis. methods: six groups ofdecerebrate rats were studied. bacteremia was induced with live e. coli, which consistently increased cardiac output - % above baseline (bl). the no-s inhibitor nm-nitro-larginine methyl ester (l-name, mg/kg iv), prevented this increase and elevated map by - %. in the first groups, total hepatic blood flow (thbf, ml/min by time transit flowmetry) and microvascular perfusion (mi-ibf, ¼ bl by laser doppler flux) were measured. in the other groups, in vivo videomicroscopy was used to observe renal microvascular responses (ila=interlobular artery, aff=afferent arteriole, eff=efferent arteriole; % bl for all). results: data are rains after e. cob. n= - /group. * p< . vs bl by remanova and § p< . vs e. coli alone by anova. ec+l-name -+ - _+ " § - _+ * § - _+ * § - + * - + * § conclusions: l-name administration in controls decreased renal blood flow, indicating no contributes to basal renal tone. bacteremia decreased mtlbf but not thbf, and mi-ibf was further impaired by no-s inhibition. e. coli caused renal preglomemlar, but not postglomerular constriction and reduced flow. l-name exacerbated these e. coli-induced alterations and caused eff constriction. these data indicate that no-s inhibition exacerbates bacteremia-induced impairment of renal and hepatic blood flow, suggesting that no is an importam compensatory dilator mechanism in these organs during sepsis. irf (iron responsive factor) is the central regulatory protein of intracellular iron metabolism able to bind to responsive rna elements (ires) present atthe 'untranslated region (utr) of ferritin mrna and 'utr of transferrin receptor mrna. binding of irf to ires results in repression of ferritin mrna translation and increased stability of transferrin receptor mrna leading to enhancement of transferrin receptor translation. we describe here that either tetrahydrobiopterin dependent stimulation as well as cytokine (ifn-~)/lipopolysaccharidemediated induction of nitric oxide synthase activates irf, which is due to direct interaction of nitric oxide with the iron-sulphur-cluster of irf. this was shown by gene expression studies using a plasmid containing a ferritin ire and a cat indicator box which was transfected into k myelomonocytic cells, which were shown to have a constitutive form of nitric oxide synthase (nos). furthermore, the increased binding of re to irf due to irf activation of irf by nitric oxide was demonstrated by gel shift assays. irf activity was much more increased in cellular extracts from murine macrophages (j ) where a cytokine inducible form of nos has been characterized earlier as compared with irf activity in k cells, where nos was stimulated by increasing the availability of the essential nos cofactor , , , -tetrahydrobiopterin. we then demonstrated that activation of irf by nitric oxide is accompanied by alterations in ferritin translation as checked by metabolic labeling and immunoprecipitation. these results suggest a reasonable mechanism for the regulation of iron disturbances under chronic inflammatory disorders, characterized by increased concentration of immune activation parameters like ifn- or neopterin and low serum iron and hemoglobin concentrations. taken nitric oxide, no, the putative endothelial derived relaxant factor, edrf, has been shown to be a potent inhibitor ofplatelet aggregation in vitro. in vivo evidence however, is scarce. accumulation of platelets in the lungs has been shown to occur during extracorporeal circulation. the aim of the present study was to investigate the effect of inhaled no on this reaction. materials and methods: the animals were divided into two groups, each consisting of pigs. platelets were selectively labelled with luln-oxine. dialysis was instituted via catheters in the femoral vessels. in group , no, ppm, was added to the inhaled gas from the start of dialysis. in group no was not given. the activity over the lungs was followed dynamically with a gamma camera. central hemodynamics was monitored via a swan -ganz catheter. results: the activity was significantly lower in group , from minutes after start of dialysis and onwards, indicating diminished accumulation of platelets in the lungs. parallel to this the hemodynamic response in terms of increased pulmonary artery pressure and pulmonary vascular resistance was blunted in this group conclusion: inhaled no in this model seems to affect pulmonary platelet sequestration. an associated attenuation of the changes in central hemodynamics was also seen. previous studies from our laboratory have demonstrated that vascular contractility decreased in endothelium-intact blood vessel rings in early and late stages of sepsis. although endothelium removal in early sepsis restored vascular contraction, the depressed smooth muscle contractility observed in late sepsis was not restored by endothelium removal. this indicates that impairment of smooth muscleper se may be responsible for such dysfunction in late sepsis. the aim of this study, therefore, was to determine whether or not smooth muscle-derived nitric oxide (no) plays a role in producing vascular smooth muscle dysfunction during late stages of sepsis. to study this, rats ( - g, n= - /group) were subjected to sepsis by cecal ligation and puncture (clp). septic and shamoperated rats then received rrd/ g bw normal saline. the animals were killed at , , or h post-clp ( h post-clp=early sepsis; - h post-clp=late sepsis), and thoracic aortic rings were prepared for contraction studies using organ chambers. the complete removal of endothelial cells was tested by the absence of any significant acetylcholine-induced vascular relaxation. contractile responses to norepinephrine (ne, to - m) were determined in the aortic rings without intact endothelium. ng-monomethyl-l-arginine (l-nmma, /~m, an inhibitor of no synthase) was then added to the organ chamber and ne-induced peak contraction was determined before and after the addition of l-nmma. the peak contraction (rag/rag tissue, mean_+sem) is shown below: the results indicate that the addition of l-nmma did not significantly affect ne-lnduced peak contraction in endothelium-denuded vessel rings at and h after clp. in contrast, l-nmma administration produces an % increase (p< . ) in peak contraction during late sepsis. therefore, the vascular smooth muscle contractile dysfunction observed at h post-clp is partially due to smooth muscle-derived no over-production. thus, unlike macrophages in which inducible nitric oxide synthase (inos) is observed in early sepsis, the inos in vascular smooth muscle appears prominent only in the late stages of sepsis. in three cases of human septic shock in which ng-monomethyi-l-arginine, (l-nmma) a nitric-oxide-synthase-inhibitor was applied, we isolated three completely different types of pathogens: candida, pseudomonas aeruginose and multiresistant coagulase-negative staphylococci. this observation suggests that endotoxin alone is not the main factor triggering hypotension in septic shock by the nitric oxide pathway. in a -years-old woman in severe septic shock due to a candida and pseudomonas aeruginosa infection complicated by adult-respiratorydistress-syndrome conditions deteriorated despite adequate conventional therapy. in this trial, effects of l-nmma on cytokin-levels were investigated. the study-protocol was approved by the ethical committee of the department of surgery. after two boll of mg of l-nmma, a continuous infusion was installed ( . mg/minute and kg body weight l-nmma). as expected mean arterial blood pressure rose ( to mmhg}, heart rate stayed stable ( + b/rain), systemic vascular resistance increased ( to dyne.sec/cm ), cardiac output decreased ( to . l/rain), and cardiac index declined ( . to . l/min/m }. before and after minutes while the infusion of l-nmma, blood samples for immunological measurements were taken and processed together. pulmonary-shunt-volume was observed before the application of l-nmma, after one hour and after matutes. neopterine increased from . to . ng/ml, tumour-necrosis-factor-a increased from . to . pg/ml and intedeukin- increased from . to . pg/ml. immunoglobulines a, g, and m ( . to . , . to . , . to . g/i), complement factor c- c and c- ( . to . , . to . g/i), alpha-l-antitrypsine ( . to . g/i), c-reactive-protein ( . to . rag/i), interleukin- ( pg/ml) and soluble interleukin- ( to units/ml) did not change significantly. pulmonary-shuntvolume decreased from . % to . % within one hour and to . % after minutes. in septic shock blocking nitric oxide as an intervention at the end of a not ~,et ful!y understood cascade might have important influences on pulmonary-shunt-volume and inter-cell-communication. department of surgery, pharmacy* and immunology**, university hospital of zurich, r~imistrasse , zurich, switzerland we previously reported that hypoferremic cba mice had an increased resistance to salmonella infection, and that injection of ammonium ferric citrate (afc) to these mice led to enhanced infection (ganthier et at. . microbiol.immuno : ) . because nitric oxide (no) is involved in the antimicrobial activity of routine macmphages towards various inttacellular pathogens, we investigated the influence of iron on the bactericidal activity of cba mouse macrophages towards s.typhimurium and on the production and activity of reactive nitrogen intermediates (rni). peritoneal macrophages hum cba mice were cultured in the presence (or not) of afc ,um, ifn-,/ u/ml, lps fig/m/, ngmonomethyl-l--arginine (mmla) ram. nitrite (no -) content of the supematants was determined by a standard griess reaction, and h release was measured by the peroxidese dependant oxidation of phenol red. for intracellular killing, macrophages monolayers were infected, and, at various intervals, lysed by triton x- , and surviving bacteria enumerated by colony counting on agar. for in vivo experiments, mice were infected ip with . ml of a suspension of . ~" s.typhimurium, strain c , and injected with aminoguanidine (ag) mg/ml in saline. our results show that the rn[ inhibitor ag strongly accelerates the mortality of infected mice, the survival rate decreasing from % in the control group to % in the treated group, days after challenge. correlatively the rni inhibitor mmla induces in vitro a decrease in the rate of bacterial killing, fxom % to %, in macrophages triggered with ifn-? + lps. the cultivation of macrophages in the presence of afc leads to a decreased no -accumulation, . nmole/well v.s. nmole/well. conversely h production is enhanced from nmole/well up to , nmole/well. nevertheless, macrophages cultivated in the presence of afc exhibit an increased tale of intracellular killing, % in iron exposed macrophages v.s, % in control macrophages. when triggered with ifn-~, alone, macrophages have a reduced antibacterial activity ( % v.s. %) whereas the addition of afc to these macrophagas restores an elevated ( %) rate of killing. in conclusion, the results show that bactericidal activity of cba macrophages towards s.typhimurium depends on the production of no by these macrophages ; but they also demonstrate that no is not the only reactive species involved in the intracellular kil/ing of s.thyphimurium ; indeed afc which strongly inhibits rni production, stimulates h release by these macrophages and increase their bactericidal activity in vitro. nevertheless afc may promote bacterial growth in vivo. crssa. unit de microbiologie. bp . la tronche cedex france. henning jahr, ulrike noack, karin braun the large amounts of no produced by the inducible no synthase in rat macrophages have direct antimicrobial effects, but inhibit the activation of the lymphocyte-dependent host defense system. the aim of this study was to investigate if complement activation influences no-generation. spleen cells from lew rats were incubated at °in tcm- / % fcs, with or without additional rat serum. after h, nitrite (end product from no metabolism) was measured by oriess reagent. in rat spleen cell preparations, most of the no is produced by macrophages. complement activation in vivo was carried out by i.v. injections of u cobra venom factor/kg b.w. at days and . significantly higher (p<o.o ) lps-stimulated no-generation was found in spleen cells prepared at day ( . - . nmol nitrite/ cells, n= ) compared to spleen cells from non-treated animals ( . ± . nmol, n= ) complement activation was effective also in vitro. when incubated in % zymosan-activated rat serum, both basal and lps-stimulated noproduction were enhanced in spleen cells (table, values increased production of nitric oxide (no) is associated with sepsis, however, the effect of no inhibition on survival during sepsis is unclear. we examined the effect of no inhibition on host's ability to eliminate bacteria and survival in mice sepsis model. sixty female balb/c mice were injected with e.coli ( qbody) into peritoneal cavity. the treated group received n-ultro-l-arginine-methyl-ester (l-name), an inhibitor of nos, one hour before bacterial challenge. thirty mice were observed for survival after e.coli challenge and the other mice were sacrificed at hours. blood was obtained by cardiac puncture and peritoneal lavage fluid (plf), liver and lung were harvested. the number of peritoneal exudative cell (pec) was counted and colony forming units (cfld of bacteria in the tissues, blood, and plf were also determined. in addition, pec was cultured in vitro with or without lipopolysaecharide (lps). tnf levels in the blood, plf, and supematants of cultured pec were measured by l bioassay. survival rate (%) qrql/,p n hr hr dav control (normal saline . ml/body i.p.) n (l-name mg/kg i. administration of l-name before e.coli injection increased the number of bacteria in plf and tnf level in plasma, the result suggests that nos inhibitor may depress the host's ability to kill the injected bacteria and that it may induce greater systemic tnf production. we conclude that nos inhibitor is detrimental to animals in sepsis. the hypothesis that sod prevents reperfusion injury to the liver by protecting the endogenous endothelium derived vascular relaxing factor (no) from being inactivated by oxygen free radicals should be investigated. male wistar rats were subjected to min of partial liver ischemia ( %) and min of consecutive reperfusion in situ. some rats were pretreated with the no synthase inhibitor nitro-l-arginin (nla: i mg/kg). sod, when used, was given as mn-containing preparation at a dose of u. i.v. i min prior to ischemia. results (sod/ nla+sod/ ni~,, respectively): bile flow (~i/g/min) : . ± . "#/ . ± . / . ± . . alt (u/ ) • ± ~#/ ± / ± . gldh (u/l): . ± . e#/ . ± . #/ . ± . . in absence of nla, sod enhanced postischemic bile flow and reduced leakage of alt and gldh into the plasma, while the effects of sod disappeared, when endogenous ~synthesis was inhibited by nla. nla had no ~ffect on untreated animals submitted to the same protocol. these results may suggest, that oxygen free radicals interfe~:e with the endogenous vasodilator no and that the benefit of sod can be attribuated in large part to a protection of no during reperfusion. nitric oxide (no) reduces pulmonary vascular resistance and increases oxygenation by inhalation in ards patients [ ] . animal studies on the endogeneous no production proved that no is exhaled after synthesis in the respiratory tract [ ] . with approval by the hospital ethics committee, we studied healthy volunteers and ventilated patients by measurement of inand exhaled no by no/no -chemiluminescence in segments of the upper respiratory tract. we found that no is synthesized predominantly in the nose and in the upper nasopharynx, leading to inspiratory tracheal no concentrations of . - . parts per million in non-smoking volunteers; data during mask ventilation per nose were as follows: non . . . . , parts per million (ppm) no, mean, n = ; ~ p < . (t-test) between smokers and non-smokers; p < . (t-test) between in-and expiration. about % of no is resorbe.d by the lung, and the exhaled no -in contrast to former presumptions -is the remaining part of the autoinhaled no. intubated and ventilated patients are deprived of no autoinhalation, and the exhaled no in the trachea decreases more than % {o. ppm before intubation vs. . ppm after intubation, ~, < . ), whereas the nasal no concentration increases by cumulation. hence, low-dose no inhalation in ards patients might be considered as a no replacement, especially since the tracheal no concentrations we measured in volunteers are similar to those which could be demonstrated to be effective for ards in former studies [ ] . the data demonstrate that no is synthesized in the nose, and inhaled and resorbed by the lung. this phenomenon of no autoinhalation, which is reduced in smokers and in ventilated patients, does possibly contribute to the regulation of the ventilation-perfusion ratio in the lung. kikuchi , yoshihiro inoue , masao yoshida critical care and emergency center, and department of bacteriology, iwate medical university. nitric oxide (no) is produced by macrophages and vascular endothelial cells. it is thought to be the true form of endotheliumderived relaxing factor, and to be involved in the fall of blood pressure during septic shock. we have reported previously that endotoxin (lps), tnf-c~ and il- contribute to the occurrence of septic shock (circ shock : ; . the present study investigated the in vitro effects of lps, tnf-o~, il- and ifn-'i on the production of no by macrophages. peritoneal macrophages were cultured with lps, il- , tnf-~ and ifn-¥. in culture with lps, no was produced in a dose-dependent manner, and the production was suppressed by a no production inhibitor, l-nmma. ifn-y, il- and tnf-c~ used alone did not promote the production of no, but helped lps to facilitate no production. a combination of il- and tnf-c( enhanced lps-facilitated no production to a greater extent than il- or tnf-c~ alone. the above results suggest that these cytokines are involved in endotoxin shock through the mechanisms that facilitate no production. - uchimaru, morioka . japan. t. yolk , , i. ioannidis , w.j. kox and h. de groot objectives: nitric oxide (no.) is known to play an important role in neurotransmission, vasoregulation, and bactericidal as well as tumoricidal cellular defense systems. by means of no-donating agents we studied the mechanism of no-mediated cytotoxicity against rat liver microvascular endothelial cells. materials and methods: -morphoiinosydnonimine-n-ethylcarbamide (sin-l) and sodium nitroprusside (snp) were used as no. donators, ldh release and trypan blue exclusion were applied to indicate cell viability. results: sin- ( mm), which releases both no. and o -., caused a time-dependent cytoreduction of % and % after and hrs, respectively. this effect was not inhibited by superoxide dismutase (sod), which removes --to form h and . in contrast, the addition of catalase (cat), which removes h to form h and , diminished the cytotoxic effect ot sin- to %, equivalent to high concentrations of snp ( mm), which solely releases no.. in addition, the amount of h formed by mm sin- equaled the amount ot enzymaticany produced h by mu/l glucose oxidase (god). whereas god in this concentration and snp in low concentration ( mm) alone were not toxic to endothelial cells, the combination caused an % reduction of viability, comparable to the effect observed with sin- ( mm) alone. moreover, toxicity mediated by high concentrations of snp ( mm and ram) was reduced by % under hypoxic conditions indicating synergism with no-and . conclusions: we conclude, that no.-induced toxicity against endothelial cells is enhanced slightly in the presence of oxygen and is not due to an interaction with -. however, toxicity increases dramatically in the presence of h . this may possibly occur either by a chemical formation of more potent reactive hydroxyl radicals or by independent actions on different cellular targets. although it is becoming increasingly clear that nitric oxide (no) is associated with otxan dysfunctions in septic patients, little is known as to die kinetics of no production in these patients to clarify these kinetics, we have investegated serum arid monocyte associated no in septic patients. five patients who had undergone gastrointestinal surgeries mid were complicated postoperatively with severe sepsis served as the subjects in this study (sgroup), using twelve healthy volunteers as a control group (c group). serum no and no levels were measul*d sliectrophotometricallymonocyte cultures were done for itrs with or without lps+ifn-t stimulation mid no and no levels in the supernat,'utts were also measured spectrophotometrically. furthermore,using an no selective electrode,time course of the lps+ifn-t induced no production by monocytes was studied. l) serum no levels in s group were slightly lfigher than dmse in c group,bnt there were no significoatt differences between the two. )both no levels in the supematmlts of monocytes cultured with lps+ifn-t mid no , no levels ill lhe supernatants of monocytes cultured without lps+ifn-y were significantly higher in s group. further,the time required for the no production by enltnred monoeytes was siglfificantly shorter also in s groap. conclusions l)in severe septic patients, monocyte no productions wei~ not only primed, but also activated concomitantly, suggesting that these monocyte activations m'e strongly associated with organ dysfunctions in sepsis. )based on the restdts of serum no nteasuremeuts, it can be deduced that no p~'oduced by monocytes in septic patients affects tissues and org~s ioeoregiomflly. objectives of the study: nitric oxide (no) is an important messenger which accounts for a wide spectrum of physiological and pathophysiological processes, e.g. mediating vasodilation in endoloxin shock investigating the signal lransducfion pathways involved in the regulation of the inducible nitric oxide synthase (inos), we report the involvement of phosphatidylcholinespecific phospholipase c (pc-plc) and proteinkinase c (pkc). materials and methods: no-production was induced in the murine macrophage cell line j with lipopolysaccharide (lps) [lljg/ml] and interferon ;f (ifny) [ u/ml]. after hours of incubation no-release was determined as nitrite (no ) by using a colorimetric assay based on the griess-reaetion. results: preincubation of cells with the pkc-inhibitors staurosporine (stp), chelerythrine, bisindolylmaleimide (bim) and d , that recently has been identified as a selective inhibitor of pc-plc, diminished significantly lpsand ]fnt-induced no -production (p<o, ). although we observed no toxic effect on cell viability, no -production was related to protein concentrations to exclude any inhibitory effect on celt growth. celts preincubated with stp [lo nm] released % less no in response to lps and ifn,[ compared to control cells cultured without inhibitor. chelerythrine [ }jm] and bim [ioijm] reduced the no -formation by % and %, respectively. interestingly, the most potent inhibitor of no-production turned out to be the xanthate d cells pretreated with d [ ~g/mt] released % less no than stimulated controls the inhibitory effect on no production decreased the later the inhibitore were added after stimulation; e.g. bim added and hours after stimulation reduced no -production only by % and %, respectively. accordingly, inqs activity present in stimulated cell lysates supplemented with l-arginine and co-factors was not suppressed by the inhibitors tested. conclusions: our findings suggest, that the induction of inos but not its activity is a pkc and particularly pc-plc dependent process. dr. k tschaikowsky, institut for anaesthesiologie, universital erlangen--nqrnberg, krankenhausstr , erlangen interleukin- (il- ) affects nearly every cell type by increasing the expression of a variety of genes associated with the promotion of inflammatory processes. these include upregulation of cyclooxygenase and nitric acid synthases. the il- ri transmits a signal(s) through the cytoplasmic domain which is structurally related to the fruit fly toll protein. we have recently cloned the promotor most proximal to the ' utr of the human il- ri gene. the genomic sequences reveal a lack of tata and caat boxes but rather a considerable ( %) gc rich region. the translation of the type i il- r appears under a significant suppression and may limit the biological activities of il- by low level of expression. on the other hand, the type ii il- r, lacking a significant cytoplasmic domain, does not transmit a signal and acts as a decoy receptor preventing the binding to the type i receptor. there are several approaches to reducing il- activity; inhibition of il- converting enzyme which cleaves pro-il-l[ , anti-il- ri, the il-i receptor antagonist (il- ra) and soluble (extracellular) il- ri and il- rii. il- ra is structurally related to il- and binds at °c to the il- ri with near equal affinity as that of bona fide il-i; however, il- ra does not transduce a signal. il- ra has been given to humans in pharmacologic levels (mean plasma levels of gg/ml) without evidence of agonist activity. in addition, there has been no affect on normal homeostatic parameters, suggesting that il-i does not play a role in health. in healthy humans given intravenous endotoxin, il-ira reduced endotoxin-associated neutrophilia by % and completely reversed endoloxin-iuduced immunosuppression, il-tra is produced naturally and is elevated in the circulation in several diseases. in a variety of diseases, plasma levels of il- ra are in -fold molar excess to those of il-i [ . it is unclear whether these endogenous levels of il- ra are sufficient to block il- activity in disease. a single injection of ]l- or ifna in humans does not induce il- but rather high levels of il- ra ( ng/ml). prof.dr.l.a. aarden interleukin (il ) is a multifunctionai cytokine with a central role in host defense mechanisms and consequently in inflammation. il is thought to be involved in the pathogenesis of various diseases. therefore, specific inhibitors could have therapeutic value. a human-mouse chimeric monoclonal antibody to il has been applied in a phasei clinical trial in patients with multiple myeloma and in primate models of sepsis. no toxicity was observed and the most remarkable outcome of this study was the build up in the circulation of il -anti-il complexes, suggesting that plasma il measurements represent a gross underestimation of il production in the patient. until now no natural antagonists of il have been described. the biological activities of il results from binding to a lowaffinity il -receptor (il r). the il /il r complex induces disulfide-linked homodimerization of the signal transducing receptor component, gp . studies on the structure-function relation of il revealed that disruption of the gpl -interaction site on il gives rise to a mutant il that, by virtue of its intact binding to the il r, acts as a potent antagonist on human hepatocytes and on human b cells. in vivo studies using this molecule will be initiated in the near future. the evolution of infla~ation involves a dynamic series of cellular events controlled by specific signals which are important to the initiation, maintenance, and final resolution of the inflammatory response. the various phases of inflammation are influenced via the expression and subsequent regulation of a number of key mediators which play a predominant role during each particular stage of the developing lesion. for example, the initial elicitation of blood born leukocytes to on inflamed area is a complex system that is dependent upon the expression of early response cytokineso these proximal mediators, including both interleukin-i (il-i) and tumor necroisis factor (tnf), are important in the initiation phase by activating both immune and non-immune cells and establishing a series of cytokine networks, thus, the above proximal mediators can stimulate endothelial cells, epithelial cells, smooth muscle cells, and fibroblasts to generate more distal cytokines. these latter cytokines include interleukin- (il- ), macrophage inflammatory protein-i (mip-i), and monocyte cbemoattractant protein-i (mcp-i). the importance of the above chemukines can be found in the role they play in leukocyte elicitation, as well as wound repair. numerous investigations have shown the diverse cellular sources of il- and the ability of il- to elicit neutrophils in vitro at pm to nm concentrations, however, recent studies have sho%~ an additional role for il- during the resolution phase of the inflammatory process. using corneal pocket animal models of angiogenesis/neovascularization, il- was found to be a potent angiogenic factor at concentrations ranging from - ng/ml. sequential fluorescein angiograms demonstrated that il- induced neovascularization by days, which regressed by weeks. in further analyses, both conditioned media recovered from either inflamed human heumatoid synovial tissue macrophages or lps-stimulated peripheral blood monocytes were found to possess potent angiogenic activity, which was effectively blocked by neutralizing antibodies directed against human il- . in addition, an il- antisense nligomunclentide blocked the expression of a functionally active angiogenic factor from lps treated monocytes. the above data demonstrate that il- has multifumctional activities during the initiation, maintenance, and resolution of a local inflammatory response. inhibits specific t-cell responses to soluble protein antigens and alloantigens. the proliferative responses of th , thl and th cd ÷ t-cell clones and cytokine production by these t-cell subsets are equally well inhibited. the inhibitory effects of il- are indirect and related to inhibition of antigen-presenting capacity and accessory function of the antigen-presenting cells (apc). however, il- also directly inhibits t-cell proli/eration induced by cross]inked anti-cd or anti-cd mabs (e.g. in the absence of professional apc), by specifically inhibiting il- gene transcription and il- protein production. il- also inhibits the production of the pro-inflammatory cytokines il-l-a, ~, il- , and tnf-a and the chemokines il- and mip-i-u, which are strong chemo attractants for neutrophils and macrophage, respectively. in contrast, il- enhances the production of the il- receptor antagonist, a cytokine with anti-inflammatory activity. il-l produced by monocytes downregulates class ii mhc expression and il- production by these cells in an autoregulatory fashion. collectively, these in vitro data indicate that il- is a powerful suppressor factor for immune-and inflammatory responses and therefore may have potential clinical utility as an anti-inflammatory agent. this notion is supported by recent studies which indicated that il- also prevents lethal lps-induced toxic shock in mice. five of the chamekines (hip-i~,era~tes. ip-io and il ) also chemoattraet t lymphocytes, while others act on mast cells. we have studied the effaces of these chemokines on t cell subsets. il preferentially chemoattracts uns~imulated t cells. raises ~ttracte resting as well as activated cd and cd memory t cells. ip- chemoattracts only preactivated (not resting) cd or cd t cells. hip-l~ preferentially chemoattracts gd t calla, while hip- more readily attracts the cd t call subset. the chemoklnes and ip-io were also sho~rn to promote the adherence of ~he same subsets of anti-cd activated t cells to ili activated human umbilical vein endothelial cells (hitvec). this was not associated with a~y i~crease in the number of lymphocyte adhesion molecules, bu~ could be inhibited by neutralizing monoclonal antibodies re lfa-i and vla- . these chemokines also rapidly increased ~ha adhesion of resting t l~phoeytes to plates coated wi~h integrlns (i-cam or v-cam) or matrix proteins such as f~bronectln. this induction of adhesion began wiehln ', peaked by hr and was completed in hr. this suggests that chemoklnee rapldly increase the binding affinity of adhesion prote~ns on t cells. we also recently observed ~hat mcaf/mcpi and rantes chemoattract unatimulated mast calls. furthermore, igs actlvared mast calls were chemoattraeted by mcaf, ra~tes, pf and mip.i~. however. ~he chemoklnee did not induce mast cells ~o release histamines. presumably, chemokines as regulators of the adhesion, migration and homing of all kinds of leukocytes participate in many types of inflammatory diseases. natural killer cell stimulatory factor or interleukin- (il- ) is an heterodimerie cytokine formed by two covalently linked glycosylated chains of kd and kd. il- was originally purified from the supermatant fluids of ebv-transformed human b ly~phobiastoid cell lines. however, in addition to b cells, phagocytic cells, i.e. monocytes, macrophages, and neutrophils, have been identified as the major physiological producers of il- . phagocytic cells produce il- in response to bacteria, bacterial products such as lps, and intracellular parasites. the cell types on which il- exert biological activity are t and nk cells. the major direct biological function of il- on these cell types are the induction of cytokine production, primarily ifn-y, the enhancement of a generation of cytotoxic cells, and a mitogenic effect on antlgen-activated lymphocytes. in part thromgh its ability to induce ifn-y production, il- , produced in response to infections, represents an important functional link between effector cells of innate resistance, phagocytic cells and nk cells, and effector cells of adaptiye resistance, t and b lymphocytes. the ability of il- to induce ifn-y production from circulating. nk cells and at least a proportion of t cells determines a rapid, antigen-independet production of ifn-y during infections. ifn-y acts as a potent enhancer of phagocytic and bacteriocidal activity of phagocytic cells, participating early in infection to activate some of the inflammatory mechanisms that represent the first innate resistance against infection. this antigem-independet activation of phagocytic cells that involves, in addition to il- , other monocyte derived cytokines such as tnf and il-l, has been shown to be important in experimental animals for the resistance against infection by microorganisms such as limteria monocytogens and toxoplasma gondii. in addition to this role, early in infection in the antigen-independet phagocytic cell activation, il- has a major effect in the ensuing antigenspecific admptive immune response by facilitating the generation of t helper type (th-i) response and suppressing a th- response. the presence of il- during antigen stimulation in vitro using human peripheral blood lymphocytes, or both in vivo and in vitro in experimental animals, induces generation of th-i cells producing ifn-y and il- , and inhibits the generation of th- cells producing il- . il- induces a direct differentiative effect on th-cells, priming them for high ifn-y production. ~is priming effect is stable and maintained even when t cell clones are cultured for extended periods in the absence of il- , however, il- needs to be present during the first few days after stimulation with antigen or mitogen and established th clones are resistant to the priming effect of ifn-y. unlike the generation of high ifn-y producing clones, the il- -mediated inhibition of il- producing cells in probably due to selective mechanisms, which may include a selective mitegenic effect of il- for thl cells and an inhibitory effect of ifn-y on th cell proliferation. in several experimental systems, it has been shown that the enhancing effect of il- on th-i responses is dependent on production of if~-y and on the presence of nk cells, possibly needed for the early production of ifn-y. the importance of phagocytic cells and nk cells in determining the characteristics of the th response during antigenic stimulation indicated that the mechanisms of innate resistance have a determining influence on the subsequent antigen-specific immune response: il- appears to have a key role in mediating the interaction between phagocytic cells. nk cells, and t lympocytes in these proccessem. trinchieri, g. , interleukin- and its role in the generation of t e cells, imm~ol. on peripheral blood monocyte/macrophages, il- behaves like il- in a variety of assays, and shows both similar and contrasting, activties with either il- or ifn-y. il- reduces inflammatory monokine and il- production. it reduces the pyrogen-induced expression of tissue factor (herbert et el, , febs lett. , ) . it mpregulates manmose receptor and ~c class ii expression, while reducing cdi expression. il- produces morphological changes (extensive cell processes, aggregation, giant cell formation) which have previously been observed with il- . it inhibits niv-i production (montaner et el, , i. exp. mad. , ) , and interferes with hiv-induced cell fusion. the activities of il- and il- differ on t-ly•ocyte and large granular lymphocyte population. in particular il- does not exhibit the suppressive effects of il- on thl-type-helper functions (ifny production) and cytotoxic functions (perforin production). data will be presented showing that il- and il-l share a common receptor on a nu~er of cell types, but not on t-lympocytes (see also zmrawski st el. , embo j. . - ), explaining both thai common and divergent activities. the levels of il- ~a in activated peripheral blood lymphocytes are greater than or equivalent to those of il- mp~ja and the two ml{nas are expressed by different t lympocyte population: in particular, t cytotoxic lymphocytes express markedly higher levels of il- ~rna. in vivo, il- may thus be contributing, significantly to some of the activites previously ascribed to il- il- . recently, we cloned the human cdna encoding interleukin- (il- ). human il- is a non-glycosylated protein of aa with a molecular mass (mr) of kd and has biological activities on monocytes and b cells, il- , like il- , strongly enhanced the expression of class ii mhc antigens on monocytes and induced expression of cd (fc~rii). furthermore, il- , like il- and il~ , inhibited the production of pro-inflammatory cytokines il- , ]l- , tnfo~ and chemokines miplc~ and tl- by lps activated monocytes. both il- and il- enhanced the production of il-lra by monocytes. in contrast, il- lacked the t cell stimulating activities of il- . the responses of monocytes to il- and il- were not additive or synergistic, supporting the hypothesis that il- and il- receptors are complex and share a common component which is important for signal transduction, taken together, these data indicate that il- , il~ and il- have important anti-inflammatory activities on human monocytes. in addition, these results indicate that il- is unique in that it can modify inflammatory reactions without stimulating (as does il- ) or inhibiting (as does il- ) t cell responses. transforming growth factor beta i (tgf-fll) belongs to a family of proteins that have potent immunoregulatory properties ranging ftom effects on the growth and dfflerentiafion of primitive stem cells to the differentiated functions of immune system effector cells. tgf-i~i is synthesized as a large secretory precursor polypeptide of amino acids that is inactive until processed to a disulfide linked homodimeric molecule of t amino acids each. recently it has been found that tgf-[~i can have autocrine as well as paracrine effects on the immune system indicating that immune cells can activate the inactive secreted form of tgi~-~i. in addition, tgf-i~i has differential intraceuular effects on cell surface receptor modulation, tyrosine phosphorylation and cytokine gene transcription as well as cell mediated cytotoxicity. the systemic administration of tgf- has proven beneficial in a variety of animal models such as septic shock, allograft rejection and experimental forms of autoimmunity including collagen induced arthritis and experimental autoimmune encephalomyelitis. moreover the increased levels of tgf-ill and other tgf- isoforms found in several disease states associated with immunosuppression such as different forms of malignancy, chronic degenerative diseases and aids implicate the involvement of tgt~-i~ in the pathogenesis of some diseases. hopefully, well designed clinical trials will define the potential roles of the tgf-[ family of proteins in the treatment of diseases of man. patient development of systemic inflammatory response syndrome (sis) after severe trauma is accompanied by a wide range of immune aberrations and altered cytokine production. in particular, t lymphocyte proliferation and ifn, t production is suppressed while monocyte (mo) tnfc~, il- , pge and tgf~ production is massively increased concomitant to decreased antigen presenting capacity. recently, two new cytokines, il- and il- , have been characterized as critical in regulation of mo tnfa and il- , as well as in induction of t lymphocyte proliferation and ifn production. in this study, peripheral blood leukocytes (pbl) from severe trauma patients (injury severity score > ) were analyzed for their il- levels, their in vitro proliferation to mitogen (pha) and their response after il- addition. since il- produced either by mo or by t lymphocytes can depress m~ antigen presenting capacity, inhibit t cell ifn,/production and directly diminish t cell proliferation, it might be suggested that immunosuppressed patients' mo and/or t lymphocytes would have increased il- levels. increased patient il- production might also be resulting from the high levels of tnfa a known stimulator of il- . conversely, since il- augments mo antigenpresenting capacity, thl induction and proliferation, post-trauma leukocytes might be il- deficient. pbl of trauma patients were compared to normals' pbl, either unstimulated or ptta induced, and their levels of il- found to be dramatically and significantly reduced. patients' isolated m~, either stimulated with the bacterial cell wall analogue, mdp, or unstimulated, also had depressed il- production concomitant to elevated tnfa production when compared to normals' mo. mechanisms for the depressed patients' mo il- were explored. increases in tgf[ may have partially contributed to the patients' depressed il- level, but elevated pge had no effect. addition of il- to patients' pbl significantly increased their mitogen responses. these data imply that sis is characterized by disruption in the interactions between mci and t lymphocytes so that patients' m~i produce excesses of some mediators (tnfa, il- , pge ) and a dearth of other monokines (il- , il-io). t lymphocytes are not activated and, therefore, unable to function in both immune defense and monocyte regulation. it is known that lge receptor-mediated or ca-ionophore-induced activation of mouse bone marrow-derived mast cells ( mmc) may result in the production of different cytokines including the interleukins (il) , , , and as well as gm-csf and tnf-a. in the present study we analyzed the effects of exogeneously applied pro-inflammatory cytokines (il- , l- , tnf-c as well as various mast cell growth factors (il- , il- , il- , il- , ngf, kl (kit ligand)) on cytokine production in primary mouse bmmc using a standard activation protocol (lxl bmmc/ml; ll.um ionomycin; - h). the actixdties of bmmc supernatants were assessed in specific biological (il- , il- il- , l- ) and/or elisa assays (il- , il- ). here we show that homogeneous populations of bmmc (> %alcian blue+/safranln-; in vitro age: weeks) generated in the presence of recombinant (r) rail- from normal balb/c mice produced modest amounts of l- and low or undetectable levels of il- , - , and - after induction with lp.m ionomycin only. however, a dramatic increase ( -to -fold) of these cytokine activities was noted, when in addition to ionomycin also human ( ) rll-la was provided during the induction period. this il- effect was dose dependent with a maximgm at - u/ml hrll-la and specific, as pre-incubation (lh) of bmmc with ng/ml hrll- receptor antagonist abolished the action of u/ml hrll-lcc similar effects were noted with hrll-lg or rurll-lb (lng/ml, respectively), but not with rhll- or rmtnf-~. both mrll- and hrll- substantially enhanced ionomycin-induced l- production of bmmc in the absence or presence of il- . il- significantly enhanced il- and il- production while decreasing il- activities to abont - % of control levels, when il-i was provided in the presence of il-l/ionomycin. a monoclonal anti-nfil-t antibody (ascites : ) abrogated the effects of mrll- . other mast cell-active cy~okines (] ,- , il- , l- , ngf, or kl) added to ionomycia-or l- /ionomycin-treated bmmc had no major effects on cytokine production. il- and il-i did not induce significant cytokine release in the absence of ionomycin suggesting tlmt cadependent signalling was required. at doses of " m, dexamethasone, corticosterone, or hydrocortisone almost completely abolished ionomycin/il- /ll- induced cytokine production. the inducer cocktails per se did not interfere with the cytokine bio-assays. in case of il- inducibility of this cytokine in bmmc was confirmed at the mrna level by northern blot analysis. hence our data show that activated mast cells are a source of il- previously recognized as a product of th type lymphocytes only. moreover, our study reveals novel functional roles for i-l-i, il- , and ghicecorticoids in the regulation of cytoldne production in mast ceils. accumulating data suggests that cytokines, peptides involved in regulation of both physiological and pathological immunological responses, predominantly are produced at the local site of antigen stimulation. a new method was used to detect cytokine-producing cells in haman tissue at the protein level. single-cell production of different httman cytokines, ilia, ill [ , illra, il , il , il , il , il , ils, ill , gm-csf, tnfa, ifn and tgf[ . , was identified by indirect immunohistochemical staining procedures and use of carefully selected cytokine-specific mab's. frozen sections were fixed with % paraformaldehyde and permeabilized by . % saponin treatment, eluting cholesterol from the membranes. the intracellular presence of all cytokines except ill, illra (late) and tfg[ _ , could be demonstrated by a characteristic perinuclear configuration in producer cells. in addition, the immunoreactivity extended over a large extracellular area encompassing the producer cell. a localization of the cytokine to the golgi-organelle was established by use of two culour staining including a haman golgi complex specific mab. this staining pattern was only evident in producer cells because injection of recombinant human cytgkines into the tissue caused a membraneous and extracellular staining pattern. both the extra-and the intracellular types of staining reaction could, however, be blocked by preincubating the cytokine specific mab with pure human interleukins. oxygen radicals (or) directly induce lipid peroxidation, indirectly they trigger adhesion and activation of pmn leukocytes. we investigated whether or also lead to a release of acute-phase response cytokins such as tnf-alpha, il-i beta or il- in whole blood cultures to maintain the induced inflammatory reaction. methods: blood samples from healthy volunteers (n= ) were incubated at °c. or were produced by the xanthine oxidase (xo)/ hypoxanthine (hx) system. after , , , , and minutes plasma levels of tnf-alpha, il-i beta and il- were determined with elisa kits. results: under the influence of or tnf-alpha plasma levels increased from , pg/ml at min to pg/ml, pg/ml, pg/ml after , and min. il-ibeta ( , pg/ml, , pg/ml, , pg/ml, pg/ml and pg/ml after , , , and min) and il- ( , pg/ml, l,lpg/ml, , pg/ml, pg/ml and , pg/ml after , , , and min) plasma levels were increased min later than tnf-alpha. summary: these data suggest that or do not only play an important role in initial accumulation and activation of pmn leukocytes but also lead to a stimulation of monocytes to produce the acute phase reaction cytokins tnf-alpha, il-i beta and il- to maintain and strengthen the inflammatory reaction. department of general surgery, steinhsvelstr. , ulm, germany jan k. horn md, greg a. hamon md, robert h. mulloy md, greg chen bs, rebecca chow bs, and christof birkenmaier md. transforming growth factor-i~l (tgf- ) is released from inflammatory ceils following injury and in sepsis. in vitro experiments have confirmed that low concentrations of tgf- ( . - . ng/ml) are chemoattractive for monocytes, whereas higher levels of tgf- (> . ng/ml) potentiate production of the immunedepressive prostaglandin e . other investigators have shown that tgf-] can cause the appearance of cd (fc immunoglobulin receptor) on monocytes exposed to ng/ml of tgf-[~i for hours. monocytes also express on their surface a glycoprotein that binds complexes of lipopolysaceharide (lps) and lpsbinding protein (lbp). such binding is associated with generation of proinflammatory cytokines such as tumor necrosis factor alpha. we have shown that cd is depressed in septic patients and therefore we hypothesized that tgf- could account for the down-regulation of cd observed in these individuals. we incubated normal human monocytes with platelet-derived tgf-[ for and hours at °c and examined ceils for cd and cd expression using flow cytometry after immunnfluoreseent staining with appropriate monoclonal antibodies. monocytes were selected on the by usual criteria for size and granularity. non-viable ceils were excluded with the use of propidium iodide. two populations of monocytes could be found afcer incubation at °c alone. one displaying high density of cd had increased fluorescence over the homogeneous expression of cd in cells maintained at °c (baseline). the other population displayed decreased cd expression relative to the baseline cells. tgf-i~i ( - ng/ml) caused a shift of ceils from the high density into the low density cd population. this trend was observed within hours of incubation and was complete by hours. we observed a net decrease in cd expression f % for all subjects studied (p< . vs controls). phorbol myristate acetate ( ng/ml) also caused down-regulation of cd to a similar degree as tfg-i~i. we also confirmed that monocytes could be induced to express cd after incubation with tgf- ( ng/ml) for hours. these studies demonstrate that monocytes incubated with immunodepressive levels of regulation of cd by tgf- deplete their surface expression of cd while generating cd . this down-regulation of cd by tgf- correlates with our clinical observations of lower cd expression on monocytes obtained from septic patients. for over years, activated t lymphocytes have been considered to be the cellular source of mif. we recently isolated and cloned the murine homolog of mif after identifying the specific secretion of this protein by lpsstimulated pituitary cells in vitro and in vivo. however, further experiments showed that mif protein is detectable both in t-cell deficient (nude) and hypophyseetomized mice, suggesting that yet additional cell types may produce mif in vivo. since monocytes/macrophages are a major source of the cytokines that appear in response to lps administration, we examined the possibility that mif also is expressed in cells of the monocyte/macrophage lineage. we found that mif is expressed constitutively in the murine macrophage-line raw . and in thioglycollate-elicited peritoneal macrophages. significant amounts of mif mrna (rt-pcr) and protein (western blotting) were observed in cell lysates. in raw . cells, mif secretion was induced by as little as pg/ml of lps (e.coli l:b ), peaked at ng/ml, but was not detectable at lps concentrations > txg/ml. similar data were obtained with elicited macrophages, but higher lps concentrations were required, unless the cells had been preincubated with ifn . production of mif by lps-stimulated (l ng/ml) macrophages peaked at hr. expression ofmif mrna and tnf mrna by lps-stimulated raw . macrophages was investigated by rt-pcr. as expected tnf mrna expression increased over the range of lps concentrations ( pg/ml to p_g/ml). in contrast, levels of mif mrna correlated inversely with lps concentration. by competitive pcr, mif mrna was observed to increase approximately -fold after lps induction ( pg/ml). mif secretion also was induced by tnfoc ( ng/ml) and ifn? ( iu/ml), but not by il- and il- (up to ng/ml). lps and ifn had additive effects in inducing mif secretion. in separate experiments, macrophages stimulated with recombinant mouse mif ( gg/ml) were found to secrete bioactive tnf~ (> pg/ml by l cytotoxicity). we conclude that the macrophage is an important albeit overlooked cellular source of mif in vivo. mif secretion is induced by lps, tnfc~ and ifn?. mif also stimulates macrophages to secrete tnf. taken together with previous observations that anti-mif antibody protects against lethal endotoxemia, these data implicate mif as a critical mediator of inflammation and septic shock. inflammation is characterized by an exacerbation of proinflammatory cytokine production. cytokines such as il- , il- , and tgf , have been identified as anti-inflammatory mediators thanks to their ability to down regulate the production of il- , il- , il- , tnfc~ by activated monocytes / macrophages. however, other cells, including polymorphonuclear cells (pmn) do contribute to the release of pro-inflammatory cytokines. we investigated the capacity of the so-called anti-inflammatory cytokines to control the release of il- by activated neutrophils. human pmn were purified following glucose-dextran sedimentation and ficoli-hypaque centrifugation. the cells were cultured at °c for h in the absence or presence of lipopolysaccharide (lps) or tnfa. il- release was measured in the supernatants using a specific elisa. among tested cytokines, il- was the most efficient inhibitor of il- production by lps-activated pmn. il- was also active, whereas no down regulation was noticed with tgfp~i. when tnfa was used as a triggering agent, none of the cytokine could prevent il- production. northern analysis are under investigation to precise the level of the il- -and il- -induced inhibition of il- production by pmn. our data illustrate that il- and il- possess the capacity to down regulate the production of il- by both monocytes and pmn, whereas tgfb has a more limited inhibitory activity. ciliary neurotrophic factor (cntf), a member of the il- superfamily, has recently been shown to promote axonal growth and neuronal healing. cntf production is also increased during neuronal and muscle damage, associated with soft tissue injury or trauma. we postulated that production of cntf may explain the loss of skeletal muscm protein that occurs in inflammation. female, wistar ( - gm) rats received either or pg/kg bw s.c. injections of recombinant rat cntf for seven days, or received sham injections and were freely-fed. additional animals were pretreated with mg/kg ibuprofen lp prior to pg/kg bw cntf. rats treated with ,ug/kg bw cntf lost . _+ . gms bw as compared to freely-fed controls which gained . _+ . gms (p<o. by anova and lsd), and ibuprofen treatment had no effect on cntf-induced weight loss (- . _+ . ). animals pair fed to the high dose cntf gained body weight ( . -+ . ), although weight gain was less than seen in freely-fed controls. rats treated with pg/kg bw had reduced body weight gain (+ . +_ . gin). food intake was also reduced by % in pg/kg cntf (from . +_ . gm/day to . _+ . gm/day; p<o. ) and was also unaffected by prior ibuprofen treatment ( . +- . gm/day). despite the loss in body weight noted in the high dose cntf animals, there was no appreciable hepatic acute phase response, since liver weight ( . + , gms vs. . _+ . gins), total protein ( . +- . gms/l vs . +- . gins/l) and albumin ( . + . gms/l vs. . +_ . gms/l) were not different between cntf and freely fed animals. we conclude that cntf causes anorexia, and increases body weight loss in excess of the associated anorexia. unlike the cachexia associated with il- and tnf infusions, which is associated with an acute phase response, cntf acts predominantly on food intake and carcass weight through a prostaglandin-independent mechanism and has only minimal acute phase inducing properties, n. joseph espat, md. university of florida, department of surgery, j-box , gainesville, fl. . of cytokines by neurotrophic factors, the neuroendocrine system and phenotiazines. cytokines, including tnf and il- , have a pathogenetic role in various diseases related to infection and inflammation. the action and/or production of cytokines can be regulated by drugs or endogenous mechanisms that involve the cetral nervous system (cns) we found that the antipsychotic chlorpromazine (cpz) potently inhibits tnf production and protects mice against endotoxic shock. cpz also inhibits brain tnf production in mice intracerebrally injected with endotoxin, whereas cpz analogs that do not cross the blood-brain barrier inhibit only perypheral, not brain, tnf. tnf production and susceptibility to the toxicity of endotoxin, tnf and il- are increased in adrenalectomized mice, indicating that endogenous corticosterone (cs) controls cytokine production and toxicity, in a feedback fashion since endotoxin and cytokines increase serum cs. increased tnf production was also observed in mice where the hypothalamus-pituitary-adrenal axis was blocked by chronic administration of dexamethasone, following a two-day washout. administration of cytokines acting through the gp signal transd,uction protein, including il- and ciliary neurotrophic factor, cntf potentiated il-l-induced elevation of cs. il- and cntf also induced hepatic acute-phase proteins. thus il- and cntf might have antiinflammatory activity, by potentiating the feedback responses of the neuroendocrine axis. these data indicate how complex can be the interregulatory relationships between the brain and the immune system, how they can be used to pharmacomodulate cytokine action and how their disregulation might exacerbate il- -and tnf-mediated pathologies. lipopolysaccharide (lps) constitutes a well established activator of monocytes/ macrophages (mizi) and murine b lymphocytes. the hydrophobic part of lps, termed lipid a, represents the endotoxic principle of lps. we now demonstrate that lps is also capable of inducing proliferation of human t cells at a dose of to pg/ml. the specificity of this stimulation was analysed by the following experiments: i) the synthetic hexaacyl escherichia coiltype lipid a (compound ) also stimulated human t cells; ii) the synthetic tetraacyl lipid a precursor (compound ) or the phosphono-oxyethyl analogue pe- , structures known to antagonize lps-induced monokine production in human mz, also inhibited lpsinduced t-cell proliferation. the t-cell proliferation expressed the following features: i) cd ÷-as welt as cd ÷ t cells proliferate in response to lps, ii) limiting dilution analyses reveal that the frequency of responding cells was between / to / cells; iii) purified t cells alone cannot be stimulated by lps, but need the help of monocytes. this help cannot be replaced by b cells or fixed monocytes. furthermore, for activation a direct cell-to-cell contact between t cells and monocyte is neccessary; iv) t cells stimulated with lps express mrna for il- and ifnf, but not for il- or il- (determined by pcr). in supernatants, ifnf was detectable (elisa); v) lps-activated cd ÷ as well as cd + t cells express cd , the high affinity il- receptor. our results indicate that in contrast to previous reports human t cells respond to lps with il- receptor expression, lymphokine production, and proliferation. the reactive cells appear to belong to the t, cell type, the finding that human t cells can be activated by lps is of important relevance for the understanding of the pathomechanisms of infections by gramnegative bacteria. this may lead to new strategies for the therapy of sepsis. we have recently shown that human eosinophils produce mrna for interleukin (il)- when stimulated with calcium ionophore (eur. j. immunol. ( ), ). we now present evidence that human eosinophils contain preformed il- protein although they do not express mrna for il- as measured by rt-pcr. il- protein expression was determined using specific anti-human il- monoclonal antibodies by western blotting, facs analysis and immunohistochemistry. moreover, preformed il- was re/eased into supernatant by % pure eosinophils after priming with gm-csf or il- and subsequent -min stimulation with paf, rantes, ionomycin or pma, however not with il- or il- , as measured by elisa. this observation implies that activation of protein kinase c and/or intracellular calcium mobilization are necessary events for il- release in human eosinophils. the determined amounts of preformed il- protein was higher in patients with asthma compared to normal individuals suggesting a role for eosinonhi! derived il- in asthma. since the eosinopnit is the ,,r~:=z~mmant cell in the asthmatic airways, we determined il- concentrations in bronchoaiveolar lavage (bal. ~ids from normal !i~.~ijvtduals and asthmatic patients. indeed, il- concentrations in bals from both groups were similar to those seen in the supernatants released by activated eosinophils. the role for il- in asthma remains to be determined. based on a well established rat model named activity-induced ulceration (asu) or activity based anorexia (aba), we have developed a rat model for chronic stress. male rats were exposed to a feeding schedule in order to reduce body weight by - % within days. while one group of rats was kept sedentary, the other had access to a running wheel. food restricted rats allowed to exercise developed highly increased activity as compared to ad libitum fed rats in wheels (ca. versus kin/day). they developed elevated plasma corticosterone levels ( _+ gg/dl) at their circadian peak, increased adrenal weight and decreased thymus and spleen weight as compared to control rats and weight matched sedentary rats, establishing this paradigm as a model of chronic stress. no differences in plasma acth were seen among the various groups, suggesting increased sensitivity of the adrenal glands to acth. the effect of chronic stress accompanied by hypercorticism on baseline and endotoxin-induced cytokine levels was studied in this model. under baseline conditions,splenic il- a was suppressed in both food-restricted groups. this was more pronounced in rats with access to a running wheel. il- and tnf activity in plasma was not affected. after administration of .tg/kg lipopolysaccharide (lps), tnf activity in plasma was suppressed by food restriction but there were no differences between sedentary or exercising rats. in addition, no differences were found among groups for corticosterone, spleen il-lc~ and plasma il- activity. we conclude, that the food restriction-induced hyperactive rat model is a useful model for studies on the effects of chronic stress. in this model, under basal conditions il-le~ in tissues may be subject to downregulation by glucocorticoids, whereas after lps-stimulation of cytokine production only tnf activity is regulated by fast acting feedback loop between cytokines and the hypothalamo-pituitary-adrenal axis (hpa-axis). this is supported by strong correlations between plasma tnf activity and corticosterone in stressed rats. cytokine antagonists modulate cytokine actions and it appears that a balance between production of cytokines and cytokine antagonists is important to control of host responses. recent observations show that during myocardial infarction there is an increase in circulating cytokines such as tumor necrosis factor (tnf) and interleukin (il- ). we tested the idea that compensatory increases in cytokine antagonists likewise occur and investigated changes in plasma concentrations of tnf and interleukin i (il- ) and those of their specific antagonists interleukin- receptor antagonist (il- ra) and soluble tumor necrosis factor receptor type i (s tnf r-i). we also measured plasma concentrations of ~-melanocyte-stimulating hormone (~-msh), an endogenous neuropeptide that occurs in pituitary, brain, skin, gut and other tissues. when administered to laboratory animals, this peptide has potent antiinflammatory and antipyretic activity, perhaps by mimicking an endogenous modulatory influence on cytokine actions. samples were obtained from patients with acute myocardial infarction at presentation in the coronary unit, every three hours for hours, and daily thereafter until discharge. we found elevations in the plasma cytokines il- and tnf only in a proportion of subjects whereas cytokine antagonists c~-msh, il-lra, and stnfr were elevated in all patients, o~-msh was elevated at presentation but it decreased progressively in successive tests, reaching normal values within hr whereas stnfr and l-lra peaked at - hr or later. there were significant correlations between plasma concentrations of cytokine antagonists and enzymes released from injured myocardium, including creatine kinase (ck), aspartate serum transferase (ast), and lactate dehydrogenase (ldh). the data show that cytokine antagonists increase in the circulation of patients with acute myocardial infarction likely to modulate prninflammatory effects of cytokines. objects of the study: interleukin- (il- ) is a multifunctionai cytokine known to be involved in important homeostatic processes. il- levels are increased in many pathological situations, and correlates with disease activity and patient outcome. to exert its effect il- binds to its receptor on the membrane of its target cell. this receptor is also present in a soluble form in plasma and in urine. in this study we quantitatively measured the availability of soluble il- receptor (sll- r) in biological fluids in healthy volunteers. materials and methods: blood, urine, cerebrospinal fluid (csf), and synovial fluid (sf) are obtained from healthy volunteers, sil- r and il- are measured using elisa's. both elisa's are tested for interference of sil- r mid il- . the effect of sll- r in the il- bio-assay (b ) is tested. results: baseline levels are (mean + sd): . -+ . ng/ml in serum, . -+ . ng/ml in urine, . _+ . ng/ml in csf and . + . ng/ml in sf. there is no interference of sll- r in the il- elisa or bio-assay and no interference of l- in the sil- r elisa. conclusions: in all investigated biological fluids sll- r can be found. these data provide baseline values for investigations concerning pathological situations. both elisa's described are useful tools to do these investigations. trauma-associated immune aberrations coincide with augmented release of immunoregulatory and proinflammatory cytokines. the present study examines the effect of thermal trauma on the capacity for specific (receptormediated) response of lymphoid cells to interleukin (il ) and to turnout necrosis factor ~x (tnfc . methods. bum patients (n= , -> % total body surface area) were studied weekly up to days post-injury. the limulus amoebocyte lysate (lal) test was used to measure plasma endotoxin levels. the percentage of il ~-and tnfcz-binding t(cd ) lymphocytes was assessed by flow cytometry analysis. levels of il receptor antagonist (il lra) in patients' plasma and cultures of peripheral blood ceils (pbc) were determined by immunoassay. results. plasma endotoxin concentrations were significantly (p< . ) increased up to weeks post-bum (means . + in non-surviving and . + . u/ml in surviving patients vs < u/ml in the control). within weeks of bum, the percentage oft ceils expressing receptors for tnfa and il [~ constitutively was elevated (by - fold). in contrast, the capacity for de novo receptor expression by activated pbc was reduced. serum levels of il ira were significantly increased (range . - x j pg/ml vs < . x j pg/ml in the control). in all patients, high concentrations of il lm were released spontaneously in unstimulated cultures of adherent ceils (range - x - pg/ml vs - x j pg/ml in the control). however, its secretion was decreased in lps-stimulated parallel preparations. conclusions. in the bum patient, susceptibility to the immunoregulatory effect of tnfcz and tl ~ may be modulated by infection-related products. alterations in the capacity for receptor expression and secretion of l lra may affect il -regulated biological responses including specific immune reactions. while studies suggest that il- is an important lymphokine involved in cell-mediated immunity, little is known about this mediator's role in hem-induced immunesuppression. our aims, therefore, were to determine: i) if il- contributes to depressed t-cell responses seen following hem; and ) how other agents, known to play a role in hem, effect il- release. to study this, c h/hen mice were bled to and maintained at a map of mmhg for h and then adequately resuscitated. mice were killed h post-hem to obtain splenic t-cells (nylon-wool purified). il- 's immunosuppressant role was demonstrated by the ability of monoclenal antibody (mab) to il- to markedly improve the t-cell proliferative response [ . #g the marked increase in capacity of t-cells from hem mice to produce il- was significantly reduced by treatment with either ibu or mabs. since ibu, tgf-~, as well as il- are all reported to directly/indirectly influence prostanoid synthesis, this implies that eicosanoids play a major role in inducing il- release by t-cells following hem which depresses t-cell function. the mechanisms underlying immunosuppression induced by thermal injury and alcohol ingestion are in part due to cytokine dysregulatinn. il- down-regulates production of eytokines by maerophages and may be an important regulator of the initiation of the immune response. il- has also been demonstrated to inhibit the production of no by macrophages. this study examined the alterations in eytokine production and effect of inhibition of no production on immunologic function in a routine thermal injury model. methods: balb/c mice (n= ) were randomized to groups: saline-sham(ns-sham), alcohol-sham(etoh-sham), ns-bum, etoh-bum. animals received % etoh or ns daily for days by gavage. a % full thickness bum was induced hrs after the last dose of etoh or ns. animals were resuscitated, then sacrificed days post bum. splenic lymphocytes were cultured for days with lps, and lps with two concentrations of n-monomethyl-l-arginine, a nitric oxide inhibitor (l-nmma . ug/ml, ug/ml). splenocyte production of il- , interferon-gamma, il- , pge were measured, and lymphocyte proliferative response examined. results: il- production was significantly suppressed in thermal injury. exogenous l-nmma normalized the suppression of .- in a dose-dependent manner, indicating nitric oxide may modulate il- and interferon-gamma production in thermal injury. il- production is normal in etoh-burn animals. conclusion: il- and interferon-gamma production is altered in this murine thermal injury model, and may contribute to this injury-induced immunosuppression. inhibition of no synthesis normalizes il- production and should be investigated further as an immanomodalator in thermal injury. surgery, infection and inflammation results in the production of pro-inflammatory cytokines which mediate metabolic and immunologic host responses. the aim of this study was to characterise the elaboration of cytokine release following a variety of surgical procedures. twenty one patients undergoing elective intermediate, hip, knee and major gastrointestinal surgery were studied. levels of interleukin- (i - ), interleukin- (i - ), the interleukin- receptor antagonist (i - ra) and the acute phase c-reactive protein (crp) were measured in bloods drawn , , , , , , and hours following operation. a portion of the results are shown (mean -+ sem). + -+ _+ one and two factor anova; *p< . , #p< . , §p< . , ¶p< . , for differences between groups i - was not detected at any time point. both ii-ira and i - increased after surgery. maximum responses occurred following major git and hip surgery, minimal responses were seen after intermediate and knee surgery. ii-ira levels increased within two hours and remained elevated for hours; the b-ira increase was a thousand fold greater than the rise in i - levels. i - levels increased up to hours after surgery. crp levels reflected maximum ii-ira and i - levels (r =. , p< . and r =. , p< . respectively). high ii- ra and i - levels reflect major surgery, however the ii-ira response is more rapid and of greater magnitude. the strong i - ra correlation with crp may indicate that this regulatory cytokine is itself a mediator of host responses to surgery. dept. of surgery, meath/adelaide hospitals, heytesbury st., dublin , ireland. change of il- and soluble il- receptor levels after surgery s. hisano, k. sakamoto, s. mita, t. ishiko, m. ogawa [objectives] under surgical stress, il- plays a main role in producing acute phase proteins and contributes to host defense mechanism. soluble il- receptor (sll- r) is considered to be agonistic to il- , unlike other soluble type receptors of cytokines. here we measured il- and sll- r levels in the serum and drain fluid from surgical field in order to investigate the changes of il- and sll- r after surgery and their origins. [materials and methods] serum and drain fluid samples from cases ( of esophagectomy and of gastrectomy ) were serially collected before and after surgery. il- and sll- r levels were measured by elisa. [results] ( ) serum il- : all cases reached the maximum level on pod-l, more precisely - hours after operation. ( ) il- in the drain : maximal il- levels in the drain were recognized - hours after operation, at almost the same time as serum il- . furthermore the il- values in the drain were much higher, about times, than those in serum. ( ) sll- r in the serum : all cases reached minimum levels - hours after operation and recovered to the preoperative levels a few days later (decrease ratio : . + . ~,, range : - ~'). ( ) sll- r in the drain : sll- r levels in the drain showed almost the same value and change as serum sll- r. [conclusions] ( ) il- is produced from the cells gathering around operative fields whereas sll- r is considered to be produced in the cells which do not gather around the operative fields. ( ) there may be a mechanism that down-regulates sll- r in the early stage of surgery. [objectives] il- plays an important role in host defense in the early stage after surgery. in the present study, we examined changes in il- concentration after major thoracoabdominal surgery and elucidated the effect of surgical trauma and factors influencing postoperative elevation of serum il- . [materials and methods] thirty-eight patients undergoing elective surgery of the thoracoabdomen were classified into groups according to the location of the operation. bloods and drain fluids were serially obtained and samples were frozen until measured, keukocytes were simultaneously collected for northern blot analysis. concentration of il- was measured by elisa and il- mrna was detected by northern blotting after total rna was extracted by the acid guanidium phenol chloroform method. [results] ( ) serum il- levels reached the maximum concentration on the st postoperative day in all patients. ( ) the il- peak was significantly correlated with surgical trauma as defined by the operation length and the volume of blood loss during operation (r= . , p< . , r= . , p< . , respectively). ( ) the peak concentration of serum il- in patients undergoing esophagectomy was significantly higher than in those undergoing pancreaticoduodenectomy (p< . ), despite a similar degree of surgical trauma. ( ) peak l- concentration observed in a patient who underwent esophagectomy was about fold greater in the drain fluid of thorax than in the peripheral blood. ( ) il- mrna was demonstrated in leukocytes from thoracic and abdominal exudate at , and hours after surgery. in contrast, il- mrna could not be detected in leukocytes from the peripheral blood. [conclusion] il- is mainly produced in the operative field and subsequently enter the peripheral blood to induce cytokinemia. the operation length, volume of blood loss and thoracotomy are factors influencing the concentration of cytokine in the blood. zaragoza spain age may be an important factor influencing the function of immunocompeteut cells releasing cytokines after both accidental and surgical trauma the aim of the present paper is to ascertain if patients (pts) over years old show a different serum level cytokine pattern than pts under after a standard surgical procedure considered as a "medium strength trauma". patients and methods: pts( females males)with gallstone disease were perspectively studied, pts were allotted in two groups: gr.a: pts under years(mean age: . +- )gr.b: pts over years(mean age: . _+ ). all pts underwent cholecystectomy and cholangiography. pts in gr.a and pts in gr. b underwent common duct exploration. spbintercctomy was performed in each group. on the day of surgery (pre) and on the st and th postoperative day(leo, po) : percentages of cd , cd , cd , cd and cd cells we measured by means of flow cytometry using moab. and levels of il- , il- , il- and tnf "in vivo" by elisa using moab. results: ere: cd % was . _+ in gr.a and . objectives of the study. after surgery for esophageal cancer multiple organ damage has been reported to be caused by polymorphonuclear leukocyte (pmn)-mediated injury. we measured serum granulocyte colony-stimulating factor (g-csf) and interleukin (il- ) levels to determine a role of g-csf and il- in pmn function after surgery for esophageal cancer. materials and methods. peripheral pmn counts, peripheral pmn chemiluminescence, serum g-csf levels, and serum il- levels were measured before and after surgery in patients with esophageal cancer (ec), and patients of gastric cancer (gc). esophagectomy with thoracotomy and laparotomy were performed for patients with ec, while subtotal gastrectomy with laparotomy were performed for patients with gc. results. peripheral pmn counts (p< . ) and peripheral pmn chemiluminescence (p< . ) of patients with ec were significantly decreased compared to those of patients with gc at and hours after surgery. serum g-csf levels of patients with ec were significantly (p< . ) increased compared to those of patients with gc at and hours after surgery. serum il- levels of patients with ec were significantly (p< . ) increased compared to those of patients with gc at , and hours after surgery. significant inverse correlations (p< . l) between peripheral pmn count and serum g-csf and il- levels were seen at hours after surgery. conclusion. these results suggest that many circulating pmns, which are excessively activated by g-csf and il- , may adhere to the endotherial cells and then migrate into the tissues, and cause multiple organ damage after surgery for esophageal cancer. immunnogical changes in patients with severe brain trauma receive increasing attention since morbidity and mortality ere still high. interleukin- (il- ) was previously detected in the cerebrospinal fluid (csf) during different pathologies of the nervous system ( , , ). in our study we monitored il- and nerve growth factor (ngf) production in the csf after human brain trauma. since astrocytes within the brain constitute one of the major cell type contributing to the inflammatory response through the release of cytokines and other factors after injury, we investigated the functional relationship of il- and ngf on a single cell niveau using cultured astrocytes. methods csf was obtained from patients with severe brain injury (glasgow coma score (gcs) < and ct abnormatities or gcs < over hours) after implantation of intraventricular icp monitoring device for therapeutic purpose and collected over hours csf and serum. il- and ngf were assayed by elisa. astrocytes were isolated from neonatal mouse brain as described ( ) . ngf production by cultured astrocytes was measured by elisa in the presence of csf, il- and il- antibody. astrocyte migration was tested in a chemstaxis chamber. results head trauma patients were included in this study (approved by the university hospital medical ethics board) and the csf was obtained through intraventricular catheters. high levels of il- were detected in the csf of these patients when compared to serum during the first days after brain trauma. furthermore ngf could be found inside the intracerebral compartment. csf containing high levels of il- could stimulate ngf production in cultured astrocytes. this effect could be [nhibited partially by il- antibodies, purified il- exposed to cultured astrocytes in vitro, stimulated the migratory activity of these cells in a dose response fashion. il- was found in the csf of brain injured patients, suggesting a role for this cytokine in the pathophysiology of brain injury. since astrocytes are involved in maintaining the homeostasis of the brain, we further investigated the possible role o il- on astrocyte functions, il- promoted ngf production in vivo and in vitro, thus contributing to neuronal cell survival and regeneration. furthermore il- stimulated astrocyte migration in a dose response fashion, potentially contributing to astrocytosis following brain injury and inflammation, these results show that il- represents a key cytokine in traumatic human brain injury with possible systemic effects, which are at preserlt under investigation. we studied a) the role of tnf and b) the therapeutic effect of a mab to tnf with regard to haemorrhagic shock (hs) related ,pathophysiologic alterations and mortality in rats. method: a prolonged hs was induced by bleeding to a blood pressure of - mmhg for pin followed by reinfusion of shed blood (sb) and resuscitation with two times of sb volume of ringer's lactate over rain. animals received a bolus dose ( mg/kg) of tnf mab (celltech, berkshire, uk) at min after resuscitation (tn ). the control group (n = ) was treated similar to the tn group but received ringer's lactate (con). results: at min the prolonged hs resulted in a metabolic acidosis indicated by a significant decrease of blood ph ( . + . ), hco -( . ___ . mm), and base excess (- . + . ram) values with pco ( . + . mmhg) and po ( . + . mmhg) in the tn with no difference to the con group. immediately after resuscitation ( min) plasma endotoxin levels were found to be increased in both groups ( . + . in tn vs . _ . pg/ml in con group) . prior to the treatment with tnf mab ( min) there was also no difference between plasma tnf levels of the two groups ( . + . in tn vs + . pg/ml in con group). treatment with the tnf mab at rain post-hs improved the hour survival rate to . % as compared to . % in the control group. macropathologic evaluations revealed frequency of intestinal bleeding in oniy animals in the tn vs in the con group. no bleeding in the kidneys was found in the tn but in rats in the con group. the significant increase in lung wet weight observed in non-survivors in the con (n = ) was prevented in animals which died in the tn (n = ) group (( . +_ . vs . +_ . g/kg). conclusion: our data suggest that tnf formation induced by hs in rats is an important mediator for pathophysiologic alterations leading to multi organ failure and lethality. antibodies to tnf might be a useful agent in the treatment of haemorrhagic shock related disorders. -+ n=ll*$ -+ n= _+ n= * * p< . vs baseline :~p< . no anesthesia vs anesthesia thus ) tnf production increased - fold by - hrs following trauma in unstimulated blood, but was reduced or not changed after lps stimulation, so circulating leukocytes are probably not an important source of tnf post trauma; ) anticd had no obvious effect on tnf production in unstimulated or lps stimulated blood, relative to vehicle, which suggests that the protective mechanism of anticd does not involve tnf suppression; ) fentanyl anesthesia at hrs following trauma unexpectedly decreased lps-evoked tnf production, which suggests that anesthesia alone can influence an inflammatory response. proinflamrnato~ cytokines have been shown to play a signific~t role in the pathogenesis of sepsis, which is a very common occurrence in born injury. tnfa is infrequently detected in the blood of burned patients, the ability to detect the shed receptors of stnfg has not been determined. serial serum mmples from burn patients were collected from the time of admission until death from septic shock. these samples were analyzed using an enzyme-linked immunosorbent assay (elisa) for stnfr, l-ira, tnf-a, and il-ib. the patients ranged in age from to yeas of age. the percentages of bum ranged from % - %. cytokine concenlrntions vmled from patient to padent irrespective of bum size. tnfa levels were consistentiy in the range of pgjml - pg/ml. peaks in the tnfa values were above pg/ml and were also associated with a peak in the stnfr levels. these levels began at < , pghnl within the in,st ins of injury and gradually increased with time. clinically. ti~ appearance of eytoklnes was independent of positive wound, blood, or respiratory cultures however peak values in tnfa and stnfr were ~ialed with a fluid requirnmenl levels of il-i ra were also elevated independent of clinical findings as well as extent of injury. in pl there is a significant corresponding peak in il-trn (> ~ /ml) at the same time as t/~:a and stnfr levels. we aimed to characterise the pattern of secretion of interleukin- beta l-ii ), intefleukin- (il- ) and tumour necrosis factor alpha (tnfa) in multiply injured patients and to relate these results to their clinical condition and outcome. two hourly blood samples were taken from ten patients from the time of injury until hours. cytokine levels were measured using sandwich enzyme-linked immunosorbent assays (elisas). injury severity scores (iss) were calculated and haemorrhage was assessed from the blood transfusion requirement over the hours. patients' ages ranged from to years. iss varied from to and transfusion requirement from to units. five patients died after the study period. ] ,- was raised in / patients (max level , pg/ml) but was unrelated to condition or outcome. / showed a rise in il- b (max level pg/ml) which was negatively correlated to iss (i=- . , p< . ). tnfa was raised in / (max level pg/ml). peak tnfc~ was positively correlated with iss ( = . , p< . ) and haemorrhage (i= . but p< . ). il-ib and tnfa production was mutually exclusive. there was no common cytokine profile for these patients. unlike elective surgery there was no correlation between peak ,- and severity of injury: tissue damage may not be the stimulus for the cytokine response to multiple injury. periods of ischemia or hypoxia produce endothelial damage in peripheral organs. tumor necrosis factor-alpha (tnf) plays a central role for regulation of endothelial physiology during septic events, taking influence on vascular permeability and coagulant activity [ ] . animal experiments demonstrated a synergism between hypoxia and septic shock on letality, leading to the hypothesis that low oxygen tension leads to enhanced sensitivity of target cells for tnf [ ] . radioligand binding studies with ~ odid-tnf on cultured human endothelial cells were performed after incubation in several environmental oxygen tensions (pc ) for hours. data were achieved by nonlinear regression of an idealized saturation curve according to the equation: b = n " k./( + k,); b = totally bound tnf; k,: association constant (concentration for half-maximal binding); n: number of binding sites per cell. p_o o (mm h¢i): _k, (nm}: n (molecules/cell): - . ± . _+ - . ± . + - , ± . -+ - . + . -+ presented are calculated values on the idealized curve + % percentiles. hypoxia induces enhanced binding of tnf to specific receptors on the endothelial cell surface in a time-and dose-dependent manner by a mechanism, which is not dependent on oxygen radicals, as shown by additional protocols with radical-scavenging drugs. with respect to former findings about a correlation between growth and tnf receptor affinity [ ] , these data lead to the hypothesis that enhanced tnf binding during hypoxia is due to a biochemical conversion of the receptor protein from the low affinity to the high affinity state, possibly by posttranslational phosphorylation of the binding protein by intracel)ular kinases. the proposed involvement of tnf-dependent pathways in pathogenesis of organ dysfunction and multiple organ failure after hypoxia/ischemia may provide a basis for understanding the initiation of hypoxic vascular injury, as manifested by increased permeability and prothrombotic tendency, and, thus, merits further attention. the levels of activity of circulating cytokines (ill, il- and tnf-alpha) which are believed to play important regulatory role in response to trauma are determined (by hioassays and respective anti-cytokine antibodies) in mice and rats subjected to scald injury ion c, see, ° v bsa, ld ) and ( c, see, ~ b ~^)~ , respectively. biphasic increase of cytokine activity was noted in mice: initial increase of il-i and il- , - hr following injury and of try activity hr after scald, followed by elevated levels of il-i and il- at hr, with tendency of decrease of activity at later time points. increased activity of tnf was noted hr following injury, in rats, initial, short-lived increase of il-i and tnf activity was detected lhr following injury, folowed by increase on days i and postburn. il- increase peaked - hr after scalding and levels remained elevated - days following injury. similar kinetics of appearance of proinflammatory cytokines (il-i and tnf-alpha) both in lethal and ncnlethal injury concomitant with differential profile of circulating il- activity (early,short-lived increase and later slow decrease of activity in lethal burn injury) with late persistent high levels of activity in nonlethai injury demonstrated in the present study highlight the need for investigation the relationship of these cytokines in burn-injury induced inflammation. zikica jovicic,lnstitute for medical research, mma,crnotravska , belgrade~yu. asadullah k ( ), woiciechowsky c ( ), liebenthai c ( ), doecke wd ( ), volk hd ( ), vogel s ( ), v. baehr r ( ); depts. of med. immunology ( ) and neurosurgery ( ) , medical school (char#d), humboldt university berlin, frg in patients after polytrauma or major abdominal surgery a hyperinflammatory phase seems to be followed by the development of a phase of monocyte inactivation. the latter is charaeterised by a decrease of monocytic hla-dr expression and a shift to anti-inflammatory cytokine production. as shown, by us and others, this phenomenon indicates severe immunodepression with a high risk of infection. however, the mechanisms leading to monocyte inactivation in the above mentioned syndromes may be multiple. to elucidate the influence of a selective, sterile trauma to the central nervous system (cns) on immune reactivity the neurosurgieal patient is an interesting model. initially, patients who developed a systemic inflammatory response syndrome following neurosurgery were analysed. in all of them a marked decrease of monocytic hla-dr expression was observed soon after the operation. these results suggest that neurosurgery alone can induce immunodepression and lead us to conduct a prospective study, in which we closely monitored l patients undergoing neurosurgery from the first preoperative day until at least day after the operation. hla-dr expression was decreased hi all patients to various extent only hours after surgery. in one patient only we found a persistently reduced hla-dr expression and this was the only patient to develop sepsis syndrome. this suggests that a prolonged, postoperatively decreased hla-dr expression is predictive of infection following cns trauma. in order to assess, whether a decrease of hla-dr expression was associated with a preceding inflammatory response, local cytokine release in the cns was compared with systemic cytokine release. for this purpose, paired samples of earebrospinal fluid (csf) from a vantricle drainage and peripheral blood plasma were obtained. in the csf extremely elevated futerleakin (il)- levels, peaking already a few hours after the operation were found. in plasma, by eontrast, il- ( and tnf-alpha) was detectable not until days later and only if infection was present. the antiinflammatory ili-ra, on the other hand, was also present in csf but peaked after il- and was detectable in peripheral plasma too. we believe there is an association between the inflammatory response in the cns and the following depression of hla-dr expression on peripheral blood monocytes. our results suggest that even a sterile cns-trauma by itself may contribute to general immunodepressinn leading to septic complications. the aim of this study was to evaluate the effect of haemorrhagic shock (hs) a) on total capacity of the host, and b) the circulating blood cells to produce tnf immediately after bleeding. in vivo studies: baboons were subjected to a limited oxygen deficit ( - ml/kg) hypotension phase (mean arterial pressure = map of - mmhg for - hours followed by adequate resuscitation). rats subjected to hs (map of - mmhg for rain followed by reinfusion of shed blood and fluid resuscitation) were challenged with endotoxin ( ~g/kg i.v.) at the end of shock (rhs group). the control group (rco) received the same dose of endotoxin as rhs group but without prior bleeding. in vitro studies: whole blood (wb) obtained from both baboons and rats before and at the end of hs were incubated with endotoxin ( ng/ml) for hrs at °c. results: at min post-lps challenge we found significantly higher plasma tnf levels in rats that were subjected to hs prior to the endotoxin challenge as compared to the control group ( _+ vs + pg/ml) . after hs the tpc was significantly decreased in in vitro stimulated cbc of both rats ( + post-hs vs + ng tnf/ml pre-hs) and baboons ( ± post-hs vs ± pg tnf/ml pre-hs). in contrast, the il- productive capacity was increased in baboons cbc (not yet analysed in rats) stimulated at the end of hs ( ± pre-vs ±_ pg il- /ml post-hs). conclusion: from our data we suggest that despite of down regulation of the cbc to produce tnf the overall tpc is enhanced at the early stage of i-is. with regard to the related literature (chaudry's group) it can be assumed that among the macrophage/monocyte populations, as the main source only the kupffer cells (kc) exhibit enhanced tnf production capacity following haemorrhage. the mechanisms of down/up regulation of cytokine response of cbc and/or kc following hs remain to be examined. d. eg~er, s. geuenich °, c. dertzlin~er °, e. schmitt*, r. mailhammer, h ehrenreich #, p. drrmer, and l. h mer gsf-instimt fox experimentelle h~znatologie, °medizinische kliulk iii, klinikum groghadern, munich, *institut for immunologic, johannes gutenberg universit/it, malnz, and #psychiatrische k/in& der georg-aagust-universi~t, grttingen, germany. it has been shown previously (ehranreich et al., , new biol. : ) that mouse bone marrow-derived mast cells (bmmc) synthesize and secrete endothelin- (et-i) and express eta-type endothelin receptors (eta). so far, however, no functions of et- /et a in bmmc have been described. in the present study we investigated the effect of exogeneously administered et- on the release of histamine, serotonin, and leukotriene c (ltc ) by primary mouse bmmc (in vitro age: weeks) caltured with different recombinant mttrine cytokines (interleukin (il- ) and/or kit ligand (kl) in the presence or absence of il ) for two weeks prior to activation. et- ( x - to lxl - m) induced an extremely rapid (_<lmin) and dose-dependent release of histamine and serotonin (up to % and % of total mediator content, respectively, comparable to ige/ag-indueed mediator release) from bmmc cultured with il- and il- . only when cultured in the additional presence of il- rather than in medium containing kl or kl plus il- alone, bmmc released histamine and serotoaln upon challenge with et- .furthermore, et- stimulated ltc biosynthesis up to -fold in bmmc cultured in the presence of il- . in contrast, the peptide was without major effect on ltc biosynthesis in bmmc culturd without il- . the release of histamine and sereotonin was not altered if bmmc were preincubated for i h with il- prior to activation with et-i, suggesting that a differentiation process rather than a functional priming effect had been initiated by ]l- . et- ( " m) -induced histamine and serotouln release from bmmc was inhibited by an eta-specific antagonist (cyclic id-asp-pro-d-val-leu-d-tel ) in a dose-dependent manner, with a complete inhibition observed at an antagonist concentration of - m. crude peritoneal cells (containing - % serosal mast cells) obtained from normal balb/c-mice released % histamine upon challenge with et- ( - m; rain). taken together, these resu/ts demonstrate that et- can directly function as a histamine and serotohin secretagogue and as a stimulator of ltc production in mast cells. il- appears to be involved in the differentiation of immature mast cell prec~trsors towards an et-l-reactive functional phenotype. when inflammatory reactions are advanced, type ii phospholipase a (type ii pla ) is produced in high levels by various cells at the site of inflammation. cytokines such as tnf-a and il-i activate type ii pla and promote the production of eicosanoid, which is one of the mechanisms by which they enhance the inflammatory reaction. in the present study, the blood levels of type ii pea , endotoxin, tnf-c~, il- and il- were determined in patients with sepsis to examine the relationship between these levels and the patients' pathological conditions. the levels of type ii pla and tnf-a in these patients were . ± . ng/ml and . ± . pg/ml, respectively, the two parameters being significantly correlated (r = . , p = . ). there were also a significant correlation between the level of type ii pla an il- (r = . , p = . ). there was no significant correlation between the level of type ii pla and il- . these in vivo findings suggest that tnf-a may be involved in the production of type ii pla . a. filzmaver, g. reisbach, e. schmitt °, r. mailhammer, and l. hiittner. gsf-iustitut ff~r experimentelle h~imatologie, munich, and °iustitut fttr immunelone , johannes gutenberg universit~t, mainz, germany the product of c-kit, a transmembrane tyrosin ldnase receptor, and a corresponding kit ligand (kl) are critically involved in the control of different hemopoietic cell lineages including the proliferation, maturation, migration, and function of mast cells. it has been reported previously that interleukin (il)- down-regulates kit receptors in human primary myeloid leukemic cells and in a human mast celt line (sinaber et al. , j. immunol. : ) . transforming growth factor (tgf) gl, was also found to down-modulate c-kit mrna and kit receptor proteins in human aml blasts, a mechanism probabely contributing to the anti-proliferative effect of tgfih on kl-stimulated aml ceils in vitro (de vos et at. , cancer res. : ) . in porcine endothelial cells transfected with a retroviral construct carrying the human (hu) e-kit gena, exogenous hu kl transiently down-regulated kit receptors (blume-jeusen et al. , embo j : ) . in the light of these previous findings we analyzed the effects of these exogenously applied cytokines (il- , tgfgl, kl) on kit receptor expression and kl-mediated proliferation and chemotactic migration of primary mouse bone marrow-derived mast cells (bmmc) (in vitro age: weeks). our results show that in bmmc cultures initiated with recombinant (r) marine (mu) il- the additional presence of rmull- for or days did not change the expression of kit protein (assessed by facs analysis with the anti-mouse c-kit antibody ack- ) nor kl-mediated proliferation or chemotaxis. in contrast, il- syeergistically increased kl-stimulated growth of bmmc in a short-term proliferation assay (mtt-tes . pre-incubation of bmmc with rhutgfl~ ( . , . , or . ng/ml) for h had no effect on kit receptor expression, although tgffil at concentrations of . - . ng/ml completely suppressed the proliferative action of kl on these ceils. similar anti-proliferative effects of tgfg were observed in various factor-dependent mast cell lines stimulated with different mast cell growth factors (il- , i,- , il- , and/or il- ). moreover, pre-incuhation ( h) of bmmc with tgf-gl (> pg/ml) significantly enhanced spontaneous undirected cell movement (chemokinesis) and synergistically increased il- -or kl-induced chemetaxis. when bmmc were preancuhated with rmukl ( ng/ml) for , . or days, a transient down-modulation of kit receptors with a maximum effect on day was demonstrated by facs analysis and correlated well with a decreased chemotactic response of these cells. in conclusion our results show that neither il- nor tgfi affect expression of kit receptors in primary murine bmmc. it is reasonable to suggest that c-kit expression is controlled in a cell type-specific manner.interestingly, tgfgl is obviously able to dissect the proliferative from the migrational signal transducted by kl in these cells. objectives of the study: antisense strategies using dna-otigonucleofides (odn) to modulate the cytokine response are presently under investigation. odn are thought to act very specifically with little or no relevant negative side effects. we now report that odn unspeeifically protect wehi cells from tnf-mediated cytolysis. material and methods: wehi subclone ceils ( x ), that are highly sensitive to the cytolytic activity of tnf, were grown on -well culture plates in rpm medium. after hours, phosphorothioate(ps)and partially ps-modified-odn as well as phesphodiester-odn ( - bp) were added ( . , and pm). four hours after incubation with odn, ce(i lysis was induced by recombinant murina tnf. after hours the plates were washed and stained with crystal violet cell lysis was determined by reading the absorbance (abs) at nm. results: wehi ceils incubated with tnf ( - ng/ml) were completely lysed after hours ( % abs). interestingly, wehi cells incubated with tnf and odn resisted complete lysis, eg cells incubated with . ng/ml tnf and jm odn showed still % of the absorbance observed in control ceils without tnf ( % abs). the protective effect of odn started at . pm, reached a maximum at ,um, and diminished at jm. with increasing amounts of tnf the protective effect of qdn decreased and no protection was detectable at ng tnf per ml conclusions: dna-oligonucleotides were found to unspecifically inhibit tnf-induced cytolysis. we hypothesize, that this protective effect of qdn results from an inhibition of the binding of tnf to its receptor, or from interference of odn with the subsequent signal transduction mechanisms. as a consequence, to discriminate the specific effect of odn in biologic systems, several control odn should be used. secondly, whether dna released by degradation of tumor cells or leukocytes can significantly impair tumor-and immune-defense mechanisms merits further investigation dr. med. michael meisner, institut for anaesthesiologie der universitat erlangen-nqmberg, krankenhausstral~e , d- erlangen. in this study we investigated the involvement of serine protease and free radical generation in the systemic release of tumor necrosis factor-alpha (tnf) and interieukin i(il- ), in the sepsis model of lipopolysaccharide (lps, mg/kg i.p.) induced hepatitis in galactosamine (gain, rag/mouse, i.p.) sensitized mice. treatment of gain-sensitized mice with lps (gain/lps) led to dramatic increase in serum cytokine (tnf and il-i) ievels and transaminase activity at hr and hr respectively. pretreatment of serine protease inhibitor, c~jantitrypsin (a j-at, mg/kg i.p.), rains prior to gain/lps treatment, fully protected the animals against the hepatotoxic challenge with significantly reduced serum tnf and il- levels. in order to block and scavenge superoxide generation, the mice were pretreated with xanthine oxidase inhibitor, allopurinol (al, x mg/kg i.p.) and pyran polymer-conjugated superoxide dismutase (sod, x unit/mouse i.v) r spectively. pretreatment with al and sod ( and hr prior to gain/lps) prevented gain/lps hepatitis and blocked lps induced released of tnf and il- into serum of the mice. the protective agents like cq-at or al/sod did not protect the mice against th~ hpp~totoxi£ ch~llpn-e indllee b'~ th~ recombinant mmlse tnf-o' ( . ~/rno~e j.p.) ~d oi~lps ~ caln-.~dlfa%aed mlce. it-l cett~aged la tnf (x/gain treated mjde was not detectable in animals pretreated with oq-at or al/sod. our study suggests that a serine protease sensitive to cq-antitrypsin is responsible in regulating tnf release, possibly by proteolytic cleavage of a tnf-precursor or membrane bound tnf. in addition our evidence suggest that the balance of extracellular protease/antiprotease activity may be regulated by free radical generation, possible superoxide anion, resulting in inactivation of the antiprotease. il- release may be subsequent to tnf release. objective: during sepsis one can observe a dramatically impaired production of proinflammatory cytokines like the tumor necrosis factor alpha (tnf-a), interleukin i-alpha (il-la), intedeukin i-beta (il-i&) and interferon gamma (if~) upon in vitro stimulation of circulating cells. however there is also evidence of a decreased ability to produce cytokines in other immuno-deficient states. in this study we compared the capacity to secrete proinflammatory cytokines upon in vitro stimulation of patients in severe sepsis and patients with malignant tumors. methods: heparinized blood samples of ten patients ( + years) in severe sepsis (sepsis score > according to e}ebute and stoner) were drawn at onset of disease, from fifteen patients with solid growing carcinoma ( + years) blood was drawn at diagnosis prior to any therapy. controls were obtained from fifteen healthy volunteers. pl of whole blood were incubated either with / of a standard medium or with pl of a standard medium and pl of phytohemagglutinin (pha) a potent mitogen. after an incubation period of hours plasma concentrations of tnf-a, il-la, il- and if-~ were determined by elisa. comments: our results suggest that down-regulation of cytokine secretion or of cell responsiveness to non-specific mitogens during sepsis has occurred. we observe a similar phenomenon for the group of carcinoma patients vs control significant for stimulated tnf-a and stimulated if-t. sustained immunological interactions between tumorcells and cytokine producing cells could effect responsiveness of the latter, a general increased immuno-tolerant state in patients with carcinoma has to be discussed. however we found significant differences between sepsis and cancer concerning the in vitro capacity of responsable cells to produce il-la and il-i#. the dramatically decrease of the ability to produce il-i upon in vitro stimulation could be more sensitive for a septic state than stimulated tnf-a or if- ,. objective: tumor necrosis factor alpha (tnf-a) has been implicated as a central mediator of sepsis and its sequelae. increased systemic levels of this cytoklne seem to be correlated with severity of sepsis and outcome. however mechanism of action and metabolism of tnf-g are not fully understood. in most studies blood samples for tnf-a determinations are obtained either by peripheral venipuncture, a central venous catheter or by an indwelling arterial catheter. very often blood samples are taken in different manners within the same study. in this study we measured circulating tnf-a and the amount of tnf-a released upon in vitro stimulation in arterial and central venous blood. methods: heparlnized arterial and central venous blood samples of ten patients ( males, females, mean age +_ ) with severe sepsis (sepsis score > , elebute and stoner} were drawn on day , , , , and of disease. blood was immediately placed on ice and processed within hour. pl of whole blood were incubated with pl rpmi-medium supplemented with antibiotics and l-glutamlne or with pl of rpmi-medium and pl phytohemagglutinin (pha) a potent mitogen. after an incubation period of hours samples were centrifuged and plasma was harvested and stored at - ° celsius before assessment of tnf-a concentration by elisa. statistical analysis was performed with the paired student-t-test. results: we found a significant difference (p < , ) for circulating mean arterial tnf-a concentration ( pg/ml _+ sem} and central venous tnf-a ( pg/ml +_ sem). upon in vitro stimulation there was also a significant difference (p < , ) between released arterial tnf-~' { pg/ml _+ sem) and venous tnf-a ( pg/ml +_ semi. conclusions: these results are difficult to interprete but could reflect the influence of pao and sao on tnf a release. it could also be the result of different concentrations of tnf-o release influencing factors like for example endotoxin, interferon-f or prostaglandin. a possible pulmonary and/or a hepatic metabolism of tnf-n and tnf-a producing cells cannot be ruled out. however for better interpretations of tnf-a release in septic states it is necessary to use either arterial or venous blood samples. early inflammatory processes following trauma and/or infections were found to be associated with the secretion of high amounts of proinflammatory cytokines. besides intedeukin-t (il- ), tumor necrosis factor-a (tnf-c and interleukin- (il- ) the multifunctional cytokine intedeukin- (il- ) was described to be a central regulatory element of the primary cellular and humeral defence reaction. the previously described close temporal correlation of pathologically elevated il- -concentrations and the extracellulary release of lysosomal enzymes from activated pelymorphnuclear neutrophils suggests, that il- may be a potential substrate of these preteases. the serine preteases elastase (ec . . . ) and cathepsin g (ec . . . ) derived from the azurophilic granules were assumed to be mainly involved in unspecific proteolysis at sites of inflammation by cleavage of structural as well as soluble proteins at random sites, if the inhibitory potential is decreased. the possible proteolytic activity of elastase and cathepsin g toward the proinflammatory cytokine interleukin- (il- ) was investigated. the addition of purified neutrephil elastase and cathepsin g to recombinant human il- leads to a rapid sequential degradation in vitro. at least two intermediate products could be detected by silver staining and western blotting following protein separation under reducing conditions. the serine protease inhibitor g-anitrypsin was shown to prevent the proteolytical degradation of intedeukin- . furthermore the loss of the biological activity of both, recombinant and natural human il- , was demonstrated by determination of the capacity of protease-treated il- to stimulate hybddoma growth ( td bioassay). these data suggest a possible downregulation of pathologically elevated il- levels by proteolytic activity of extracellulary released enzymes at sites of inflammation. the aim of the study was to compare circulating levels of three cytokines -il- , il- , _- -between critically ill subjects who developed gram-negative sepsis and who did not. materials and methods: the patient population consisted of patients admitted to an intensive cars unit, with different underlying diseases. sepsis diagnosis was given according to pre-estabilished cdteda. nineteen cases were enrolled in sepsis group, twenty in control group. serum sampling was collected in sterile tubes at study entry and every three days until study dismissal. serum concentrations of il- , _- and il- were measured using commercially available test kits, based on the dual immunometric sandwich principle. results: the causative patogens of sepsis were: pseudomonas aeruginosa, acinetobacter, eseherichia co~i, serratia marceseens, proteus mirobilis and citrobacter freundl the time of observation was equal to days, for a total of four tests performed (to, tl, t , t ). i .- was not detected in any samples. the serological profiles of the two cytokines .- and _- were similar; augmented levels were found at study entry and throughout the observation period, peaking at t and decreasing at t . however, in patients with sepsis, il- and _- concentrations were significantly higher in respect to control group. conclusion: our observations shown that in icu patients increased il- and il- release may be induced by cdtical illness; however, in subjects in which sepsis occurred, il- and il- production appears more significantly elevated, suggesting a role of il- and _- in the pathophysiology of sepsis. the fact that ii. objective: to check whether continuous veno-venous haemofiltration (cvvh) could remove the cytokines, namely tumour necrosis factor alpha (tnfc and interleukin (il- ) from the circulation of critically ill patients with sepsis ad multiple organ failure (mof). setting: the intensive therapy unit of the medical school teaching hospital. patients: nine critically ill patients with sepsis and mof treated with cvvh. methods: blood samples were collected before the cvvh had been started. then, blood and ultrafiltrate samples were collected simultaneously after hours and every hour. tnfct and il- levels were measured using the bioassays with cell lines wehi- ci and td , respectively. other data were recorded from the patient notes and intensive therapy unit charts. results: no measurable concentrations of tnfct were detected in either blood or ultrafiltrate samples. il- was found in all the patients' plasma samples and five patients' ( . %) ultrafiltrate samples. the il- blood level ranged from . to . u/ml (mean . , sd . ). the il- level in positive ultrafiltrate samples ranged from . to . u/ml (mean . , sd . ). conclusions: our preliminary results suggest that il- is present in bloodstream of septic patients. we assume we could not detect tnfa in any sample because we usually started observations when septic state had developed. cvvh could extract cytokines from the circulating blood. it remains under discussion, whether that extraction may be beneficial to patients with mof. the pattern of some significant cytokines tnf, il- and il- and their pharmacomodulation were evaluated in an experimental model of polimicrobial sepsis induced in cd- mice by cecal ligation and puncture (clp) in order to understand their roles. this model of sepsis, which resembles the clinical situation of bowel perforation, was also compared with that induced by administration of pure endotoxin (lps). tnf was detectable in serum and tissues during the first h with a peak h after clp at a significantly lower level than after lps. il- was measurable in serum only after h, significantly increased in spleen and liver after and h and in mesenteric lymphonodes from to h after clp compared with shammice. il- was significantly increased in serum throughout the first h after clp. pretreatment with dexamethasone (dex), ibuprofen (ibu) and nitro-l-arginine (n-arg) significantly reduced the survival time while chlorpromazine (cpz) and tnf did not affect it. only the antibiotics and pentoxifylline (ptx) significantly increased the survival in clp. however cpz and dex protected from lps-mor~ality. in conclusion, by inhibiting tnf with dex, cpz, ptx a reduced, unchanged and increased survival time was observed and by increasing tnf with ibu and tnf administration the survival was decreased or unchanged respectively suggesting that the modulation of this cytokine does not seem to play a significant role in clp unlike lps_ moreover the negative effects of ibu and n-arg suggest an important and protective role by prostaglandins and no in clp. to gain more insigths on the contribution of tnf~, il-i~ and if to lps toxicity, we explored the time-course of the cytokine production in ealb/c mice given different doses, from the lethal (= ld ) to the sublethal (= / ld ) of three different lps (e.coli oiii:b and :b ; p.aeruginosa r ) endowed with different degree of toxicity cytokines were measured in serum and organs with specific elisas up to i h after lps administration. results demonstrate that i) circulating and organ levels of tnf~ do not reflect lps toxicity. in fact, the lethal dose of lps :b induced as much tnf~ as the sublethal dose of lps :b ; furthermore, lps r , whose cytokine inducing capability is far lower than that of lps from e.coli, induced higher tnf~ levels at the sublethal than at the lethal dose. in addition, policlonal anti tnf ab, that were able to protect mice from e.coli lps induced mortality, failed in mice treated with lps r ) circulating il-i~ levels are generally low and increase significantly only in muribond animals. on the contrary, in spleen and lung very high levels of il-i~ are persistent from i to h post lps administration moreover, the treatment with mgr of neutralizing policlonal anti il-i~ ab, did not modify survival in lps challenged mice. ) circulating and organ levels of if are proportional to the dose and degree of toxicity of all the administered lps even if lps r was again a less efficient cytokine inducer than lps from e.coli. csa is an immunos~ppressive drug, able to inhibit gene expression for many cytokines, including if . to study the effect of cytokines modulation on lps toxicity, csa was administered to mice twice at the oral dose of i mg/kg before the challenge with lps. mice were monitored in terms of mortality and tnf~, il-i~ and if production. together with the total ablation of if , the strong reduction of tnfu and unmodified il-i~ levels, a significant increase of lps toxicity was also observed. these results suggest the hypothesis that the numerous factors that jointly mediate lps toxic effects, can also be protective, the final outcome depending on their relative ratio rather than on the absolute amount interleukin- (il- ) mediates the septic shock syndrome and affects intestinal secretion in vitro. we studied the intestinal production of il-t and its effects on diarrhea during endotoxic shock. cd- mice were randomized to mg/kg e.coli :b lps or saline infusion (i.p. or i.v.). diarrhea invariably occurred following lps infusion. mice were sacrificed at , ', lh, . h, h, h, h, and h ( mice/group/time-point). the small bowel was compressed and the intestinal contents were weighed and expressed per g sb weight. the small (sb) and large bowels (lb) were eventually frozen, weighed, and homogenized for either cytosolic protein or total rna. il-i~ (cell-associated agonist) was measured with a radioimmunoassay specific for mouse il-l~ (detection limit pg/ml) and expressed as ng/g weight + sem (lowest detectable amount ng/gwt). northern analysis of total rna and in sfu hybridization of paraformaldehyde-fixed frozen tissue were done with [ ~- p]-iabeled mouse il-lc~ cdna probes. only sb had il-i~ constitutively present ( . + . ng/gwt). lps i.p. or i.v. induced elevation of il-lc¢ in both organs in a biphasic pattern; lps i.v. induced -fold more il-i~ than lps i.p. following lps i.p., il-i~ in sb was . + . ng/gwt at lh, reached maximal levels at . h ( . -+ . ng/gw-i) and returned to baseline at h. saline controls maintained their constitutive il-i~ levels. sb had fold more il- ¢ than lb and identical kinetics, but lb showed a clearer doseresponse. northern analysis of sb-total rna showed induction of il-i~ mrna by lps in correlation with il-lc¢ kinetics. il-i~ mrna producing cells were mononuclear cells in the lamina propda and epithelial cells at the bottom of the crypts of ueberkuhn. mucus and fluid were increased in the small bowel post-lps in correlation with intestinal il-lc~ kinetics (r = . ). separate mice were pretreated with saline i.p. orthe il- receptor antagonist (irap, mg/kg bolus i.p.) and were challenged rain later with . mg/kg lps i.p. or saline i.p. specific blockade of il- by irap decreased intestinal secretion at h and h post-lps challenge (p<_. . , student's-t-test). these data indicate that local (intrinsic) intestinal il-i~ mediates sepsis-induced intestinal changes. inflammatory cytokines initiate the host response to endotoxemia, causing severe physiological and hemodynamic changes which may lead to septic shock. among the regulatory systems that play an important rote in controlling host inflammatory responses is the pituitary. it has been known for many years for example, that hypophysectomized animals are extremely sensitive to lps lethality. while investigating the possibility that protective, pituitary mediators might explain this phenomenon, we identified the cytoldne mif to be a specific secretory product produced by pituitary cells in vitro and in vivo after lps challenge. analysis of serum mif levels in control, t-cell deficient (nude), and hypophysectomized mice revealed that pituitary-derived mif contributes significantly to the rise in serum mif that occurs after lps administration. of note, pituitary mif content ( . % of total pituitary protein) and peak serum mif levels ( - ng/ml) were determined to be within the range observed for other pituitary hormones that are released after pituitary stimulation. to investigate a possible beneficial role for mif in septic shock, we co-injected mice with purified, recombinant murine mif (rmif) together with lps ( mg/kg). surprisingly, rmif markedly potentiated lps lethality compared to control mice that were injected with lps alone ( % vs. %, p = . ). to confirm these results, mice were treated with anti-rmif antibody prior to injection of a high dose of lps ( . mg/kg). anti-rmif antibody fully protected mice against lps lethality, increasing survival from % to % (p = . ). serum levels of tnf,~, the first cytokinc that appears in the circulation after lps challenge, were reduced by . _+ . % in anti-rmif-treated mice. we conclude that pituitary derived mif contributes significantly to circulating mif in the post-acute response in endotoxemia and may act in concert with other pituitary mediators to regulate both pro-and antiinflammatory effects. moreover, mif may play a critical regulatory role in the systemic host response in septic shock. our results suggest that anti-rmif antibody might be of potential therapeutic use in the treatment of septic shock. although anti-interleukin- (il- ) antibodies and il- receptor antagonist have been shown to improve survival in animal models of endotoxemia and abrogate the lethal effects of tnf, the presence of il- in the serum does not correlate well with outcome. we hypothesized that this may be because il- acts mainly in a paracrine fashion and is metabolized before it diffuses into the circulation. methods: we measured the il-i~ mrna expression with the differential reverse transcription polymerase chain reaction (rt-pcr) using g-actin as internal standard in the peritoneal macrophages and lung tissue in normal controls and mice after cecal ligation and puncture (clp). clp resembles human intra-abdominal sepsis in that it is characterized by very slight elevations of serum il- levels. results: il-lg mrna levels after clp are expressed as % of normal (mean+sem, n= in several experimental models of infection exacerbation of disease was observed, when infected animals were depleted of tuajor necrosis factor (tnf). after sublethal cecal ligation and puncture (clp) leading to peritonitis and sepsis the survival of mice also critically depends on tnf as demonstrated in earlier studies, when clp-treated mice injected with anti-tnf antibody died, whereas mice injected with a control antibody survived after clp (echtenacher et al. , j. inununol. : ) . from a panel of different cell types (macrophages, neutrophils, t lymphocytes, natural killer cells, mast cells) able to produce tnf upon activation~ the mast cell is apparantly the only one capable of storing in cytoplasmic granules preformed tnf-ct which is rapidly released following challenge. in the present study-we analyzed serum tnf after lps injections as well as the outcome of clp in severely mast cell deficient mutant mice (wav v) as compared to syngeaeic wild-type littermates (+/+). we proposed that concentrations and/or kinetics of serum tnf should be different between wavv mutants and wild-type mice, if mast cell-derived tnf significantly contributes to the rise in serum tnf levels following systemic stimulation with endotoxin. although similar levels of increased tnf were detected in the sera of both genotypes after and hours of lps injection ( btg/ . ml / mouse i. p.), mast ceil-deficient mice indeed showed decreased serum tnf levels iron after injection amounting to only to % of the concentrations observed in the corresponding sera of normal wildtype mice. in the clp model of septic peritonitis we found that mast celldeficient mutant mice were dramatically more sensitive to clp than syngeneic normal mice resulting in % mortality in w/w v versus % mortality in +/+ mice . days after initiation of clp. further experiments with w/w v mutants selectively reconstituted with cultured bone marrow-derived mast cells from normal syngeneic wild-type mice and the use of an antibody specifically blocking the action of tnf tn vivo should clarify a potential protective function of mast cells in this model of septic peritonitis. interleukin- (il- ) inhibits cytokine production, including tumor necrosis factor (tnf), by lipopolysaccharide (lps)-aetivated maerophages. we recently observed that lps injection (e.coli :b , gg ip) into balb/c mice induces the rapid release of circulating il- ( ± u/ml at min). blocking endogenous il- using monocional antibody (jes - a , mg, h before lps) resulted in a massive increase in tnf production ( ± in lps+anti-il- treated mice vs ± ng/ml in lps alone, p< . , n= to mice per group) and an enhanced lps-induccd lethality ( % vs % in anti-il- +lps or lps alone respectively, p= . , n= mice per group). irrelevant igg rat monoclonal antibody (lo-dnp) did not influence neither tnf production nor lethality associated with endotoxin shock. this led us to study the production of il- during human septicemia. plasma samples were obtained from patients with gramnegative (gns, n= ) or gram-positive septicemia (gps, n= ) and from healthy volunteers. among these patients, suffered from septic shock at the time of sampling. il- levels were measured by elisa (detection limit: i pghrd). we found that patients ( %) had increased il- plasma levels (range to pg/nd). patients with gps had il- levels similar to the ones observed in gns (median: vs . pg/m, respectively). patients with septic shock had higher il- values (median: pg/ml) than septicemic patients without shock ( pg/ml, p= . ). no il- was detected in plasma from healthy volunteers. we conclude that il- is produced daring human septicemia. our experimental data suggest that il- might be involved in the control of the inflammatory response induced by bacterial products. dr arnand marchant, immunology department, hopital erasme, route de lennik, brussels, belgium. to provide information about the role of tnf in sepsis and mods we measured tnf and stnfr-i levels in septic patients and investigated if there is a relation between plasma concentration of these molecules and the severity of sepsis evaluated by two scores (apache i and sss). patients and melhods: septic patients fullfilling sepsis criteria of american college of chest physician and society of critical care medicine were studied. tnf-cc and stnfr-i ( kda) were measured by enzyme immuneassays (norms values = + pg/ml and . _+ a ng/ml respectively). results: the mean tnf and stnfr-i values for each patient (mean+sd) were + pg/ml and . + . ng/ml respectively. these values are approximately seven and ten times greater than those observed in normal healthy volunteers (p< . ). mean tnf concentrations for each patient were significantly greater in non survivors ( + vs _+ pg/ml p< . ); stnfr-i levels also were greater in this group, but the difference was not statistically significant ( . + . vs . _+ . ng/ml). plasma tnf and stnfr-i concentrations were significantly correlated (r = . p< . ). mean tnf levels were significantly correlated with apache ii (r = . p< . ) and sss (r = . p<o. ); stnfr-i levels were likewise correlated with both scores (r = . p< . and r = . p< . respectively). tnf and stnfqgi levels increase with the number of dysfuctional organs; in particular tnf and stnfr-i increase when hemodynamics deteriorate and kidney failure ensues. conclusions: the correlations between tnf and stnfr-i levels and sepsis severity scores suggests that tnf is involved in sepsis and may influence the occurrence of mods and finally clinical outcome. tnf and stnfr-i are in fact especially increased when mods occurs. in particular their concentrations are elevated when cardiovascular system and kidney failure ensue, suggesting that tnf can have a direct role in hemodynamic derangements caused by sepsis and that kidneys are involved in tnf and stnfr-i excretion. lif is a pleiotropic cytokine that has been implicated in the pathogenesis of sepsis in animal models. we conducted a prospective study in septic patients to correlate lif plasma levels with patient's clinical and biological data (among them il- ). plasma was drawn daily from day one to .ten and lif presence was determined with a specific elisa and with the dai,a bioassay (sensitivity of pg/ml and ngml respectively). risk factor associated wftt~ with elevated lif plasma level was determined by an univariate analysis. a multivariate stepwise logistic regression analysis was subsequently performed with a bmdp statistical software. lif was detected with the elisa and with the bioassay in and out of the patients, respectively. lif peak plasma levels were statistically associated with high creatmin levels, temperature and il- . multivariate regression analysis showed that high serum creatinin level was the major independent risk factor associated with elevated lifplasma levels. this correlation was also found for il- . peak plasma levels of both lif and il- correlated inversely with patients survival duration. cox's analysis for plasma levels of lif > pg/ml yelded a hazard ratio of [exp ( . )= . ]. our study indicates that lif levels were associated with clinical and biological parameters of illness severity and significantly increased (cut-off value pg/mi) in patients with fatal outcome. current consensus exists about the central role of tumor necrosis factor (tnf) alpha in initiating the systemic inflammatory response syndrome (sirs). a correlation with sirs has inconsistently been found. tnf effects its pleiotropic reactions upon two distinct cellular receptors. soluble extracel]ular fragments of the human kda tnf receptor (stnfri) and the kda receptor (stnfrii) are detectable in the circulation. the kinetics of these endogenously produced tnf-inhibitors were measured to evaluate their role in patients with sirs. fourteen patients of an operative icu were included with the diagnossis of sirs (mean apache ii score: points). serial blood samples were obtained within h after diagnosis of sirs, every hrs for the first hrs and every hrs thereafter until patients died or recovered. soluble tnfri and stnfrii were assayed by an enzymed-linked immunological binding assay. soluble tnfri and ii could be detected in all samples with a significantly higher level (p<o,o ) compared to healthy controls (normal value: tnfrh , ng/ml; tnfrii: , ng/ml). the serum concentration of tnfri ( , ng/ml) as well as tnfrii ( , ng/ml) were significantly higher in nonsurvivors (n= ) compared to survivors ( , and , ng/ml; n= ) at the onset of sirs and during the course of the inflammation response (p< , ). a positive correlation exists between both receptors (r- , ; p < , ). increasing levels and maximal values of stnfri ( ng/ml) and i ( ng/mi) were detected only in patients who died. the serum concentrations of patients who recovered did not change and are remaining at the initial level. tnf alpha bioactivity was detected in out of patients. no significant correlation exists between the concentration of both receptors and tnf alpha as well as the apache ii score at the onset of sirs. elevated serum concentration of stnfri and are found in patients with sirs. these naturally occuring antagonists reflect the inflammatory process. the measurement of soluble tnf receptor levels may be useful in monitorina sirs and in the prediction of outcome. - is given to patients with advanced melanoma or renal carcinoma. however, this therapy is accompanied by severe side effects, including the vascular leak syndrome (vls) that closely resembles septic shock. to investigate the involvement of cytokines and phospholipase a z in the pathogenesis of the vls we collected serial plasma samples from patients during the first hours after administration of il- . in these patients we monitored temperature, blood pressure and heart rate and assessed levels of the cytokines tnf, il- and il- using immuno assays. in these plasma samples we also measured phospholipase a activity using an enzyme activity assay, since this enzyme is beleived to play a major role in the generation of lipid mediators. we demonstrate that during il- therapy the cytokines tnf, il- , and il- are produced and that the release of these cytokines is followed by an induction of phospholipase az activity in the plasma of these patients, we further discuss the role of these mediators in the development of the vascular leak syndrome observed in patients receiving il- . objectives of the study: sepsis caused by candida albicans (ca) is no longer a clinical rarity but a common consequence of immunosuppression and surgery, and is associated with high mortality. tumor necrosis faetor-c¢ (tnf-<~), interlcukin-lg (il-lg) and interleukin- (il- ) are thought to play an important role in the pathogenesis of the sepsis syndrome. we therefore studied the in vitro production of tnf-<x, il-ib and il- by human peripheral blood mononuclear cells (pbmc) stimulated by ca compared to stimulation by bacterial lipopolysaccharide (lps). materials and methods: pbmc were isolated from venous blood of healthy volunteers and cultured at a concentration of . • ~ eells/ml in culture medium with a dose-range of either heat-killed ca or lps. supernatants were harvested after hours. using elisa, tnf-c~, il-ib and il- concentrations were measured. ca was isolated from a patient with ca sepsis and cultured under sterile conditions. results: ca and lps stimulate the production of tnf-~t, il- ] and il- by human pbmc. we observed a dose-dependent synthesis of these three cytokines in human pbmc. tnf-c¢, il-ib and il- in ng/ml as mean _+ standard error. ca/ml . . ( ) we constructed a single-chain fv-fragment (sc-fv) from the variable domains of a neutralizing antibody to human tumornecrosisfactor-alpha (tnf) because sc-fv should have some advantages in vivo. the sc-fv has a similar affinity ( , x - m) as the fab-fragment ( , x - m) but bind the antigen with a eightfold lower avidity compared to the parental mab ( , x - ). the parental mab as well as its fragments can compete the binding of rhutnf to both tnf-receptors. this was shown by competitive binding to the cell line hl- and to immobilized rtnf-receptors. in the nutralization assay on the cell line, l , the sc-fv can neutralize tnf but in comparison to the mab or its fabfragment, the capacity was three-fold lower as expected from the molar ratio of the dissociation constants. the in rive-neutralizing capacity was tested in a mice receiving toxic dose of rhutnf. the sc-fv showed a -fold lower neutralizing capacity in comparison with the fab-fragment. this could be explained in different manners: i) partial instability of scfv at c, ii) shorter half-life because sc-fv but not fab-fragments are eliminated via kidney, iii) elimination of tnf-immunocomplexes may be improved by opsonization mechanisms which requires some structures of the constant region (as in fab or mab). in summary, despite the encouraging in vitro experiments, the in vivo data suggest that sc-fv are not the right strategy for neutralizing tnf in vivo. tnf production in endotoxin non-responder mice, effect of a glucocorticoid antagonist g. iazgtr jr, e. duda, j. ol~th, e. husztik, g. iazar glucocorticoids inhibit lipopolysaccharide (lps)-induced tnf production and tnf can stimulate pituitary adrenocorticotropin secretion, resulting in the release of corticosterone. earlier studies ( ) reveales that the glucocorticoid antagonist ru , nufepristone, sensitizes both endotoxin responder and nonresponder, c h/hej, mice to endotoxin lethality. we have also shown that the glucocorticoid antagonist ru sensitizes endotoxin-tolerant (endotoxin-pretreated) and normal mice to the lethal effect of septic and endotoxin shock. on this basis, we set out to study the influence of ru on tnf production induced by endotoxin in endotoxin responder and non-responder mice. one and hrs following lps injection, ru significantly increased the tnf concentration in the serum, liver and spleen of treated animals as compared with the control and methylprednisolonetreated groups. in tissue cultures, ru induced the tnf synthesis of myeloid cells and increased the tnf production of genetically modified hela cells, which synthesize tnf constitutively. normal and tumor cell cultures exhibited an increased sensitivity toward tnf in the presence of ru . however, the same dose of lps did not induce tnf production in the serum, liver and spleen of endotoxin non-responder mice and this was not influenced by concomitant ru treatment. these studies suggest that ru aggravates lps lethality via factors other than tnf in endotoxin non-responder, c h/hej mice. the cytokine response to a novel exnacellular mitogenic factor, mf, produced by the group a streptococci (gas), and to the streptococcal pyrogenic exotoxins (spe) a and b, was determined by in vitro stimulation of peripheral blood mononuclear cells (pbmc) obtained from healthy blood donors. the induction and kinetics of different cytokines was studied at single-cell level using cytokine specific monoclonal antibodies and intracellular immunofluorescent staining. all three mitogens induced a massive ifny and tnfi response in - % of the pbmc after - hours of cell stimulation. in contrast, il and tnfc~ containing cells was only detected in - % of the pbmc. the induction ofil , il , il , and ill , was weak or completely absent. thus, the response indicates activation of th cells. however, illc~, illl , illra and il , were consistently found and gradually produced, peaking at hems in approximately - % of the pbmc. mf induced an equally extensive cytokine as well as proliferative inducing capacity, as did spea and speb, which suggests that also mf is a superantigen. a marked inter-individual variation could be noted between lymphocytes isolated from different individuals, both in the toxin induced proliferation and cytokine induction. this may be one explanation for the varying clinical severity noted in patients after infection with clonal gas strains. introduction -tumour necrosis factor (tnf) is released by mononuclear cells in response to inflammation and sepsis. it has been implicated as a possible mediator in inflammatory bowel disease (ibd) but its pathogenic role remains uncertain. this study assessed the relationship between tnfct and disease activity by measuring plasma and faecal tnf concelnmtions in an experimcntai model of ibd. methodologo' -colitis was induced in male wistar rats by intmcolonic instillation of rag , , -trinitrobenzenesulphunic acid in . ml % ethanol (n= ). control animals received an isovohlmetric instillation of normal saline (n= ). faecal pellets were collected before induction of colitis (day ) and throughout the experiment. after days the colon was excised, ueighed and the colon macroscopic score (cms) assessed plasma tnf (ptnf) samples were assayed by bioassay and elisa. faecal samples were vortcxed in water and the supernatant removed for estimation of protein and faecal tnf (itnf) content (elisa). there is a significant increase in itnf on day -#p= alld the total ftnf measured during the study correlatcs with the cms oll day -p= . there is no correlation between ftnf and ptnf. conclusions -therc is evidence of coloific tnf excretion by macroscopically normal animals and following induction of colitis there is increased faecal tnf which correlates with disease actmty. there is no significant elevation in bioactive or imnmnoreactive plasma tnf in colitie animals this data would suggest that faecal tnf is a marker of colonic inflamrnatiort and serial tnf assessment inay be useful as an indicator &severity in ibd. to study the effect of in-vivo hypoxia/reoxygenation on cytokine elaboration by routine peritoneal macrophages. materials and methods: adult male cba mice ( - g) were primed intraperitoneauy with either lipopolysaccharide (lps) ug]anlmal or saline. five days later, the animals were subjected to hypoxia ( % ) for , followed by of normoxia. harvested peritoneal macrophages were plated in-vitro, culture supernatants were collected at , , and and assayed for tumor necrosis factor (tnf), prostaglandin e (pge ) and nitric oxide (no). control animals underwent the same procedures, but were maintained in normoxia ( %o disease , berlin, germany the precise mechanisms of reactivation of latent human cytomegalovirus (cmv) infection are still unknown. apart from the permissive effect of diminished cellular immunity there is evidence of a cytokine mediated cmv reactivation as it is known for other systemic virus infections (e.g. hiv). we found that tumor necrosis factor-alpha (tnf) -in contrast to all other cytokines tested -can stimulate the activity of the cmv-ie-enhancer/promoter region in the human monocytic cell line, hl . we wondered whether our in vitro results were actually reflected by the incidence of cmv reactivation in diseases which go together with high tnfalpha levels. cellular immunodeficiency as well as at least temporarily increased tnf levels are known to occur in septic disease. we tested for the presence of cmv infection in peripheral blood mononuclear cells (pbmnc) by means of h centrifugation culture, immunocytological detection of different cmv antigens (apaap-technique), and pcr technique (cmv-ie dna). in striking contrast to healthy controls almost all examined septic patients were positive, irrespective of the method for cmv-ddtection applied, including the less sensitive immunocytology. follow-up studies showed that cmv-antigen positive pbmnc ceased to be detectable in patients with good outcome once septicaemia had been overcome. to further back up our hypothesis, we looked for a coincidence of enhanced tnf-alpha serum levels and cmv antigenaemia (immunocytology) in some other diseases which are known to have either enhanced tnf serum levels or increased incidence of active cmv infection and found the majority of patients with b-cell chronic lymphocytic leukemia, liver cirrhosis, and common variable immunodeficiency to be positive for these two parameters. we now wondered whether, apart from cmv reactivation, tnf-alpha could also cause cellular immunodeficiency this way promoting cmv replication and spreading and eventually causing cmv disease. in summary, we were able to show that a diminished cellular immune response results from/n vitro or in vivo methylprednisolone (mps) is used to suppress both inflammatory and immune responses. il- receptor antagonist (il-lra) and tnf binding protein (tnfbp) are naturally occuring anti-cytokine proteins, possibly modulating inflammatory and immunological responses. to define mps modulation of cytokine and anticytokine responses, we examined effects of mps on il-lra production and tnfbp generation as well as il-i~ and tnfa production by human peripheral blood mononuclear cells (pbmc) stimulated with lipopolysaccharide (lps). pbmc were purified from the blood of healthy volunteers, then incubated with lps ( ng/ml) supplemented with different concentrations of mps ( , pg/ml, mg/ml). after hrs incubation, the supernatants were collected for rias of secreted cytokines. the cell lysates obtained by cycles of freeze-thaw, were also collected for r ias of cell-associated cytokines. both the supernatant for secreted cytokines and the cell lysates for the cell-associated cytokines were subjected to rias for il-i~, tnfa, il- ra, and tnfbp-i (tnfsrp ). il-la, il- ra, and tnfbp were produced mainly as cell-associated forms in response to lps, whereas most tnfa was secreted into the supernatant of lps-stimulated pbmc. mps supplement resulted in reduction of il-la, il-lra, and tnfa production. il-la production was reduced up to . + . %( mg/ml) by mps in a dose dependent fashion, whereas about % decrease in tnfc, and il-lra production was observed at both high and low dose mps supplement. however, total tnfbp generation was not reduced significantly by mps supplement. furthermore, tnfbp secretion was increased times more in the supernatant of lps-stimulated pbmc with gg/ml of mps. these data suggest that mps could effectively block tnf activity by both reducing its production and up-regulating tnfbp generation and that mps works as an anti-inflammatory drug as well as an immunosuppressant by modulating cytokine and anticytokine responses. in severe gram-negative sepsis, excess of proinflammatory cytokines is associated with increased morbidity and the mortality. we have found that immunocytes possess functional -adrenergic receptors (~-ar) which, when activated, down regulate the lipopolysaccharide (lps) induced gene expression and subsequent secretion of tnf-~ in vitro. in the present study, we used a lethal endotoxic model in mice to test the hypothesis that -ar stimulation will down regulate the gene expression thus decreasing the circulatory levels of proinftammatory cytokines and improve the survivals in severe endotoxicosis. the animals (iso group) were injected times with ! -ar agohist isoproterenol ( . mg/kg i.m. and . mg/kg s.c.) , and hours prior to a lethal dose of lps injection ( mg/kg i.p.). control group (ctl) received same volume of saline at the same times before the lps insult. at the appropriate time points after lps injection animals were sacrificed and venous blood was collected from the inferior vena cava. the plasma levels of tnf-cc and il-loc were determined by elisa. in the mortality study, each grou the data showed that isoproterenol significantly decreased the mortality and the circulatory levels of tnf-c~ and il-lcc (fig. ) . these data suggest that -ar activation of immunocytes down regulates cytokine gene expression, decreasing circulatory eytokine levels thus reducing endotoxicosis mortality. these results provide a new pharmacological approach to reduce the excess of proinflammatory cytokines and mortality in sepsis. introduction: cytokines released from monocytic cells are thought to play an important role in the pathophysiology of sepsis. during the last few years several investigations have been performed aimed at modulating this mediator response. in the present investigation using a full blood model we have studied the effect of a standard immune globulin and an antitipopolysaccharide (lps) immune globulin preparation and a monoclonal anti-lps antibody in modulating the endotoxin induced cytokine response. methods: citrated blood from healthy human donors was incubated at °c in rotating polystyrene tubes. samples were taken before addition of x ng/l e. col± endotoxin and after hours. plasma was assayed for the cytokines minor necrosis factor alpha (tnf-~) and interleukin- (il- ) using elisa methods. the eodotoxin concentration was assayed by lal and end-point chromogenic substrate technique. the blood was preincubated with standard immune globuline (human igg from pooled plasma, gammagardr, baxter) or with an anti-lps immune glubuline (human anti-lps igg obtained by screening of blood donors, novo nordisk) in the concentrations of mg/ml or mg/ml or with the monoclonal lipid a igm antibody ha- a for ten minutes before the endotoxin was added. results: two hours after endotoxin addition markedly elevated tnf-~ and il- values were found.in the plasma. cytokine values at hours: tnf-ec pg/ml (mean) and l- pg/ml (mean). preincubalion with mg/ml standard immune globulins reduced il- values by % (mean) while there were no effects on tnf-c~ values at hours. a slight reduction in il- values was also found with the lower concentration, mg/ml, but this was not statistically significant. preincubation with anti-lps immune globulins had no effect on il- nor on tnf-cc values. preincubation with the monoclottal lipid a igm antibody ha- a in variable concentrations had no effect on cytokine release in this model. in this full blood in vitro model standard immune globuline reduced endotoxin induced l- release while tnf-cc values were unchanged.the anti-lps immune glubuline preparation and the monoclonal lipid a igm antibody ha- a had no effect on the il- or tnf-ct release. the effect of anti-tnf treatment in severe haemorrhagic/traumatic shock was investigated in a conscious rabbit model. the jugular vein (for administration of substances and blood withdrawal) and right femoral artery (for measurement of bp) were cannulated and an aortic thermistor probe inserted into the left; femoral artery for the measurement of cardiac output (co). the following day, upto % of the estimated blood volume was withdrawn over - rain, to reduce bp to - mmttg and co by / mad withheld for rain. shed blood ( %) was then reinfused followed by lactate solution to give a total potential dreulat%ag fluid volume of %. zymoeen activated plasma ( , gg/ml) was given rain prior to haemorrhage and during blood r~n%eion, all ~,~ir, ak were killed at h and o~gane removed for histology. rabbita received either monoclonal antirabbit tnf (r , rat igg , mgkg i.e. n= ) or emine (nffi ), rain prior to haemorrhage. the cardiovascular and biochemical changes during the haemorrhage and hypotensive phase (is. haemorrhagic stimulus) were similar in both groups. upon reinfusion, haematccrit and white cell count remained sigutfia~utly (p< . ) higher in saline compared to r -treated animals, indicating a relative haemoconcentration (i,e. reduced circulating volume) in saline animals. the lettkocytosis persisted in the saline animals upto h. plasma glucose, lactate and asparteto .m~-o transferase all rose similarly in both gorups but plasma ¢rea~!~+-e levels were markedly (p< . ) higher in ealine ve r animals at and h indicative of kidney damage, using a macro and micro. pathological scoring system, major organ damage was seen in the lung, liver and kidney which was significantly (p< . ) attenuated in r treated animals. in the hmg and liver, this was primarily due to a reduced bleeding and pmn infiltrate and to an additional maintenance of tubular integri~:y in the kidney. hence, in tlais model anti-tnf treatment markedly reduced the biochemical and histological indices of severe ,, ~gan damage during liaemorrhage and ranerfn~ion. thermal injuries and systemic bacterial sepsis produce a wasting diathesis with anorexia and marked loss of lean tissue and body fat. endogenously produced cytokines, including interleukin- (il- ), are thought to mediate many beneficial as well as pathologic host changes that occur during burn injury and infection. to evaluate whether bluckade of il- in vivo would affect survival and attenuate the anorexia and cachex[a associated with a thermal injury and chronic fulminant gram negative infection, sprague-dawley rats were studied. anesthetized rats were divided in groups, implanted with alzet r minipumps and randomized to receive the following treatment for days:i: gg/kgbw/min of il-lcc; ii: ~tg/kgbw/min of il- receptor antagonist (il-ira); iii: buffered vehicle. the animals were subjected to a % bsa, full thickness scald burn and the wounds then infected with + cfu/ml pseudomonas aeruginosa. eight additional rats were anesthetized, but were not burned, and served as healthy controls. . il-hx reduced food intake transiently but was otherwise without effect however, il-lra significantly attenuated weight loss over the first days and improved food intake between days and . we conclude that blockade of il- after a thermal injury with superimposed infection does not adversly affect the progression of the disease, but does attenuate the anorexia and weight loss associated with this model. these data indicate that il-i receptor blockade may offer a means to minimize the morbidity associated with catabolic illness. tumor necrosis factor (tnf) and its downstream induced mediators have pivotal roles in the pathogenesis of sepsis and septic shock. the suppressive effect of pentoxyfillin (ptx) on tnf production may be of clinical importance. when peripheral white blood ceils were stimulated with either lps or staphylococcus aureus, pentoxyfillin inhibited tnf production. in contrast, no inhibitory effect was observed on the induction of il- . ptx inhibited not only the tnf production of monocytes but also the tnf secretion of both granulocytes, and unseparated whole blood. the facs analysis revealed that the expression of cd antigen on monocytes was not influenced by pentoxyfillin. the in vitro tnf and il- producing capacity in septic patients were higher than in the control group, but decreased on subsequent days especially in fatal cases. administration of ptx ( mg/day) in septic patients resulted in tnf and il- productions similar to those found in control donors. it also subsequently led to an improvement of the clinical status. a further improvement in apache score could be achieved by administration of pentaglobin ° (biotest)( ml/kg/day ). the prevention of lpsinduced in vitro tnf and il- production by pentaglobin ° could be demonstrated in in vitro experiments involving the use of whole blood rather than purified lymphocytes, very probably because of the presence of lps binding protein in the plasma. the level of soluble icam- in sera of septic patients was significantly higher ( - ng/ml) than in normal individuals ( - ng/ml), but it decreased following the ptx and pentaglobin ° therapy. it is presumed that ptx and pentaglobin ° can antagonize eytokine production at different levels, resulting synergistic action being beneficial in the treatment of sepsis. albert szent-gy rgyi medical university, institute of microbiology, szeged, hungary h- ddm t. . e~i~im~/tii, septic sh ~ '. tnf alfa/pge, and somatostatln lands ji., alvarez j., gram m., llanos k., alcalde j., sanchez ja., balibr~d jl. taurine, a semi-essential sulphur-containing t:~-amian acid, promotes neutrophil phagocytic activit ' against yeasts and enhances intracellular killing of e.coli. paradoxically it protects against hypochlorous acidmediated biomembmne oxidatio~ and abrogates the pyrogenic effects of intracerebral endotoxin. it is therefore possible that taurine mediates some of these effects by modulating the cytokine cascade. aim to assess the cytekine responses in a rat model of intraperitoneal sepsis, pretreated with supplenmntary taurine, by measuring tnf and il- concentrations. methodology female wistar rats (wt - g) (n- per group) were prefed with % tanrine, . % glyciuc ( in tap water) or tap water (tw) for days prior to caecal ligation aud puncture (clp). normothermia was maintained intraoperatively and the animals received . % saline subcutaneously ( mls/ g) post-procedure. animals were venosected by direct cardiac puncture at or hours post-operation and the blood placed in endotoxin-free tubes. centrifilgation and storage of plasma at - °c was completed within hours. tnf and il- were measured using wehi and b bioassays respectively. results (means ± sem) bioactivc tnf concentrations were not significantly different between clp or sham groups. however plasma il- estimation revealed a statistically significant reduction at hours in tanrine-treated animals compared to glycino and tw controls ( objective: to evaluate the effects of allogeneic blood transfusion, thermal injury and bacterial garage on interteukin (il- ), tumor necrosis factor alpha (tnf) production and host mortality and to study if the administration of thymopentth (thy) could affect these events. materials and methods: balb/c mice were transfused with allogeneic blood (from c h/hej mice) and treated daily with thy (i mg/kg)(t+thy) . control animals were transfused but not treated (t). after days systemic blood was harvested to determine the circulating levels of il and tnf. a second group was treated with thy for days and then received a gavage wide lxl escherichia coli and a % burn injury (bg+thy). one hour post-bum, blood was collected to measure cytokins. control animals received the same treatment but thy (bg). a third group was transfused, treated with thy for days and then received gavage and burn (tbg+thy). one hour post-burn, blood was collected to measure cytokins. control animals received the same treatment but thy (tbg). all treated and control groups had mice/group. in separate groups (n= /group), receiving the same treatments, mortality was observed for days post-burn or transfusion. the production and release of oxygen radicals by phagocytic leukomytee is one of the most relevant and important functions of these substances in biology. when neutrophilic granulocytes or certain macrophages phagocytize they produce super oxide and hydrogen peroxide and form secondary products of these activated species. all of these substances are released in to the phagosome. it has been appreciated since that the amount of oxygen consumed by phagocytes in producing free radicals is prodigious. what has not been totally appreciated is the significant contribution this consumption contributes to total body oxygen consumption. our understanding of increased oxygen consumption following sepsis is compounded by a paradox of increased cardiac index and a narrow av difference. it was mclean in a study reported in that showed an increase in cardiac index and a narrowing of the avo z difference in humans following sepsis. other studies documented similar changes in humans and it has recently been speculated that increasing o~ delivery might have a favorable impact on outcome. at least three different explanations have been put forward as to why there are possible alterations in energy metabolism during sepsis. these include decreases in oxygen supply, peripheral shunts and direct action o~ cellular mediators on o~ delivery, a provocative review by hodgkiss and nark in shewed that in experimental animals sepsis did not cause any evidence of bioenergatic failure in muscle i liver, heart or brain tissue. they further showed that the increase in serum lactate is mot necessarily due to cellular hypoxia. they conclude that cellular hypoxia and defects in energy producing metabolites are not the cause of metabolic abnormalities in sepsis. we set out on a series of experiments to try to explain the paradox in cellular metabolism and whether or not white cells might contribute to total body oxygen consumption during sepsis. the first set of experiments involved growing rat cardiac myocytes on tissue culture. pyruvate was added to the medium as substrata and physiologic levels of peroxide were also added simultaneously, carbon labeled co~ production was measured as was nucleotides and degradation products from the cell. the peroxide induced a significant inhibition of pyruvate dehydrogenase. in addition, there was a loss of cellular atp and a corresponding rise in the release of inosine and adenine from the cell. we concluded from this first sst of experiments that physiologic levels of peroxide are a potent inhibitor of pyruvate dehydrogenase in isolated cardiac mitochendria as well as the cultured myocyte. we further showed that pyruvate dehydrogenase inhibition blocks the aerobic oxidation of glucose and leads te adenine nucleotide metabolism with adenosine and inosine release from the cell. other enzymes within the tca cycle did not appear to be specifically blocked by peroxide. this would explain the increase in lactate and the ability of the cell to continue to make high energy phosphate by entry of metabolites in to other entry points of the tca cycle, the second set of experimbnts was designed to estimate the magnitude of whole body reactive oxygen generation via nadph oxidase following granuloeyte activation invivo. using a guinea pig model baseline oxygen consumption was determined. ~iaphenyl iodinium (dpi) was used as a specific inhibitor of granulocyte nadph oxidase. animals were divided into two groups; those that received dpi and those that served as control, all animals were then injected with phorbcl myristate acetate (pma) intravenously. pma is a potent stimulus for granulocyte activation and subsequent reactive oxygen generation. whole body oxygen consumption measurements were then repeated after the p~la injection. in addition, arterial blood gas amalysis was performed, circulating neutrophils were collected and assayed for their ability to generate hydrogen peroxide and the r~ght lung was removed for wet and dry weight measurement. total body oxygen consumption increased by percent after pma injection. arterial oxygen tension fell significantly in the control animal. neutrophil hydrogen peroxide generation rate doubled and lung water in the untreated animals increased by percent. in this animal model we could show that granulocyte activation substantially increases whole body oxygen consumption to approximately percent of control values. the nadph oxidase inhibitor, dpi, decreases granulocyte hydrogen peroxide generation invivo and prevents the pulmonary injury induced by pma. using this animal modal it is possible to transpose this to the human septic state. if we assume there are , neutrophils per cubic millimeter of blood, a kg man would have ~ . xi u circulating neutrophils. when activated ixl ~ neutrophils generate one nanemole of hydrogen peroxide per minute. t~erefore, the circulating neutrophil pool could generate - . xi nanomoles of hydrogen peroxide per minute. this corresponds to an oxygen consumption of - . ml/ojmin by the circulating neutrophil pool alone. this does not take into account the production of oxygen by macrophages or the amount of oxygen consumed to produce nitric oxide. manipulation of oxygen delivery in human sepsis may or may not be beneficial. irshad h. chaudry, ping wang, and alfred ayala life threatening blood loss, due to soft tissue and bony injuries, is a frequent complication in trauma victims. although numerous organs and cells are adversely affected by hemorrhage, the focus here will be to discuss whether or not there are any differential alterations in splenic and hepatic immune functions. in particular, m~ antigen presentation (ap) and associated processes will be described since one of the important functions of the m is to activate resting t-cell lymphocytes by processing and presenting foreign antigens in a mhc class ii-restricted fashion. studies have shown that splenic m and kupffer cell (kc) ap was significantly depressed following hemorrhagic shock and remained so for at least h alter resuscitation. the presentation of antigenic fragments associated with mhc class ii antigen itself was not decreased following hemorrhage, but the catabolism of antigens in antigen-presenting cells was decreased. this is likely due to a significant loss of cellular atp. although m ap was depressed in splenic, as well as kc, only kc showed an enhanced capacity to produce inflammatory cytokines, il- , il- , and tnf. this difference in response between kc and splenic md may be due to differences in the microenvironment in which these cell populations are found, as well as potential differences in the effects that hemorrhage has on the environment from which these cells are obtained. splenic m from hemorrhage-resuscitated mice exhibited a significantly reduced cytotoxic response, whereas kc showed an enhanced cytotuxic capacity. the increased kc cytotoxicity is probably mediated through the increased expression of cell-associated tnf and the release of reactive nitrogen. the enhanced production of reactive nitrogen may play an important role in the clearance of microbes translocated from the gut following hemorrhage. however, excessive release of reactive nitrogen by kc may have deleterious effects on the adjacent hepatncytes. such an effect could, in part, explain the reduction in active hepatocellular function, which is seen following hemorrhage-resuscitation. thus, hemorrhage induces differential effects on splenic and kc m populations; it decreases splenic m but increases kc capacity to mount a cytotoxic response. the depressed splenic md and kc ap was, however, significantly improved by posttreatment of animals with atp-mgcia, chloroquine, diltiazem or interferon-'/. these agents also decreased the susceptibility to sepsis following hemorrhage. thus, the use of atp-mgci~, dfltiazem, chloroquine or interferon- offers new therapeutic modalities in the treatment of immunosuppression and for decreasing the susceptibility to sepsis, which is observed following severe blood loss. the production of macrophages from bone marrow precursor cells is a dynamic and highly regulated process. the differentiation of myeloid lineage-restricted progenitor cells is initially controlled by interleukin- , which drives the progenitors along a maturation pathway that leads to their response to specific lineagerestricted colony-stimulating factors(csfs) we have previously hypothesized that thermal injury can initiate a self perpetuating cycle of production of defective immune cells: thermal injury can initially affect circulating immune cells. then these cells, by unbalanced production of colony stimulating factors and other mediators, can cause a derangement of hematopoiesis resulting in an abnormal production profile of tnf, il-i, and il- and cytotoxic activity of bone marrow derived cells. the results of our studies so far have supported parts of this hypothesis. il- and il- +m-csf treatments increased the production of tnf in burn day macrophages and progenitor cells compared to normal cells. il- +m-csf+il- increased the production of il- by burn progenitor cells compared to normal macrophagee. preliminary results for the ratios of tnf/~ actin mrna indicate that il- +m-csf increased the mrna for tnf in the -day macrophages derived from burned animals compared to macrophages derived from normal animals. ratios of il- /~ actin mrna indicated that il- , il- +m-csf, and m-csf increased the il- ~rna in progenitor cells from burn animals compared to progenitor cells from normal animals. these preliminary results support our hypothesis that bone marrow derived macrophages and progenitor cells from burned animals act differently compared to cells from unburned animals regarding the production of inflanunatory cytokines. more specifically, the results suggest that the different cell types are regulated in different ways by cytokines, and cells from burned animals are regulated differently than cells from unburned animals. it i,~ to ~ssume that the translneatinn is due to a ixx~h,v functioning ~astroiutestlnal surface pro|ection system, which leads to an unacceptably high load ¢ln the imrsunc dcfcncc system, partlcul~ly the local system in the gastrointestinal wall, leading tu exh~ustiou of ihi~ system. tlae g&~lrointesliual i]'ac( can be regal'deal a.s a t~ servojf of appr m ~ separating i~ eucayotic ceils of the hosl ttom l ~ bacterial culls. in the human body the the myriad of cndngan¢nts micrix)rganistns, exogenous itl,~ttdittg micro~ganisms altd taxies m-'e sepia"areal li'otll lhe rest of the body by a simple epithclhd layer. the barrier function is heavily tlcpcnding tm =~ proleclive layer cmtsisting ie. surl~:emts, nluclts, probiotic bacteria, and ,~ub~tances with strong antioxid~lt, antipfotease al~d other i~rotective eft'ecru, the surfaet~ml htycr consists at tile besl if i(.) bimolecular layers, fl is thus very iltil~, the epilhelial layer is renewed every hours , and tile tanuwer of the mucus is ~so fa,~t, all attdphy of die epithelial layei induced by g&sttointestinal st~'vation does also include the mu~usprndocing cells, gnhlet cells, which leaduhg lu slmnage aad luwer quality of gi mucus, altered viscoelas,jc properties and reduced protection, ]~'obioiic bactcrla keeps the ppm's low, produce nutrients for the intestinal mllcosa, eliminates tuxia~ and stimulates the local immune system, the gl surface is conslanlly under hc wv wearing by ingested bacteria and their enzymes, ingested substaucas, chefftie,'ds at~d toxins. 'll~e n~tective flora is reduced in disease, by stress and by cm'clcss antibiotic therapy. wc have made attempts tn recondition the i,,.astroiniesli!l~d. tnucosa by rcstlpply of surfactants or sttrfactanfliko glyc~lipids, gels with pseudomuein [until.oil, and probiotl¢ laetobaeilli. by supply of glycolipids we have bt:cn able m prevent and heal intlammatory and tlleerallve injuries (and io p)'cveut microbe transhteatkln) in uppe~' and lower (. u'acl, this c~al be fu~'ther augmentented by shnultaueos supply el' a p.~uedomucin,likc gel like pectin. ()at contain~ one hundred times more ot membrane lipid$ th~a =nay other food, much of fiber, ~spceially watcrsnlnhlc betaglucaal~, at~d has an close to ideal amino acid cornpo~ition, <')at, termented by species-specific lactobacilli, has a strol~ ability to prevent local inflammatory and ulcerative chunges,transh)cadnn and sepsis in experimeut~d attimals mid to pl~ven~ revert mof in ba,nan.~.lt seems us, that it the mucos~lnucus/probiotic bacterial filnclinns cat'= %' restated by mucosa reconditioning, even in severely sick iudividuals) the hx:~d iuuuuue ~y,~teme will be capable tu pr~)tec! the ix~y ag~lls~ sepsis ~nd mof. the impaired immune response associated with multiple system organ failure (msof) has been most widely studied following surgery for inflammatory disease and trauma. the majority of late deaths following trauma are due to infection and msof. not all patients with multiple organ failure have concomitant infection present, yet most have been septic at some time in their hospital course. their generalized inflammatory condition often persists whether or not organisms have been recovered. immune failure probably precedes msof with or without overt infection and indeed may perpetuate such widespread sepsis. macrophage tumor necrosis factor-alpha (tnf) production is thought to represent an important pathogenic mechanism by which this is mediated. cecal ligation and puncture (clp) is a clinically relevant murine model of intra-abdominal infection and sepsis. serum tnf and endotoxin levels, and peritoneal macrophage tnf production are only slightly elevated in this model even in endotoxin sensitive animals. mortality in this model, therefore, does not appear to be attributed to overwhelming endotoxemia and/or tnf production. it has therefore been postulated that tnf and other cytokines may act in a paracrine fashion to cause local injury. tnf messenger rna (mrna) expression was therefore measured and found to be increased in the lung and liver following clp. a different pattern of expression was seen after endotoxin administration, characterized by a more rapid rise and fall, and enhanced tnf mrna expression in the spleen as well. route of spread of infection as well as the type of stimulus may determine the organ specific cytokine response. these data support the concept of locally produced tnf as a contributing factor in tissue damage and multiple organ failure during sepsis. the estimation of histamine's role in sirs changed over the years based on increased knowledge in shock pathogenesis, evidence later found to be faulty, and the discovery of other, more fashionable mediators. over the decades, the prevailing view has been that histamine is a noxious mediator contributing to the fatal outcome of shock. the analysis of experimental data on exogenously administered, endogenously released and/or newly formed histamine in septic/endotoxic shock suggests that histamine contributes to the early cardiovascular changes via hi-receptor vasoconstriction thus excerbating (directly and indirectly) the effects of catecholamines. in the later phase of septic shock (low out-put, high resistance states), however, it can be assumed that histamine exerts strong vasodilator and positive inotropic effects via h -receptors. these effects are considered beneficial in counteracting or attenuating the effects of sympathetic responses of catecholamines and other mediators. thus, a blockade of the early reaction with hi-antagonists and a stimulation of the h -receptors by h -agonists are worthwhile therapeutic approaches. shock produc~s ~ij alterations, an encrgy crisis and eventual c~ll damage, however, shock in itse|f do~ not lead freqoenfly to r~mote organ damage. in animal ~xpcrhnents and clinical expariez:ces in korea and vietnam, shock i~r s¢ was not associated with lung damage, renal failure or ards. the same is true with g.l bleeding. however, when shock is due to trauma or associated with tlssus injmy, then organ malfunction m~d damage is frequent. shock is bclleved to increase the frequency of infection, but clinical evidcnc~ for this is scant. hemonhsgio shock akme is an unusual o~orrenee dinica[ly. immune dysfolletion dons occur witl~ experhnental hypovolemic shock and in pailcnts with hypotcnsion or after receiving blood ~ansfosions. tbc most significant factor affecting reoorrcnce of resented ca,lorectal liver mclastasis was hypotensivc episodes during operation. blood transfosions depress immune function, improve transplant ~raft survival and increase ttll'rmr rec~r'tcnos ill co[eli and head and nc~k cancers. in experimental hemorrhagic shock, we found decreased response of [ymphocytes to mitogens, el:clad mixed lymphocyte reactilln and i[,- decreased. othe~.x hsvc found decreased macrophage and t and b ¢¢lt function, deci~ased re,ease of/l~i, increased poe v depressed macrophagc antigen presanlatiota, increased ien y, decreased il- , and , and shared mscrophags funclion with loss nr f and c b r~ccpto~s. this is inhibited by chlornqoine, ibuprofen, dihiazem, and atp. shock may activate ncutrophils contributing to ilappitlg in cspillarics, no refluw, increased adhesion, cytotoxicity and organ damage. this may be related to decreased clearance of bacteria after shock. t~lls shock, hypotcnsion and decreased microcirculatory blued flow initiate or set the stage for immune dysfmtction. they, along with tissue injury trigger inflammatory cascades. this also contributes to immunologic dysfonctitm, which is associated with increased lufoction. thus altered bh,od flow and mediator cascades are bolh involved, the question now is can wc rapidly improve microcirculatory blood flow, and dg'masa inflsrmnatory fosponss, which is also necessary for survival the effe~ of ~nterferon ~amma @n wour~ healing was ewaluated ~n a routine mo~el. ~mma ~n~erferon we g~ven in doses of ~ . to ~ , u~%$ synchronous with ereatio~ of a pa~splnal woumd then daily for is ~lays. ~mteet~on ~amma impaired tensile strength a% all ~oses relative to control. m zphology suggested ~reas~ ¢oll~gen deposition and r~du~-~ neovag~ulaeit¥ ~n t~eat~ animals, interferon ~amma was a so ~valuated in a murine mo~el of cecal llgatlon and punneure. one hundred to ,s uni~ vere ~iv.n following ~nju~ an~ than daily. interferon qamma was associated with inco:ea~ed mortalit~ and earlier death a~/a~n ~n a dose dependant manner (p< , ). afmlnistra~ion the proinfiammatory cytokines tumor necrosis factor-c~ (tnf-c , interleukin- (il-ii ), interleukin- (il- ), and interleukin- (il- ) have been implicated in the pathogenesis of the multiple organ dysfunction syndrome (mods) following shock and trauma. these mediators which are released in high concentrations by activated macrophages, endothelial cells, and connective tissue cells cause a systemic inflammatory response syndrome (sirs), thus leading to a shock-like state and tissue destruction. recently, a number of proteins have been characterized in in vitro and in vivo studies demonstrating potent anti-inflammatory properties. these latter cytokines include interleukin- (il- ), interleukin- (il= ), transforming growth factor- (tgf-j ), and the newly sequenced interleukin- (il-i ). they are considered antiinflammatory, since in vitro studies using purified macrophage cultures or whole blood assays revealed an inhibitory effect of these antmnfiammatory cytokines on ~he synthesis and release of tnf-cl and il-u . in addition, they reduced the severity of disease and reduce plasma levels of tnf-c~ and il-ii when administered to animals with infection or inflammation. furthermore, naturally occurring substances have been described that specifically neutralize the bioactivity of il- b and tnf-a. the il- receptor antagonist (il-i ra) is related structurally to il-i and binds to the same cell-surface receptors, but does not stimulate the cell. in animal models ore. cob-induced shock, inflammatory bowel disease, and peritonitis, injection of il-lra significantly reduced the severity of disease. the cytotoxicity of tnf-c~ can be inhibited through two types of soluble tnf receptors (stnfr) type i (p ) and type ii (p ). these stnfrs are proteolytic cleavage products of the cell-bound tnfreceptors. when given to baboons to combat e. coil-induced shock, soluble receptm's to the tnf type [ receptor decreased the severi~ of the shock-like state. it has been well accepted that shock and severe injury result in an increased release of proinflammatory cytokines with a high incidence of sirs and mods. our studies investigating plasma levels of anti-inflammatory mediators (il- , il-lra, stnfrs) in patients after severe injury further suggest that shock and injury lead to an activation of anti-inflammatory processes with altered plasma levels of these mediators. however, while plasma levels of il- and l-lra were significantly increased in trauma patients compared to healthy volunteers, stnfrs did not differ from control samples. thus, shock and severe injury result in different activation patterns of anti-inflammatory processes. m,l. rodrick, boston, b~usa following severe thermal injury significant suppression of the immune response has been demonstrsfed. these changes are associated with increased susceptibility not only to co,on human pathogens, but to organisms not normally pathogenic in the uncompromlsed host. early observations included prolonged graft rejection and skin test anergy in patients following burn injury. work from our laboratory and that of numerous others has shown that the~e is a profound £mmunoeuppresslon following severe thermal injury. i~mune deficiency has been identified in these patients hyz ii lack cf t nell responses to mitogens, ) early decreases in total t and helper t cells in the peripheral bloo~ } lack of response to tetanus toxoid i~uniza~io~ in spite of increased non-speoifi~ i~k~unoglobulin praduction and ) severe and prolongei deficiency of interleukin- (il- ) prcductlon by peripheral blood mononuclear cells (pbmo). this il- deficiency could be an underlyin~ cause of all the afo~ementloned immune defects by failing to activate both helper and suppressor t cell functions. mo~a recent work has focused on the molecular mechanisms of this il- deficiency end shown that the defect lies post-transcrlptionally since mrna for il- is also depressed following thermal injury. we have also investigated the potential of a defect in ii- receptor status on peripheral blood mononuclear uolls from patients fqllowing burn injury and in a murine model. in both oases no decrease in il- r was found either by phenotypic markers or by funational assays. another hallmark of thermal injury is hyperao~ivatlon of proinflammatory ~ytok~ne secretion, which may play a significant role in multiple organ failure following burn injury. therapy o~ major burn injury may reasonably be aimed, therefore, at up-regulating t cell ~unction and down-regulating hyperactive secretion of proieflaam~ntory cytokines. the majority of patients dying of bums succumb to sepsis which coincides with dysfunction in the specific and non-specific host defences. generally, concepts relating to the mechanism(s) of specific immune failure in thermal trauma imply that inhibition of t (cd +) cell responses is imposed by the injury or infection-related factors. however, the same factors elicit strong biological reactions within the lymphoid compartment. recent evidence indicates that systemic activation is inherent in the burn patient. to establish the relation of molecular and cellular events to the development of post-bum anergy we examined the state of and the capacity for t cell activation with regard to: ) occurrence of activation-induced cell death (aicd), ) activation-related phenotypic and functional_ diversity in the pool of peripheral cd + t cells. initially, (up to days post-bum), peripheral blood lympliocytes from severely injured (> % total body surface area) patients exhibited high levels of constitutive expression of surface receptor for ]l (cd ) and spontaneous blastogenesis. the presence of activation-related t cellproducts in bum plasma was also apparent. subsequent impairment of the t cell receptor (tcr)-regulated t cell responses in vitro was accompanied by significantly increased dna fragmentation that is associated with cell death by the mode of apoptosis. using molecular markers we established that flesh peripheral blood ceils from immunosuppressed patients also contain large numbers of apoptotic cells. fluctuations in the number of viable (pi-) peripheral blood lymphocytes involved primarily cd +/cd ro+ (memory) subset of t ceils. the above observations suggest that thermal trauma-associated t cell anergy develops through aicd, a phenomenon commonly associated with the tolerogenic activity of bacterial superantigens. persistence of staphylococcal infections in the burn patient may support this assumption. response following trauma jane shelby, ph.d. the immune system is integrated with other physiologic systems, and is exquisitely sensitive to changes in nervous and endocrine systems changes following traumatic stress challenge. the immune, nervous and endocrine systems interact via both direct and indirect pathways which utilize neuro and endocrine hormones, neurotransmitters, neurepeptides and immune cell products. it is now known that the immune system may be affected by all of the neuroendocrine products produced during a stress response, with evidence for innervation of iymphoid organs, lymphoid cell receptors for neuroendocdne products, and leukocyte production of chemicals which are virtually identical to certain neuroendocdne peptides (acth, endorphins). trauma induced alterations in the equilibrium of various neuropeptides and neuroendocdne hormones have a significant impact on immune response potential, affecting control of proliferation, differentiation and function of immune cells. for example, the neurohormone melatonin is thought to be a natural antagonist to counteract glucocorticeid associated immunosuppression resulting from stressful challenges, such as surgery and trauma, plasma melatonin levels are known to be significantly reduced in burn patients. the administration of exogenous me[atonin improved cellular immune response following burn injury in an animal model. melatonin was also shown to have in vivo cytokine regulatory activity, increasing the potential for il- secretion and downregulating excessive il- and ifn~ in burn injured, stress susceptible mice. the regulatory interactions between the immune, nervous and endocrine systems provide mechanistic pathways for trauma associated immune dysfunction. increased knowledge of these interactions will enhance the potential for the design of novei clinical interventions to improve immune response and decrease the risk for infection in trauma and surgical patients. . animals receiving e were given a single dose daily of either . g/kg of e in a % solution by garage (ge), or . g/kg of sterile ive in saline. four hours following the last dose, bum animals were subjected to a % body surface area bum injury to their dorsum. twentyfour hours following injury, the animals were sacrificed and spleen cells were harvested for assessment of lymphocyte function. splenocytes were prepared by mincing the spleen, followed by incubation on glass petri dishes to remove adherent macrophages. non-adherent cells were then tested for proliferative response to t-cell mitogen concanavalin a (con a) and b-cell mitogen lipopolysaccharide (lps). data were analyzed by anova. results: chronic alcohol exposure and burn injury independently inhibit lymphocyte response to con a but not to lps. the combination of e plus bum injury, however, pmfouedly decreases this response to both con a and lps as outlined in the this data clearly identifies the synergistic impairment of immune function produced by ethanol and bum injury. it is furthermore apparent that ibis effect is gut mediated and that gastrointestinal exposure to alcohol is necessary to produce this effect. further studies will work to identify cellular and subcellular mechanisms to explain this effect. in experimental animal studies and investigations on human volunteers endotoxin infusion is mgulary accompanied by the release of the cytokine tumor necrosis factor a (tnf-~) determined by elisa technique. in patients with menigococcal sepsis also elevated tnf-a values have been found using a functional assay. we have studied the role of tnf-et in surgical icu patients with sepsis. using functional technique, we were not able to detect tnf-~ activities in the patient plasmas. when this cytokine, however, was determined by immunochemicai technique (el sa) elevated tnf-e~ values where frequently oberserved. in order to further elucidate these observations, we studied shedding of tnf receptors in the patients. in these studies, we noticed that shedding of tnf receptors oecured regulary in the patients. at the time of diagnosis, soluble tnf receptor p and p were both - fold higher than values found in plasma samples obtained prior to die diagnosis of sepsis. we also observed that the sepsis patients revealed higher maximum values of p and p during the icu stay compared to values found in surgical icu patients without sepsis. these observations indicate that soluble tnf receptors are available in sufficient amounts to bind tnf-ot which is released in surgical patients developing sepsis. this mechanism may explain why functional tnf-c~ was not detected in the patients. institute for surgical research, rikshospitalet, the national hospital, university of oslo, oslo, norway. decker, d., sch ndorf, m., bidlingrnaier, f., hirner, a., yon rfcker, a. the advantage oflaparoscopic cholecystectomy over conventional open surgical approaches in the treatment of symptomatic cholelithiasis has been shown convincingly by clinical studies. in order to facilitate comparisons of different surgical approaches, we evaluated the cell biological characteristics of tissue trauma by measuring changes in various cell surface markers on leukocytes and eytokines in plasma as a possible means to assess tissue trauma in choleeystectomy. patients recruited into our study had experienced at least one typical bifiary colic, had ultrasound-proven cholelithiasis (stages -ii according to me sherry), were - years old, and presented for elective choleeysteetomy. patients could choose between laparoscopic and conventional eholeeystectomy after being informed about the advantages and disadvantages of each procedure. cell surface markers on leukoeytes were determined using whole blood techniques with the help of commercially available fluorescent monocloml antibodies and flow cytometry. shed cell surface markers in plasma and cytoldnes were measured with the help of sandwich-elisa kits. blood samples were drawn h before surgery, immediately before incision (after anaesthesia), h and h after incision. seventeen cell surface markers were examined on different cell populations and cellular subsets in laparoscopic and open-surgery patients. three soluble cell surface markers and six cytokines were monitored. by statistical analyses (multivariate regression analysis, student's t test, wilcoxommann-whituey's rank sum test) the six markers/cytekines that best distinguished open surgical from laparoscopic procedurea were determined. these were . the interleuldn- receptor and im soluble form (cd /scd ); . the activation antigen fd- and its soluble form (cd /scd ), a member of the nerve-growth-factor receptor family; . the cd ro epitope which characterizes t memory ceils; . the trausferrin receptor cd ; . the soluble adhesion molecule icam- ; and . the cytokines interieukin- and interleuldn- . on the basis of these results, a tissue trauma activation (tta) index was calculated by combining the marker/cytoldne measurements by simple multiplication. anaesthesia and pre-ineision maneuvers did not significantly change cell marker or cytokine levels in either surgical approach as compared to h before surgery. h after incision the tra index in open cholecystectomy showed a distinct - fold increase, whereas in laparoseopic surgery a mere - fold increase was noted. h after incision, the tra-index returned to near pre-surgery levels. in conclusion, our results demonstrate that changes in cell surface markers and cytokines can help evaluate the magnitude of tissue trauma in diffei'ent surgical approaches. the relationship between lymphocyte subpopulation changes after thermal injury and the increased susceptibility of burned patients to infection is unclear. in this study, we have attempted to correlate such subpopulation changes with the presence of infection in burned patients. peripberal blood from patients was monitored for lymphocyte subpopulation changes three times weekly for three weeks postburn and weekly thereafter for three additional weeks. mean bum size was . % (range %- %) of total body surface and mean age was years. infection was diagnosed by carefully defined clinical and laboratory criteria and its presence or absence noted each time blood was drawn. samples taken when patients had wound infection, bacteremia, or pneumonia were compared with samples taken in the absence of systemic infection. whole blood samples were stained with four monoclonal antibodies, the red blood cells lysed and the leukocytes fixed and analyzed by flow cytometry. for each patient sample, the proportion of lymphocytes falling within the light scatter gates was determined as the percentage of cells negative for cd and most strongly positive for cd . this percentage was used to correct each sample for the presence of debris or nonlymphocytic cells. the proportion of cd and cd positive cells was slightly greatc~ in the samples from infected patients, while the proportion of b cells (cd +) was unchanged and nk (cd +) cells were decreased by ahnos[ % compared to sampie~ li'om uuiuleclcd patients. the percentage of cells positive for cdilb (c~ integrin) decreased sharply and cd ro (memory cells) decreased slightly in samples from infected patients while the expression of the lymphocyte homing receptor and cd were unchanged. cd (il receptor) and cd (early activation marker) were significantly increased in the samples from the infected patients while hladr was unchanged. these changes in lymphocyte phenotype correlate with the presence of infection. if they closely precede or occur during the early development of infection they may be valuable clues to the mechanism of susceptibility following thermal injury. trauma patients are subjected to an immediate massive impact on their host defense integrity due to the combined effect of tissue trauma, shock and endotoxemia. cytoldnes are playing a crucial role within the course of an impaired cell mediated immune response (cmi) resulting from a disruption of intact m%/tcell interaction. the current study was undertaken to further elucidate the mechanisms of dysfimctional cmi following major burn and mechanical trauma -via comparative analysis of mrna expression and protein release. the major regulatory levels for different cytokines were determined in mitogen, respectively lps stimulated peripheral blood mononuclear cell (pbmc) cultures of trauma patients on consecutive days ( ) t, , , and post injury. we analyzed the cumulative data for interleukin- beta (il-i[ ), il- , il- as well as tumor necrosis factor alpha (tnf-~) and saw a considerable impairment of the protein release in the stimulated pbmc cultures until d post-trauma and recovery thereafter. *p < . , ** p < . vs control comparing the autoradiographies of the specific cytokine mrna expression with the protein release in the supernatants, we saw a good correlation between mrna signal intensity and protein synthesis for il- and ,- , suggesting that for these cytokines the main regulatory mechanisms are located at the pre-/transcriptional level. for the other cytokines investigated one has to suppose posttranseriptional mechanisms. the analysis of our data clearly indicates a severe impairment of forward regulatory immune mechanisms following trauma. most likely the regulatory mechanisms, that are involved are greatly different among the cytokines investigated. it may be concluded, that depressed cmi responses post-trauma are partly due to an impaired pro-inflammatory cytokine production. the severity of the injury (iss) correlated with the development at multiple organ failure (mof-score; r= . ). the levels of mediators and markers of the inflammatory response were generally higher in the more severely injured group (iss> , n= ). i - , - , g-csf, fpa, and c a -levels differed significantly (p< . ) between the iss-groups (>-< iss ) at the time of admission, whereas on day tnfa, c a, - , and ealpi showed significant differences. beyond the first week, major differences were restricted to pge and c a. the formation of two groups with respect to later multiple organ failure (mof < ; mof > n= ) yielded similar results. leukocyte-facs analysis revealed significant differences mainly in the cd (monocytes), cd /cd (i - r + t-cells), and cd /cd (th calls) populations. summarizing our findings we were able to detect some alterations in the surface antigens of immunocompetent cells. the inflammato d response, however, seemed to be more pronounced and correlates wi~ the further clinical course. using an experimental bum model in rodents, we have demonstrated that administration of a full thickness, scald burn involving % or more of the total body surface area (tbsa) elicits systemic responses which are characterized by numerous alterations in t-ceu function (i.e., lymphokine production and contact hypersensitivity (ch) responses) plus an enhanced susceptibility to bacterial infection. in the present study we questioned whether the apparent systemic effects mediated by large burns would be elicited as site-specific alterations in immune function following administration of small area burn trauma ( % tbsa). following a % tbsa burn, ch responses to contact sensitizing antigens were found to be altered. the depression in ch responses could be induced independent of the site used for topical skin sensitization. following a % tbsa thermal injury, development of ch responses were affected in a site-specific manner. immunization of % tbsa thermally injured mice in a site near the position of the burn resulted in depressed responsiveness, whereas immunization through a contralateral site resulted in responses that displayed both the intensity and kinetics of a ch response equivalent to sham-bumed mice. similar systemic and site-limited changes in lymphokine production were observed with % and % tbsa thermal injuries, respectively. a % tbsa injury affected the lymphokine producing potential of all cells regardless of which lymphoid tissue the cells were isolated from. the effect of a % tbsa burn was significant but site-specific. thus, ceils from lymph nodes receiving drainage from thermally injured tissue were specifically affected, whereas lymphokine production by cells from lymphoid organs receiving drainage from unaffected skin was normal. it was concluded that modulation of lymphokine production and cellular immune responses may be a normal consequence of burntrauma regardless of the size of the burn. changes in immune competence can be mediated either regionally or systemically in direct proportion to the area of skin exposed to the burn injury. this work is supported by phs grant gm and the office of navy research n - -j- . division of cell biology and immunology, department of pathology, university of utah school of medicine, salt lake city, ut . post spleneetomy septic sequelae may be fatal, but the mechanisms remain unclear. the objectives ef this study were to assess the mortality from concomitant splen-'etomy and ]~eritoneal bacterial challenge and to elucidate the local cetkdar responses. cd- mice were randomised to receive laparotomy and sham splenectomy (l) or splenectomy (s) with simultaneous ca'-cal ligation and "):mcture and the survival patterns assessed. subsequently, cd- mice were randomised into control (c), l or s groups and peritoneal cells studied at hours for bacterial phagocytosis and killi:~g, superoxide ( -) and tumour necrosis factor (tnf) production and macrophage activation vsing mac-i(cd- b) receptor in~.ensity expressed es mean channel of fluorescence (mcf). these resides indicate that sf!enectomy predisposes to nrortal~ty from bacterial sepsis ia the early pos~ operative period compared to sham operated animals. failure ~f p'.acrophages to kill bacteria in the splenectomv group '~:cured in t?~e absence of impairment of oxygen freeradical or tnf pred:~ctien. the macrovh~ge ac!ivotion marker mac- was significantly reduced in both l and s groups and impaired phagocytosis of bacteria oceured in both operative groups compared to controls. laparotomy a!one reduces macrophage activity in terms of surface re:eptor mac- expression and !ingestive capacity. splenectomy however s~gnificantiy ~mpairs r-acrophage-wediated l~,acterial killing and this qefect rttav co~tribut~ sig~ifjcav'ly to th-~ dissemination of local infection and to n':ortalit). depts of haem~ tology & surgery, beaumont hosoital, dub!in ,eire. introduction: loss of cell membrane integrity appears to be a common pathway of injury to tissues subjected to high-voltage electrical shock. the cell membrane is the most heat labile structure in the cell, and is also the most vulnerable to externally-imposed electrical forces. skeletal muscle and nerve cells are particularly susceptible to electroporation by clinically relevant electric fields. restoration of membrane integrity is essential for cell survival in victims of electrical shock. we have studied the effect of non-ionic triblock copolymers ( poloxamer class) on the transport properties of isolated rat skeletal muscle cells following electroporation-induced membrane disruption. - mm long adult skeletal muscle fibers were isolated by enzymatic digestion from the rat flexor digitorium brevus and maintained under standard culture conditions. they were loaded with the calcein-am dye and placed in a ,c chamber for recording by real-time video confocal microscopy. the cells were subjected to msec, v/era, a field pulses with a low duty cycle to allow thermal relaxation. peak temperature rise was , .c. the uye content of the cell was monitored in real time. experiments were carried out in calcium-free phosphate buffered saline, with mm mg%. experiments were repeated with mm neutral dextran ( the aim of the present paper is to ascertain if thuracotomy induces a different pattern of variations of cytokines, immunocompetent cells and antibodies from laparotomy in the early postoperative period. patients ( males females,mean age: . _+ ) with gallstone disease and with non neoplastic pulmonary disease were studied. none of these patients received blood transfusion, biological response modifiers, radiotherapy or surgery for at least months before being included in our study. anaesthetic procedures were similar in all patients and none were matnourished. on the day of surgery and on the st and th postoperative days (pre, lpo, po) percentages of cd , cd , cd , cds, cdi were measured by means of flow cytometry using moab., and levels of ig a, lgg, igm, ige. by nephelometry cytokine levels in peripheral blood(il- , il- , il- , il- , tnf) were measured in pts. of each group by means of elisa using moab. _r. esults:variations of il- and il- were not s.s.. il- increased but differences between groups were not statistically significant (s.s). il-i decreased on po and increased on po in both groups but were only s.s. in the th.g., and therefore, the differences between groups were s.s (p< . ).tnf decreased in the l.g. and increased in the th.g. on the po, the difference was s.s(p< . ); on po, tnf decreased in the l.g. and decreased in the th.g. but these variations were not s.s. cell percentages decreased an lpo and increased on po, except for %cd cell that increased on lpo and decreased on po ,in both groups of pts. differences were not s.s. ig a, igm decreased and ige increased in both groups (p< . i), but differences between them were not s.s. in contrast, igg decreased on po (p< . ) and increased on po in both groups, but the decrease iu the th.g. was greater than in the l.g. twenty male children,aged from six months to years,admitted for elective inguinal operation were studied. the operations were performed under balanced combined anaesthesia (fentanyl,thiopemtone,vecuronium, % nitrous oxide in oxygen) and blood samples were collected before flunitrazepam premedication,after anaesthesia, and hours after anaesthesia. cells from the wound were collected with cellstick sponge which was removed from the wound or hours after anaesthesia. the study was approved by the local ethical committee. the percentage of neutrophils was increased and that of lymphocytes was decreased in perpheral blood after the operation.the values in the wound were close to the values found in peripheral blood. the percentage of t-lymphocytes (cd ) and helper-t-cells (cd ) decreased in peripheral blood being lower in the wound than in peripheral blood after the operation. the percentage of t-eytotoxic cells (cd ) also decreased in peripheral blood and was similar to that in the wound. b-lymphocyte (cd ) percentage was increased in pe~pheral blood after the operation and was higher than in the wound. the percentage of activated t-cells (cd +hla-dr-positive cells) in peripheral blood increased while that of natural killer cells (cd +cd +leu -pos) was increased just after anaesthesia being decreased at g and hours after the operation. spontaneous lymphocyte proliferative responses didn't change while phytohemagglutinin a and concavalin a induced responses were decreased in peripheral blood samples hours after the operation with recovery at hours.pokeweed mitogen induced lymphocyte proliferative responses were decreased at hours (p<o. ) and hours after the operation we previously reported that plasma ige increased after traumatic injury. in this study, we measured plasma ige ievels in trauma patients on hospital admission and x weekly in the intensive care unit to evaluate ige kinetics. patient characteristics were: mean age -+ years ( m, f), mean injury severity score (iss) + , sepsis ( patients), sepsis syndrome ( patients), ards ( patients), renal failure ( patients). ige increased in patients ( %). the mean increase was ng/ml (range to ng/ml; % ci was to ng/ml). increase in plasma ige was significantly greater in patients with sepsis syndrome (p= . ) and renal failure (p< . ). although mean plasma ige was higher with ards, pneumonia, hepatic dysfunction, and shock, these differences were not significant (p> . ). plasma ige increase was not related to severity of injury by iss score (p = . ). the mean day to highest ige was . -+ . . the day sepsis was first observed preceded the day of highest ige by . + . days. there was a significant association between the day of sepsis onset and the day of highest ige (p= . ). eight of nine patients with sepsis syndrome had > % increase in plasma ige from admission. one patient's ige levels were normal ( - ng/ml) for days and then increased to ng/ml over the next days, after onset of sepsis syndrome. changes in ige plasma levels may reflect the action of cytokines, such as il- , which concurrently regulate production of ige and il- receptor antagonist in a response to sepsis. sepsis remains a leading cause of late mortality in trauma and hs. although hs-induced bacterial translocation is supposed to be the major cause of sepsis and mof, depression of the res increases susceptibility to infection after injury. the purposes of this study were: a) to evaluate the res in the lung, spleen and liver after hs and subsequent hypertonic saline (hsl) treatment, and b) to document the patterns of phagocytic activity in these organs during hrs. adult male wistar rats ( +_ gin) were submitted to hs (sbp tort) and after t hr (shock i hr) and hrs (shock hrs) hsl (nac . %, . ml/kg) treatment, e. coli (i ) was injected into the portal vein ~tci (n_> ). twenty minutes later, the lungs, spleen and liver were harvested and scintilographic counts obtained. data is depicted as mean_%+sem * p< . , ~" p< . and statistical analysis was performed by analysis of variance and wilcoxon tests. one hr after treatment, lung uptake was increased and liver and spleen uptake were reduced compared to sham. twenty four hrs after treatment, all organs, except lung uptake, returned to normal values. radioautographic histological analysis revealed radiolabeled particles inside phagocytic cells of all organs. we conclude that pulmonary phagocytic activity increases after hr of hs hsl reatment, diminishing by hrs although still above normal values. in contrast, res suppression occurs in liver and spleen after hr hs hsl treatment, returning to normal values by hrs. these results may explain lung complications and immunosuppression after trauma. infusion of endotoxin as well as major surgery is followed by lymphopenia in peripheral blood. the purpose of this study was to investigate to which tissues the lymphocytes are redistributed in response to endotoxaemia and major surgery. in addition changes in lymphocyte subpopulations and expression of mecii was measured. lymphocytes were isolated from peripheral blood of rabbits, labelled with indium-tropolene and reinjected intravenously into the rabbits, i rabbits received an infusion of escherichia coli endotoxin ~g/kg, while i rabbits were subjected to a major sham operation and i rabbits served as a control group. the redistribution of lymphocytes were imaged with af gamma camera, and calculated with an interfaces computer before, and , and hours after major surgery or infusion of endotoxin or saline. interleukin-l~ and serum cortisol were measured. in addition we followed cd , cd , cdlla/b, cdis, cd , cd , mhcii and cd /cd ratio. following endotoxaemia interleukin-lf~ increased significantly, following endotoxaemia as well as major surgery serum cortisol increased significantly. following major surgery as well as endotoxaemia there was significant lomphocytepenia in peripheral blood with a decreased cd /cd ratio while the cd positive subpopulation increased. in addition there was a decrease in the expression of mhcii on the lymphocytes peripheral blood. the radioactivity of the lymphatic tissue in and around the intestine increased to % of initial values following endotoxaemia and to % following major surgery. the results indicate that endotoxaemia as well as major surgery induces redistribution of lymphocytes from peripheral blood to lymphatic tissue. among the lymphocytes staying in peripheral blood there was a decreased expression of mhcii and a relative decrease in cd cells compared to cd positive lymphocytes. in order to analyze the effects of immune suppressive substances on expression of mrna of interleukin- (il- ) and interleukin- reeeptor(il- r), this study was carried out. twenty male rabbits with comminuted fracture were used in the study. ten ml blood were taken at , i, , , days after injury. the sera were tested for the effects on lymphocyte blastogenesis and induction of il- stimulated by concanavalin a(con a): the sera from the rabbits days after injury were analyzed with sds-page gel eleetrophoresis, and divided into three groups by ultrafiltration (ufpi ttk, kd,milipore; centricon- , kd,amicon), that are less than kd, between i and kd, and more than kd. each group of the substances also was tested for the expression of il- and il- r by the dot blot hybridization. the results showed that: i) all sera from the rabbits after injury had significant suppression on lymphocyte proliferation and secretion of il- by the con a-stimulated splenocyte in mice; ) the sera from the rabbits days after injury had more profound suppression than other injured sera; ) there was a marked band at about kd in sera from the rabbits days after injury, but nothing at the same position in normal sera analyzed with electrophoresis; ) the substance with molecular weight of about iokd had more obvious suppressive action on expression of mrna of il- and il- r than other groups substances, of which molecular weights are more than kd. it is concluded that: i) the sera from the injured rabbits can reduce immune response; ) there is kind of substance, of which molecular weight is about kd, it is probable the main factor involved in the pathogenesie of postinjury suppression immune; } the substance can depress the expression of mrna of both il- and il- r. research institute of surgery daping, chongqing, p. r. china acute ethanol uptake prior to injury modulates monocyte tnfo~, production and mononuclear cell apoptosis. g. szabo, b. verma, p. mandrekar, d. catalano monocytes (mo) have been shown to contribute to immunosuppression after both major injury and alcohol consumption. we reported that acute ethanol exposure of m( results in decreased antigen presentation, induces tgf- and pge while inhibiting inflammatory monokine production. we also showed that post-trauma immunosuppression is mediated by hyper-elevated mo tnfc~ and il- . consequently, here we investigated rnonokine production in trauma patients (n= ) who had elevated (>o.lmg/dl) or had no blood alcohol level (n=t ) at the time of emergency room admission. none of the patients had chronic alcohol use history. met tnfc~ production from trauma patients with prior alcohol uptake was undetectable during days - post-injury in contrast to patients without alcohol exposure. furthermore, decreased tnf~x levels were found in alcoholic patients' mci after mdp or ifny + mdp induction. however, mcl tnfc~ levels during the - days post injury period became higher in alcoholic trauma patients. furthermore, over days post-injury, alcoholic trauma patients showed significantly elevated mci tnfo~ production after adherence isolation, mdp, or ifn+mdp stimulation compared to patients without alcohol. these results suggest that acute ethanol uptake prior to injury decreases tnf(x inducibility in the early post-trauma period, but these patients' mo produce hyper-elevated tnfa levels later post-injury, thereby prolonging their cytokine shock risk. tnf ng/ml - days post-injury days post injury stimulus ale. pt. pt . . . . immunosuppression might also be increased by the elevated apoptotic activity found in trauma patients' mononuclear ceils, which was even greater in alcoholic trauma patients' cells. in non-alcoholic trauma patients' preactivated mo, in vitro acute ethanol ( - mm) exposure resulted in a significant down-regulation of tnfc~ (p< . ) and il- (p< . ) production. in contrast, in vitro ethanol exposure increased the production of inhibitory monokine, tgfi]. these results provide both in vivo and in vitro evidence for the effect of acute ethanol exposure increasing immunosuppression and cytokine shock. the 'systemic inflammatory response syndrome' (sirs) with consecutive septic multi-organ dysfunction represents the major cause of late death following major mechanical and burn trauma. systemic hyperinflammation and concurrent depression of cell mediated immune response (cmi) render the traumatized host anergic, resulting in profound susceptibility to opportunistic infection. monooytes/macrophages (mo) play a central role within the host defense system in developing and manifesting states of injury, shock and sepsis. the mechanistic scrutiny of the synthesis patterns of crucial cccytokines appears to be a helpful tool to further analyse mo behaviour in the compromised individual. the objective of this study was to further dissect the characteristics of cytokine regulation in pbmc under stressful conditions, via analysis of the expression of cd + receptor, the proinflammatory mediator il- , the macrophage activating factor ifn- ,, and neopterin (npt) a metabolite of activated mo. we investigated pbmc's on consecutive days , , , and after mechanical trauma of and after bum trauma of patients (mean age ~ years; mean iss ± pts). in trauma patients we saw a massive increase of pha induced neopterin synthesis compared to controls. however, when discriminating the npt levels in the supernatants for the amount of mo stimulated, the npt output of the individual cell was lower compared to mo of nontraumatized individuals. interestingly there was a contrary coarse in the cumulative protein release patterns of il- and ifn- in mechanical versus burn trauma patients. wheras in burn patients ifn-y was decreased significantly ( + u/ml) compared to controls ( + u/ml) as well as mechanical trauma ( + u/ml). il- showed a significant suppression following mechanical trauma ( + u/ml) vs control ( + u/ml) and bum patients. the rt~,na signal intensity for beth eytokines was in concurrence with the protein release in more than % of the individual patients investigated. from these data we can conclude that the inadequate low npt synthesis predominantly in bum patients appears to be a sign of cellular immaturity and is probably partly due to low t-cell ifno t signals. in addition we could state that the quality of trauma is apparently responsible for the different synthesis patterns of ]l- and ifn-q,. it has been postulated that bacterial invasion or endotoxemia are necessary for cytokine production following burn injury. we studied the organ distribution and kinetics pattern of il-fc~ (cell-associated il- agonist) in eutrophic rats subjected to either % tbsa cutaneous scald injury (bi), muscle scald injury of equivalent % tbsa (mbi), sham muscle bum (resection of skin only, up to % tbsa) (smbi), and sham cutaneous burn (sbi), followed by saline resuscitation ( mukg i.p.). separate rats were infused with mg/kg e.coli :b lps or saline lv. unmanipulated rats were baseline normal controls. liver, lung, spleen, ileum, thymus, kidney, skin, and plasma were harvested at various time-points within the first h. tissues were frozen, weighed, homogenized, the homogenates centrifuged and the supernates assayed with a radioimmunoassay specific for rat il-l(z (detection limit pg/rnl). il-lc~ was expressed as ng/g weight + sem (lowest detectable amount . ng/gwt). il-lo~ was constitutively present only in the skin ( + . ng/gwt). cutaneous burn and sham cutaneous bum induced biphasic elevations of il-lcc in the liver and lung only, with maximal levels at . h (in the liver, bi = . _+ . ng/gwt, sbi = . + . ng/gwt, p _< . ; in the lung, bi = . + . ng/gwt, sbi = . + . ng/gwt, p -< . ). of note, both bi and sbi rats had detectable il-i~ in the liver at timepoint already ( min real-time). these levels increased in parallel until min and became eventually different by log at - . h. all other organs as well as plasma were below detection limits. muscle burn injury and sham muscle burn (skin resection) induced similar elevations of il- ~ in the liver at lh, indistinguishable from each other and from cutaneous burn. in contrast, lps challenge induced dramatic elevation of il-t~ in all organs tested except for the kidney; the spleen was the most responsive organ to lps-induced il-lo~ production. these data indicate that thermal or mechanical injuries induce very early and organ specific production of il- c~ in vivo by mechanisms other than endotoxemia. injury-induced complement and platelet activation may be involved as well as the neuro-endocrine axis, which may explain the low levels of il-lo~ induction observed in all rats at the very early time-points. trauma services, massachusetts general hospital, and department of surgery, harvard medical school. fruit, st, boston, ma . j. f. schmand *#, a. ayala* and i. h. chaudry* studies indicate that i.v. infusion of the colloid hes in normal animals does not adversely affect non-specific immunity. it remains unknown, however, if lies affects cell mediated, specific immune functions after trauma and hemorrhage (hem). to study this, non-heparinized c h/hen mice underwent midline laparotomy to induce trauma and were then bled to and maintained at a bp of mmi-ig for rain. the animals were then resuscitated with either times (x) the shed blood vohune as lactated ringer's solution (lrs) or x lrs + lx % lies. sham mice were neither hemorrhaged nor resuscitated. at or hours post hem serum, peritoneal (pm~) and splenic macrophages (sm~) were obtained. bioassayes were employed to assess the levels of ii-l, il- ( alternatively pmqb showed no differences in il- release between all groups at and h, while sm~ from the lrs + hen group showed a depression at h. tnf production by pm~ was depressed in all groups at h and remained so in the lrs + hes group at h. sm~b showed decreased tnf release values in both hem groups at and h. in summary, the levels of inflammatory cytokines (particularly the values of circulating il- ) after trauma/hem are positively influenced by the administration of hes. this might be due to a protective effect on pmqb and sm~, but also on other cytokine producing cells, e.g. kupffer ceils. we conclude that hes is not only a safe, but also beneficial agent in the resuscitation of patients atler trauma/bemorrhagic shock. this study investigated endotoxemia and consecutlve immune response in patients with multiple trauma (median injury severity score = , ). blood samples.were collected shortly after injury and after , , , , s and l days. endotoxin was measured with limulus-amebocyte lysate test and the specific antibody content (sac) against endotoxins of the classes igg, igm and lga by elisa-technique. five antigens were used: lipopolysaccaride (lps) of e.coli (ec), lipid a of e.coli (la), lps of pseudomonas aerog. (pa), lps of vibrin cholerae (vc) and cx-hemolysin of staphylococcus anreus (oth). a nephelometer indicated the total concentrations of igg, igm and iga. differences were checked with wilcoxon-test and p< , s was considered significant. cross-reactivity was calculated with rank correlation coefficients. results: endotoxemia peaked shortly after injury ( - h) at , eki/ml (median), decreased thereafter to , eh/ml at day s and remained on this level. sac oflgmclass increased to all endotoxins and peaked at day revealing the lfighest level to la followed by pa (= % of la-sac), ec (= % of la-sac) and vc (= % of la-sac). lga antibodies increased as well but only slightly and not significant (exception: sac to la was elevated significantly at day ). igg antibodies increased similar to iga class only slightly and again only sac to la was significantly higher at day and . however sac to (xh of all ig-classes remained continuously on the same level troughout the observation time. correlation analysis revealed strong cross-reactivity (r> , ; p< , ) most often between antibodies of igm-elass ( %) followed by igaclass ( %) and lgg class ( %]. conclusions: multiple trauma is associated with temporary endotoxemia. endotoxins probably translocated from the gut cause specific increase of anti endotoxin antibodies in blood of the igm-class. endotoxins cause no increase of antibodies to gramposilave bacteria. igm antibodies are most unspecific. during cardio-pulmonary bypass, as well as postoperatively, high levels of endotoxin, interleukin- (ii- ) and c-reactive protein (crp) were measured in patients. i female and male, ageing from to with a median age of . blood sampling was done preoperatively, immediately after induction of anaesthesia, after thoracotomy, after cannulation of the aorta and right atrium after the first half of the reperfusion phase, after closure of the thorax, and hours after the operation and then every morning until the th postoperative day. blood was drawn into heparinized tubes (i iu/ml) which were free of endotoxin. crp levels were determined through the use of the behring nephelometer. - levels were measured by using commercially-available elisa test. the endotoxin level was determined by a chromogenic modification of the limulus amebocyte test. the statistical analysis was done using the wilcoxon ranks test and correlation analysis. a significant increase {p . ) in endotoxin plasma occurred during surgery, culminating in a peak (median value of . eu/m!) during reperfusicn. plasma levels of endotoxin continued to be slightly raised till the th day after surgery, whereas those of interleukin- rose at the end of the operation and were at their highest hours later (median value of . pg/ml). crp levels were also high postoperatively with a median value of mg/l, and were markedly raised on day ( mg/l). a definite, statistically significant correlation between the plasma levels of endotoxin and - during the operation was establisthed (p . ), leading us to conclude that the endotoxin liberated during cardiac surgery acts as the main trigger in the releasing of - , and thus induces the postoperative acute phase reaction. there was no evidence of a correlation between crp and endotoxin or - plasma levels. impaired immune function is well described following trauma and hemorrhagic shock (hs). prior studies have utilized peripheral blood or spleen cells to index immune function following hs. however, changes in mucosal immunity are not weii characterized in this setting. gut origin sepsis is thought to be an important cause of organ failure and death following trauma. a rodent model was utilized to allow comparison of mucosal-associated immune function vs, systemic compartments after hs. fischer rates underwent hs (map ± mm hg) for minutes followed by resuscitation with shed blood and lr. sham animals were instrumented only. rat tears were collected at and hours following hs for quantitation of slga by ria. animals were sacrificed at hours and spleen (spl), peripheral lymph nodes (pln), and mesenteric lymph nodes (mln) harvested for cell population analysis using flow cytometry and mitogen stimulation analysis. cell marker expression analysis revealed no changes in t or b ceil populations following hs. mitogen mucosal immune function appears relatively spared following hs. the mechanism(s) for this variability in immune function requires further investigation. we have found that transplantation of bone marrow in a hind-limb graft to syngeneic lethally irradiated recipient is followed not only by rapid repopulafion but also overpopulation of bone marrow cavities. the question arises whether this unexpected phenomenon could be the result of stimulation of stem cells by factors (cytokines) released from surgical wound at the site of anastomosis of graft with recipient. aim of the study was to investigate which tissues damaged during the procedure of limb transplantation may be a potential source of humoral factors accelerating in vivo bone marrow proliferation. methods. experiments were carried out on lew rats in groups. in group i, the hind limb was transplanted orthotopically to a syngeneic recipient; in group ii, sham operation was performed; in group iii, a four-cm long cutaneous wound was made on the dorsum; in group iv, limb skin was harvested, fragmented and implanted into peritoneal cavity; in group v, bm from femur and tibia was implanted intraperitoneally. bm, lymphoid tissues and blood were sampled and days later for cell concentration and phenotype evaluation. results. the yield of nucleated cells from tibia was on day in the control . + . , in group . + . , in group ii . + . , in group iii . + . , in group iv . _+ . , in group v . _+ . x ( ). the evident increase in bmc yield in all groups continued until day . increase in weight and total cell count of spleen and mesenteric lymph nodes in all but group iii was also found. no differences in percentage of maturing erythroid cells, but higher of mature myeloid cells and lower of lymphocytes were observed. conclusions. trauma of skin, muscles, and bone brought about an increase in bone marrow cellularity and acceleration of maturation of myeloid lineage. transplantation of bm ceils alone did not produce this effect. transplantation of bm in limb graft is a good model for studies of natural factors reaulatin~ bm hemormesis. this study sought to determine a relationship, if any, between the degree of hypochclesterolemia upon trauma patients' admission and their subsequent outcome. all blunt and penetrating trauma patients admitted to a level i facility from through , and who had serum cholesterol assayed during the first hrs were retrospectively studied for development of death or significant organ dysfunction. the mantel-kaenzel chisquared test was used to determine significance of data at the p< . level. results: trauma patients were admitted during the four-year period who had serum cholesterol assays performed in the first hrs. patients had cholesterol levels less than mg/dl; of these ( . %) died, ( . %) developed ards, ( . %) developed acute renal failure, and ( . %) developed multisystem organ dysfunction; hypocholesterolemia in these patients was not due to liver injury or massive fluid administration. the risk of death was times greater and risk of multi-organ failure times greater in this group than in those with a normal serum cholesterol (>if mg/dl; patients; p< . ). conclusions: admission serum cholesterol level in the trauma patient serves as a powerful marker for those at risk of subsequent organ failure or death. hypocholesterolemia in this setting may result from organ hypoperfusion and humeral mediator release. lung tissue contains many immunocompetent cells. resection, therefore, is expected to activate extensively inflammatory mediators such as pmn-elastase, pmstanoids and pteridines. in a prospective clinical study we compared patients (pts) undergoing either thomcotomy with or without lung tissue msectioh and tboracoscopic lung resection concerning activation of inflammatory response. material & methods: group a pts (n= ) had thoraantomy but no lung tissue injury; group b pts (n=ls) had thoracotomy and lung tissue resection due to benign diseases; group c (n= ) represents group b tissue resection but using a thomcoscopic procedure. the following parameters were determined pre-, peri-, and postoperatively: elastase and crp as indicators of activation of pmn-leukocytes and injury severity; prostacyclin (pgi ) and thromboxane (txa~) as parameters of lung endothelial response; prostaglandin f ~ (pgf~) and pgm representing pulmonaly metabolic activity; pge a and neopterin as proof of macmphage activation. statistics were performed using analysis of variance for repeated measures. results: group b pts revealed postoperatively an increase in crp (p< . ) indicating a higher injury severity in comparison to the thoracoscopic procedure (c). both, controls (a) and group c pts did not show pmn-activation, whereas group b demonstrated a reversible increase in elastase. surgical trauma caused in all groups a release of pgi z and txa which was more pronounced in c (p< . ) and most in b (p< . ). similar results were found for pge~ and pgf =. there was no activation of maerophages since neopterin did not increase. apparently, metabolic lung function was not impaired because there was no marked rise in pgm except in b (p< . vs. c). discussion: our results demonstrate that lung tissue injury aggravates the mediator release induced by thoracic traum. these mediators among others are able to increase capillary pressure and hence lung edema formation. impairment of lung function, however, seems dependent on the extent of the liberation. therefore, the maximal release reactions occured in group b and c after lung tissue resection, whereas the controls showed the highest levels immediately after the incision. we conclude that thoracoscopic procedures are superior in reducing the resection trauma per se and hence might prevent severe mediamr-induced (pulmonary/systemic) sequelae. in a prospective study we investigated patients using radiochemical method according to sch~dlich (s) and photometric method according to hoffmann (h). serum of severly traumatized patients was withdrawn directly after admission at our emergency room and in narrow time intervals during first hours after trauma. follow up control samples were taken daily until day ten. whereas no elevated pla-ca was found during first hours, a peak was regularly observed around day four. there was high correlation between pla-ca and iss (r= . , p<o.o ) except patients suffering from thoracic trauma, thoracic trauma {tt) provoked similar gons-score-and pla-ca-values compared to multiple trauma (mt) despite significantly lower iss: pla-ca (h) mt . + . tt , +_ , n.s. pla-ca(s) mt . +_ . tt . _+ . n.s. goris mt . - . tt . _+ . n.s. iss mt - tt - p< . we found delayed elevation of pla-ca after severe trauma, however detection of delayed pla-ca in the serum of traumatized patients cannot give reliable information about the exact role of pla in the inflammatory reaction after trauma as latest results show that pla is secreted early but bound at lipophilic sites of vascular membranes. hern~mdez m j, amiguet ja, monreal ji, vid~n jr, jim nez f j, l pez-vivanco g acute phase reactant proteins increment in serum of patients with traumatisms and inflammation has been previously reported. alpha- antitrypsin (aat), alpha- macroglobulin (amg) and ceruloplasmin (cp) are evaluated in the following of patients, males and females (mean age: years), with compound fractures. % of them were located in tibia and fibula. intercurrent infection developed in patients and internal fixation rejection in one. measurements were made by radial immunodiffusion on days , , , , , and . a control group of healthy volunteers was also evaluated. aat and cp showed increased values from day which kept elevated untill the end of the study. amg elevated from day . when infection developed, aat and cp values were even higher whereas amg values decreased. fixation rejection caused aat, amg and cp increment. aat and cp increment in non complicated fractures might be due to accompanying inflamation, by means of cytokines release and aprps hepatic synthesis induction. therefore, increment is higher when infection or rejection develop. amg behaviour at early stages of evolution is secondary to hiperconsumption, considering mean life shortening after proteases ligation. amg modifications in fixation rejection remain obscure. aprps increment modulates inflammation and bony callus formation by means their antyprotease and antioxidant properties. clinically, aprps might be useful parameters in determining complications onset in fractures evolution. hemorrhagic shock (hs) is a common complication of trauma, as well as some major surgical procedures. the alteration of the immune system by hs is thought to contribute to the increased septic morbidity and mortality seen in these patients. multiple mediators are released following hs. il- , il- , tnf, pge and tgf-b have all been implicated in these immune system changes. in vitro, pge causes many of the immune system changes following hs, yet the time course of pge release has not been well deliniated. the aim of this study was to determine the time course of pge release by peritoneal and splenic macrophages following hs. c h/hen mice were bled to a mean bp of + mm hg for minutes. the animals were resuscitated with the shed blood and normal saline. control animals were cannalated, but blood was not withdrawn. the animals were sacrificed at , , , , and hours following hs. peritoneal and splenic macrophages were harvested from each animal and cultured with lps for hours. the supernatants were collected and frozen until assayed. pge was assayed using an elisa (cayman chemical). results are shown below for the peritoneal macrophages: pge release by peritoneal macrophages was significantly elevated at , and hours over control. it was maximal at hours, but by hours it had started to decline. splenic macrophage pge release was much more variable. (data not shown.) there was less consistency between time points and no clear trend was seen. in conclusion, pge is significantly elevated at hours following hs, and reaches a peak at hours. pge release may be responsible for the immune system changes seen in the first few days following hs. splenic and peritoneal macrophages respond differently in their release of pge following hs; which may be due to differences in their milieu. there is an obvious association between the altered immunocompetence of patients following traumatic injury of various types and the increased riskto develop complications. the present investigation was undertaken in order to analyze the value of both neopterin (n) and c-reactive protein (crp) in monitoring disease course in patients with multiple trauma. we were interested to compare nconcentrations as marker of t-cell/macrophage activation with crp levels as indicator of the inflammatory acute-phase response daily serum concentrations(n and crp) were measured in patients ( male, female, mean age . ), admitted to our icu following serious trauma (mean iss= ) and in control subjects. the clinical course of each patient was evaluated with apacheii score according to knaus. mean stay in icu was . (range - ). patients didn't develop organ failure(nof-group), patients survived, developing mof (s,mof-group), patients died with mof (ns, mofgroup). three patients(one s and two ns) showed signs of septicemia and septic shock. the serum samples were measured for neopterin (immu-test-ria, henning-berlin) and for crp (immunoturbidimetric method) -at the university hospital for internal medicine, innsbruck, austria. the highest crp levels were measured h after trauma, but they were not accompanied by significant increase in n-values. we found significantly elevated n-concentrations from the days - . n and crp levels showed a parallel release peaks on the days - and the values discriminated significantly among the three outcome groups(the second crp peak is lower in comparison to the first posttrauma peak). by the ns-group we found constant and parallel increasing crp and n levels, reaching extremly high values - h and preceding clinical signs of mof and sepsis. the values increased dramatically before death. the serum levels by all control subjects were upper the normal limit for n and crp.. the parallel occured peak changes in n and crp concentrations showed a significant correlation with clinical status, using a disease activity score (apac h eli). our findings suggest that both-cellular and humoral mediated immune mechanisms are activated after multiple trauma and that simultaneous determination of n-crp may be of advantage as diagnostic and prognostic parameter in polytrauma-patient monitoring panel. it is apparent, that measurement of very high levels may be of value as a srong indicator in developing of mof or septic complications and thus offer the possibility for earlier therapeutic intervention. the modification of t-cell/macrophage and acute-phase responses may be potentially useful in the treatment of icu patients, resuscitated after severe trauma, and suggest that n-crp may be relevant indicator for testing experimental immunomodulating therapies. although several in vitro studies suggested the catalytic action of iron in oxygen free radical generation, few data are available concerning iron-metabolism following ischemia-reperfusion injury and hemorrhage in vivo. aim of the present studies was to evaluate iron metabolism following mild and severe hemorrhage in the presence and absence of intraperituneal hematoma. methods. male lewis rats ( g) divided in groups (observation time hrs): a: mild hemorrhage by sequential blood sampling ( . ml each)( , , , , , , , , hrs). b: a with hemoperitoneum (hp)( ml/ g), c: hemorrhagic shock: blood withdrawal of ml/ g over min and resuscitation with ringer's lactate ( x shed blood) and isogenic donor blood; d: c with hp. parameters: serum iron ([g/dl], ferrozin-method); fe labeling of erythrocytas (application of ci fe i.a. into a donor rat, days later bleeding of the rat and injection intraperitoneally in experimental rat; plasma transferrin ([g/ml], ria). t-tests and mann whitney. data are expressed as mean + sem. results. compared to baseline, mild and severe hemorrhage caused a significant increase in serum iron at and hrs, respectively ( + vs. + ; +_ vs. +_ ). hp reduced this increase ( +_ vs. + ; + vs. +- , p<. ). i-ip significantly increased hemoglobin between to hrs in mild ( . +_. vs. . +. ) and severe hemorrhage ( . +. vs. . +. ). in mild and severe hemorrhage comparable maximal resorption ( fe labeled erythrocytes in circulating blood) of intraperitoneal hematoma occured at hrs (mild: +_ vs. severe: +- counts/rain). hp increased survival-rate following hemorrhagic shock (no hp: / ; hp: / ). in mild hemorrhage no alterations of plasma transferrin concentrations. in shock group without hp, there was at hrs a significant higher transferrin level than with hp alone ( . +_. vs. . + . ). in conclusion, hemoperitoneum with hemorrhage prevents increase in plasma iron levels by increasing hemoglobin through resorption of erythrocytes and thereby suppressing iron mobilization from endogenous iron resources, e.g. liver. this suggests that intraperitoneal hematoma not necessarily promotes iron-mediated oxygen free radical production, especially since survival in these groups was improved. increased transfarrin levels in group c at the end of the experiment suggest increased iron turnover which was not observed in shock groups associated with hemoperitoneum. primary immune response to thymus-dependent (srbc) and thymus-independent (vi-polysaccharide) antigens was determined during days after cct. antigenic challenge was made on day i, , or . number of spleen plaque forming cells (pfc) and serum haemagglutinin (ha) titre were studied on day after immunization. cct stimulated immune response to t-dependent, but not to t-independent antigen. enhanced response was noted when srbs were given in posttraumatic day i, it was higher than preceding one after injection on day and reached a maximum when antigen was presented on day after trauma (pfc number . times exceeded the level of immunized, but nontraumatized rats). the rise of pfc number in spleen correlated with increased ha level. thymectomy had been performed days before cct completely abolished posttraumatio stimulation of immune response to t-dependent antigen. standard thoracotomy also enhanced humoral response when srbc were administered on day after the operation. thymus trauma modeled by pincett squeezing of its right lobe and performed at the same time with thoracotomy fully abrogated as well as thymectomy stimulation of immune reaction. thus, different experimental chest traumas are able to increase antibody production via thymus-dependent mechanisms. endothelin is a amino acid peptide produced by ischemic or injured endothelial cells. in vitro and in animal studies, et is also a potent constrictor for renal mesangial and coronary vessels, a negative cardiac inotrope and an endocrine regulator. our lab has shown that et is an agonist for monocyte production of interleukins i, & , prostaglandin e (pge ) , and substances which trigger superoxide production. systemic et levels increase in hypoperfused and septic patients, and et may be yet another important cytokine in critical illness. but while et has been shown to be a potent vasoconstrictor in healthy dogs, systemic vascular resistance does not increase in critically ill patients with high et levels. (we hypothesize that this might be due to pgez-mediated vasodilation predominating over et-mediated vasoconstriction.) we next asked what happened to systemic et levels in patients with major burns (> %.) ten hemodynamically stable patients resuscitated by a modified parkland formula to a urine output > cc's per hour had et levels drawn on admission, at i, , , and hrs. et levels were measured by radioimmunoassay. mean levels were elevated at ± pg/ml at all time points versus levels in healthy controls of ± . in summary, systemic et levels increase significantly in patients with major burns. et may be yet another cytokine playing a significant role in the immune, inflammatory and multiorgan dysfunction observed with major burns. restoration processes in an organism after ischemic damage are realized through ~n~lammatory mechanisms~ the intensity of which is significantly defined by blood levels of neuropeptides. myocardial infarction (mi) was chosen for studyin these processes since it eradicates the influence of infectious factc~rs. dogs~ in whom mi underwent different forms o¢ healer, g; bhn~ed ~h~t during the acute phase of the disease there was a characteristic rise of ne!~ropeptides in the blood. these neuropeptides had nociceptive and antinociceptive effects. particularly substance p and -endorphins triggered off the development of compensatory and adaptive mechanisms and defined the intensity of inflammatory reaction at the zone of ischem~t: damage-notable fall in substance p levels after an ~nitial increase, while the ~-endorphins stayed high was an important condition for non complicated healing of mi. on the other hand high levels of substance p with low ~-endorphin concentrations lead to increased infiltration o~ neutrophils into the infarction zone and weakened the activity of synthetic processes~ thereby leading to left ventricular aneurysm. at the same time low intitial levels of substance p slowed down the development of necrotic processes which lead to delay in refunctioning of the heart and complicated the healing process. thus, regulation of the levels of neuropeptides in the blood in trauma forms a perspective method of its treatment. of laparascopic versus open choleocystectomy c. schinkel, s. zimmer, v. lange, d. fuchs, e. faist the impairment of immune function due to surgical trauma may be followed by deleterious septic sequelae. compared to open abdominal surgical procedures (lap), laparaseopic surgery (lsc) is associated with a decrease in hospital stay and in accelerated patient recover. the aim of the study was to evaluate the sensitivity of the immune sermn parameters of il- , saa and neopterin, the percentage of cd + cells, the in-vitro il- synthesis after mitogen stimulation and lymphocyte proliferation, in order to purposefully discriminate differences in the severity of trauma. we investigated the blood of patients with cholecystolithiasis undergoing either laparascopic ( ) or open (i ) cholecystectomy on consecutive perioperative days - , , and . there was no significant difference between the two groups concerning age and sex. patients with clinical signs of acute cholecystitis were excluded from the study. operation time and hospital stay were obviously longer in lap patients ( versus minutes, versus days) compared to the lsc group. concerning the unspecific acute phase reaction we could show no difference in the increment of senun amyoid a (saa) synthesis in the lsc group (d-i + lng/ml, d + ng/ml) versus lap group (d- + ng/ml, d + ng/ml), while in serum il- levels we saw a less steep increment in the lsc group ( -fold from d- to d ) compared to the lap group ( -fold from d- to d ). the analysis of cd + receptor expression and serum neopterin did not reveal any difference between the groups. lymphocyte function showed an impairment of proliferation to antigen stimulation in lap (d - : . + . cpm, d : . + . cpm) compared to the lsc group (d -h . + . cpm, d h . + . cpm). in both groups il- synthesis was decreased post-operatively. our data indicate that laparascopic cholecystectomy reusults in a less distinct unspecific acute phase reaction post-trauma compared to that following lap. neopterin serum levels and cd receptor expression show that these parameters apparently are less useful markers to detect differences of surgical trauma severity while it appears that the impact of lap is reflected most impressively on the lymphocyte compartment. trauma alters the host resistance of organism and is accompained by appearence of excgenic and endogenic proteins in the body. to understand the molecular mechanisms of host resistans disorders in trauma, as a first step, the genetic regulatory mechanisms of immune response after antigen injection has been studed. the appearence of specific protein factors ( - and kda), in the nucleus of rat splenic and brain cells, accordingly, was shown after immunization with sheep erythrocytes. the stimulatory effect of these factors on the il- mrna and il- production was detected. the nucleotide sequences of the human il- gene regulatory region bounding by the splenic nuclear proteins were determined between + - b.p. the il- trans-factors shows the affinity to splenic and thymic lymphocytes in vitro. thus, the antigen causes the appearence of specific protein factors in the cells,which act on the gene level,stimulate il- production and the host resistance. these results cause the next step of experiments using the same model, but after trauma. these investigations will let us verify the hypothesis that the protein il- gene trans-factors may play a definite role in the decrease of the cell immune responce after trauma. confronted with the routine procedure of prophylactic treatment of candidates for surgery in a rural african hospital, we initiated studies on the fre'quency of post-surgical malaria. in tanzania non-pregnant patients from rural areas were followed. of preoperative patients % had a parasitaemia and those maintaining it showed no increase or complaints. nine percent of patients without detectable parasitaemia before surgery came down afterwards and one-third had malaria-like complaints. spinal and general anaesthesia were equally applied in these last patients. in burkina faso we studied patients of which % had a parasitaemia on admission and % had postoperative malaria. half of the surgical patients came from rural areas, whilst only % of those with malaria lived in the city (with much less exposure and immunity). % underwent major surgery and % minor. bloodtransfusions ( % with parasites) never evoked a parasitaemia in recipients. post-surgical malaria is thus a reality in about % of the adult cases, both in east and west africa. surgery evokes a cascade of factors, varying from cortison to interleukines and acute phase proteins; immune responses may temporarily be suppressed. clinical attacks of malaria in otherwise immunes could be evoked by one of these factors. though malaria can easily be cured, the differential diagnosis is difficult because of post-surgery fevers; we found that % was treated without justified indication. the involvement of "student-doctors" a. this study examines glucose uptake and hexose monophosphate (i~ip) shunt activity in normal human peripheral lymphocytes and polymorphonuclear leukocytes (pmn). glucose uptake was determined by measurir,g the uptake of tritiated deoxyglucose, a non-metabolized glucose analogue. adsorption of co derived from [i- c] glucose was used to determine knp shunt activity. in vitro assays were carried out in hormone concentrations approximating normal and elevated trauma blood levels. (normal -cortisol . ~g/ml, glucagon #g/m , epinephrine ~g/ml, insulin t~u/ml; traumaeortisol . ~g/ml, glucagon /*g/ml, epinephrine ~g/ml, insulin ~ij/ml. analysis of twenty subjects showed a reduction of ° ~mp shunt activity by lymphoeytes and a ] % reduction in glucose uptake by p~n in normal vs. trauma hontc,nes p < . . lymphocyte glucose uptake was also reduced by trauma hormones p~ . . it ha~ be.ea~ suggested thgt idiopatno pulmonary fibrous (y.pf) [s a consequence of severe alveolar epithelial injury and is associated with an nveolar irnammamry reactio~ and the presence f.neutr phils. there~bre, neutr pk~ chemoattra~ant~ are probably important in the genegs oft.he infial lesions of ipf. the obse,"wson that stimulated macrophages are or~n histologically promin~t in fibmfio [-~gs ~.nd am capable of p~oducmg a v~dery f flbrogenic pep'ides also a~gues for their role ~n the pathogenic prc~e~ oflpf. the observation that stimume~ maerophages ere often histologica[iy prominent in fibrotio lungs and ~re ~pable of producing a varie~, offibroge.~e peptide~ also argues for tkek role in the pathogenic process, therefore, we ha-~e tested the potentn for iater!eukln- (i ..- ) and mo~tocyte chemotacde pop, de (x¢cp- ) to induce neutro~hil ~d mononuclear phagocyte accumuhdon in lungs of pafient~ with pulmonary .~r~idosis and i~f. brenet~o.alveolar lavabo (bal) fluids from ipf and sar~qidosis patient were conexntratea by reversed-phase chromatography, ~d ii. arid mcp-i asso.~ed by ells& ehemotaxis mad enzyme-reieasing ~ssas's on msnocyte~ and neatrophiis. elisa revealed significenfly elevated b al-eoneentrations o£mcp-i ( . ng]mg aibumm) in purisms with p~monary sarcoidodis artd in ipf ( . ng!mg) in comparises to . normal individuals ( . ng/mg) and to patients w~th obreic bronentis (cb) (~, rig/rag). similarly, chemota*dc ac~a~' for monocles (mcp- e.qu/va]ent) was strongly increased in sareoidosis ( . ngjmg) as well as ~n f pag,nts ( . ng/mg). norra.al indlvidu~s and cb patiants hzd a . or -fold lower ~cn%i~y, re~peefively. patients with ipf and sarcoidosi~ also h~l eievated il- ievei~ ( . and . rig/rag, respe~veiy; nomzls: . rig/rag; cb: . ng/mg) mad nvatropmi ohemotax~ ( . ~'~d . nnmg, res!z~ztiveiy; aormals: . ng,'mg; cb: l ngmg). these data suggest that increased ievels of born mcp. ~d il- may be oharacted~tie for ~arcoidosis or ipf_ it appears iikely that both ehernoattraetants ~ontribute to the influx ofmonocytes and neutrophils into the pulmonary alveoius and interstit~um in these dlsea~es. we have recently shown that the combined administration of noninjurious doses of lps and paf in the rat produce ards-like lung injury characterized by neutrophil adhesion to lung capillary venules, neutrophil accumulation in lung parenchyma, pulmonary edema, and increased protein and neutrophil count in bal fluid. this new paradigm of lung injury was associated with elevated serum tnfc~ and pretreatment with anti tnfa mab dose-dependently prevented these responses. also, the combined administration of lps and paf induced lung mrna levels of tnfe~ ( fold vs. lps or paf alone), ll-lg ( fold), kc ( fold) and il- . taken together, these data suggest that this new paradigm of lung injury is cytokinemediated and that lps/paf in vivo can functionally couple to the activation of gone expression of a multi-cytokine network system, all of which may be involved in the pathogenesis of ards. materials and methods. the sheep model included hemorrhagic shock and closed femoral nailing at day , hourly injections of e. coli endotoxin and zymosan-activated autologous plasma at clays - and further observation and measurements at days - . from venous blood and bronchoalveolar lavage(bal)fluid of ten merino sheep (mean weight kg) neutrophil counts ( e pmn/ml blood or epithelial lining fluid-elf-), the elf/ plasma ratio of albumin (r), and the zymosan-induced (stim) and non-induced (spont) chemiluminescence response (cl) of blood ( e cpm/ , pmn), and of blood-and bal-isolated pmn ( e cpm/ , pmn) were measured. for statistical calculations the wilcoxon test was used. data of the changes in polymorphonucleur leukocyte (pivinl) metabolism have been suggested to play a pivotal part in the post-traumatic systemic inflammatory response syndrome. the underlying cellular mechanisms which control this response are not yet completely understood. since the 'ca + second messenger'-system has been shown to be involved in regulation of pmnl-'respiratory burst', we investigated changes in pmnl-ca z÷ regulation in relation to oxygen free radical mediated injury. methods. in polytranmatized patients (mean injury severity score = ) arterial and venous blood samples during days. daily evaluation of horowitz-quotiant (po /fio ), plasma lactate (mg/dl) and body temperature ( results. body temperature peaked at day and (day : +. ; day : . +. ). plasma lactate was significantly increased at day l ( + ) and day ( . + ). hurowitz-quotient (day : + ) was low at day ( + ) and day to ( + )(p<. ). at day a substantial rise in venous pmnl-superoxide production (day : . +_. , day : . +. , day : . +_. ), oecured with significant increase in plasma lipid peroxidation (day : . + . ; day : . + . ). pivin~-myeloperoxidase activity was high at day ( . +--. ) and then continuously declined (day : . +. ). plasma antiexidant activity (glutathione pemxidase) was reduced by % at day (day : . +. ; day : . +_. ; day : . +. ). whereas basal ca + concentration remained unchanged (day : +_ , day : +_ ), fmlp-stimulated cytosolic ca + mobilization increased at day (day : + , day : , day : + ). conclusion. the present study in polytraumatized patients shows, that seven days after injury the agonist-induced pmnl ca + mobilization is significantly enhanced. at the same time, pmnl-oxygen free radical release and phagocytotic activity, systemic fever response and lactate concentrations were maximal. these observations were accompanied by post-tranmatic respiratory failure and in some patients by clinical signs of multiple organ failure. preliminary data from an ongoing study using hes-and dextran-infusions in these patients show attenuation of this inflammatory response. stefan rose, m.d., trauma surgery, univ. of saarland, homburg/saar donnelly sc, haslett c, dransfield i, robertson ce, grant is, carter c, ross ja, tedder tf. dept's of respiratory medicine, accident & emergency, intensive care, surgery, university of edinburgh, scotland and dept. tumor immunology, dana farber cancer institute, boston. the selectins are a family of adhesion molecules (l-selectin, e-selectin, pselectin), all of whom are implicated in inflammatory cell transendothelial migration. they, as a family can be proteolytieally cleaved from their parent cell and exist in a soluble form within the circulation. ards is a disease state in whic neutrophils and neutrophil transendotheliat migration have been implicated. in this study we wished to investigate whether the levels of these circulating soluble receptors from patients at-risk of ards at initial hospital presentation, correlated with subsequent ards progression. eighty-two patients were enrolled (pancreatitis (n= ), perforated bowel (n= ), and multiple trauma (n= )), of whom progressed to ards. assays for soluble l,p & e-selectin were performed on collected plasma samples via a sandwich elisa. (ns = not significant, **** = p<o. ) we have found a highly significant inverse correlation between a low circulating soluble l-selectin (and not soluble e & p-selectin) and subsequent ards. these results further our understanding of neutrophilendothelial interactions in the early stages of ards pathogenesis and offer the promise of sl-selectin in combination with other markers of inflammatory events being used to identify individuals at particularly high risk of ards progression on initial hospital presentation. it has been suggested that polymorphonuclear leukocytes aggregate in the lung capillaries of patients developing the adult respiratory distress syndrome (ards) and account for the endothelial damage while releasing toxic metabo-iites such as o.a. free oxygen radicals. among many antioxidants which have been investigated in in vitro systems and in animal models, n-acetylcysteine (nac) has been established to be useful as a free radical scavenger in vivo. to assess the influence of n-acetylcysteine (nac) on the activation of neutrophils in patients undergoing cardiopulmonary bypass (cpb) surgery with extracorporeal circulation (ecc), we evaluated the plasma levels of elastase and myeloperoxidase (mpo) throughout the operation and up to hours after surgery. four hours after surgery also a bronchoalveolar lavage was performed. a spectrophotometric method was used for the detection of plasma elastase activity and mpo levels were measured using a radioimmunoassay. we found that pretreatment with intravenous nac prevented the increase in elastase activity ( _+ pmol/i vs _+ ; p - . ), but not the release of neutrophil related mediators ( . _+ . ng/i vs . _+ . ; p= . ). besides, nac had the capability to prevent the enhancement of neutrophil numbers in lavage fluid as is normally seen during cpb ( . + . % vs . _+ . ; p = . ). although not significant, nac prevented also the increase in elastase levels in lavage fluid ( . + . pmol/i vs . + . ; p = . ). it is concluded that nac is able to protect against the inactivation of a -proteinase inhibitor, the main inhibitor of elastase activity, and that nac interferes with adhesion and migration of neutrophils. therefore nac may be useful in the prevention of tissue damage. this study is supported by inpharzam belgium. sodium nitroprnsside (snp) has previously been shown to attenuate the neutrophil induced lung injury associated with limb ischaemia and repeffusion. glyceryl trinitrate (gtn), already widely used in aortic surgery, also increases nitric oxide but has a less marked splanchnic "steal" effect. we examined the effect of gtn on lung injury, neutrophil infiltration and activation in a model of aortic occlusion ( rain) and repeffusion ( min). sprague dawley rats were randomized into: control (n=i ); ischaemia repeffusion (ir) (n= ); and ir treated with gtn ( ug/kg/min) during repeffusion (n= ). myeloperoxidase activity (mpo) measured pulmonary neutrophil influx. pulmonary endothelial permeability was measured by wet to dry weight ratio (w/d), broncboalveolar lavage protein (bal) and neutrophil counts (bal pmn). neutrophil superoxide release (mean channel fluorescence mcf) was measured by flow cytometry in a further ir v gtn experiment (n= per group). control _+t "* _+ _+ ** bal pmn/mm l+- " + # _~ *p< . , #p< . v control/gtn;**p< . v ir. students t test the significant increase in mpo activity produced by ir was attenuated by gtn. the increase in pulmonary microvascular leakage after reperfusion was also prevented by gtn. neutrophil superoxide release increased significantly from . + . to . _+ . mcf after minutes repeffusion (p<. ). this increase in superoxide was prevented in the gtn treated group. these results indicate that gtn inhibits neutropbil superoxide release during limb reperfusion, thus preventing pulmonary vascular leakage and neutrophil infiltration. these data suggest that the beneficial effects of gtn in aortic surgery may be due in part to a protective effect onpulmonary microvasculature. department of surgery, beaumont hospital, dublin , ireland. lipton adult respiratory distress syndrome (ards) is marked by increased vascular permeability of the lung to white blood ceils (wbc). indeed, influx of wbc into the lung is believed to be the central mechanism in acute lung injury of ards. evidence is developing that the neuropeptide c~-melanocyte stimulating hormone (c~-msh), a proopiomelanocortin derivative, inhibits inflammatory reactions in animai models of inflammatory responses in humans. to test the influence of a-msh on experimental ards, the peptide was administered to rats after intratraeheal infusion of endotoxin (s. typhosa, #g in . ml saline). three groups (n= each) received: intratracheai infusion of endotoxin plus ip injections of o~-msh ( ~tg in . ml saline) at , , and hr post-endotoxin treatment; intratracheal endotoxin infusion plus saline injections; control intratracheal saline infusion plus saline injections. the bal data showed overall differences among groups (f , = . , p<. ), o~-msh treatment inhibited endotoxin-induced wbc migration into the pulmonary tree (p<. ). circulating wbc counts were markedly lower in both groups given endoroxin than in the control group (p<. ), but there was no difference in wbc count between these two endotoxin-treated groups. the results indicate that c~-msh can reduce wbc migration in experimental lung injury. in further experiments we tested the hypothesis that c~-msh, administered alone or in combination with an inhibitor of gram-negative bacterial growth, increases survival in a model of peritonitis/endotoxemia/septie shock. cecal ligation and puncture were performed under sodium pemobarbital anesthesia ( mg/kg, i.p.) in female balb/c mice ( - g) that were then randomly assigned ( - mice per group) to receive at time and hr later: control saline thjectioas (i.p.), injections of ~-msh ( ~tg), gentamicin sulfate (i mg/kg), or both ~-msh and gentamicin. one ml of normal saline was given s.c. to each animal for fluid replacement. both ix-msh and gentamicin treatments administered singly improved survival; when given in combination survival was even greater these findings suggest that the anticytokine ot -msh molecule might be useful for treatment of systemic inflammation, perhaps particularly when used in combination with agents that inhibit bacterial growth. previous studies showed a close relationship between xanthine oxidase activation, membrane damage and postischemic cardio-respiratory failure following aortic clamping and reperfusion. aim of the present study was to evaluate alterations of polymorphonuclear leukocyte (pmnl)-metabolism and signal lransduction systems during ischemia/reperfusion induced by aortic clamping in man. methods, in patients ( female, + years) with elective reconstruction of infrarenal aortic anearysms, arterial (a) and venous (v) blood samples were obtained before clamping and declamping, and min after declamping. arterial pla concentrations were higher than venous ( + vs. + ). while cytosolic basal pmnl ca + concenlxation was not altered at the end of ischemia (v: . + ; a: _+ ) and during reperfusion (v: + ; a: + ), fmlp-stimulated cytosolic ca + mobilization showed a significant arterial increase as compared to venous ( _+ vs. + , p < . ). these presented data indicate that the reperfusion syndrome after infrarenal aortic clamping is characterized by ) pulmonary membrane damage possibly due to pmnl-degranulation, ) activation of pmnl-superoxide radical production with release of activated pmnl in arterial circulation, and ) a significant arterial increase of pmnl cytosolic ca + mobilization after fmlp-stimulation parallel to pmnl-activation. in conclusion, ischemia/reperfusion in man induces pulmonary damage and activation of pmnl superoxide production possibly due to an altered pmnl-ca + messenger system by inflammatory mediators (e,g. ii- , tnf, paf). the septic lung diseases (i.e. ards) generally show distinct alveolar damage and surfactant disturbances. it is thought that alveolar macrophages are involved in specific release products like h and cytokines like tnf. in this pathway the type ii alveolar epithelial cell (p cell) is not only an important target, but as recently shown it is also capable of producing h . the aim of this study was to investigate the influence of endotoxin on h release of p cells. we obtained p cells from lungs of female wistar rats and investigated the effect of lipopolysaccharid (lps) on h release of fresh isolated cells and on cells cultured for days in a fibronectin matrix. furthermore we conditioned isolated alveolar macrophages for hours with p.g/ml lps and tested the conditioned medium (mcm) on cultured p cells. p cells h ex vivo were _> % pure, _> % vital and had an basal h release of . _+ . nmol h per hour and million cells. adding p.g/ml lps to the incubation medium the h release decreases slightly but significantly to . _+ . nmol. adding . p.g/ml phorbol myristate acetate (pma) to the basal incubation medium the h release increased -fold to . _+ nmol. pma induced h release decreased to . + . nmol after addition of p.g/ml lps. after culture days the p cells were _> % pure and showed a pma inducible h release of . _+ . nmol addition of p.g/ml lps had the inverse effect as on freshly isolated cells as it increased the h release up to . _+ . nmol. addition of mcm to cultured p cells increases pma-stimulated h release to . +_ . nmol. the release decreased to . _+ . nmol when an murine anti-tnf-alpha antibody was added. vitality of cultured cells was > % in all experiments. the results show that lps has an direct effect on p cells cultured on fibronectin. we conclude that the observed additional stimulatory effects of mcm seems to depend on tnf-alpha. the induction of h release of p cells could be important for generating internal oxidative stress in p cells before external oxygen radicals exceed. the produced h did not necessarily damage p ceils, but it can effect surfactant metabolism, especially when extracellular h release of alveolar macrophages following an immune response is increasing. introduction: primary stabilization of femoral shaft fractures in patients with multiple trauma is beneficial. however, in patients with associated lung contusion we have found an increased incidence of ards, apparently associated with primary reamed femnral nailing (rfn). previous animal studies revealed, that perioperative disturbances of lung ftmetion appear to be related to the reaming procedure, ix~ssibly due to pulmonary embolizafion of bone marrow fat. in a prospective clinical analysis we compared effects of intrameduuary nailing with and withont reaming on parameters known to be related to ards-pathoganesis. in order to gain further insight into the role of endotoxin and cytokines in the pathogenesis of the adult respiratory distress syndrome (ards), we enrolled patients with severe lung injury after sepsis ( ) or polytrauma ( ) and obtained multiple blood samples ( days) for endotoxin, tumor necrosis factor e (tnfa), interleukin (il- ) and interleukin (il- ) determination. to evaluate the cytokine releasing capacity of the blood, plasma concentrations of tnfe, il-l and il- were also determined after the "in vitro" stimulation of the whole blood samples with lipopolysaccharide (lps, . ng/ml) for hours at c (stimulated values). the difference among stimulated cytokines levels and the basal plasma concentrations were defined as "delta values", an expression of the cytokine releasing capacity of the blood. the pao /fiao quotient was used as an index of the severity of lung injury (sli). the endotoxin plasma level was significantly higher in patients with sli < ( . ± . eu/ml, mean values ± sem) versus the patients with a sli > ( . ± . eu/ml, p<o. ). the basal plasma concentration of ll- also correlates with the sli index (p<o.o ). the delta tnfe and delta il- values were s~gnificantly decreased in patients with a severe lung injury. compared with the survivors (n: ), the deceased patients (n= ) showed higher endotoxin level, a reduced tnfa and il- releasing capacity of the blood and higher basal il- levels. we can conclude that endotoxemia, high il- plasma level and a decreased capacity of the blood to release tnfa an il- under endotoxin stimulation associates with the severity of lung injury. [objectives] experimental and clinical findings implicate the involvement of inflammatory cytokines in the pathogenesis of the decreased oxygenation in the lung after major surgery, though the mechanism remains unclear. in the present study, we elucidated the involvement of il- in the pathogenesis of lung injury defined by deterioration of pulmonary oxygenation after esophagectomy. [materials and methods] seventeen patients underwent subtotal esophagectomy through a right thoracotomy. in all patients, tbe alveolar-arterial oxygen tension difference (aado ) was measured everyday and bronchoalveolar lavage fluid (balf) samples were obtained from a single segment ($ or $ ) of the right and left lung through a bronchoscope on days l, , and days after surgery. they were then examined for cell analysis, measurement of cytokines by elisa, and measurement of neutrnphil elastase (ne) by elisa. [results] aado unexceptionally deteriorated postoperatively and the mean aado in patients reached the maximum (mean ± sem; _+ mmhg) on the rd postoperative day. the mean concentrations of il- , ne and neutrophil count in balf also increased postoperatively and reached their maximum level ( + pg/ml, -+ gg/l, and ± x cells/ml, respectively) on the rd postoperative day. these increases in balf were recognized in both the right and left lung. a highly significant correlation was observed between il- and ne levels in balf (r= . , p= . ). also, significant correlations between aado and the neutropbil count, and the concentration of ne or l- were observed. in contrast to il- , neither il- , il- nor tnfa was detected in balf. [conclusion] major surgical trauma such as esophagectomy may induce recruitment of neutrophils to the lung and cause lung injury. il- increased in the lung is an important mediator of neutrophil recruitment and activation in the lung. phorbol myristate acetate (pma) is commonly used to cause edema and other tissue damages in the lung. lung injuries induced by the administration of pma has been shown to be mediated mainly by neutrophils. neutrophils recruited to the lower respiratory tract may damage lung tissues by releasing reactive oxygen species, neutral proteases and lysosomal enzymes. the present study was conducted to investigate whether c~tocopherol, entrapped in dipalmitoylphosphatidylcholine liposomes and delivered directly to the lung, could counteract some of the pma-induced lung injuries. plain liposomes or c~tocopherol-containing liposomes ( mg c~-tocopherol/kgbody wt.) were instilled into the lungs of rats h prior to pma exposure ( pg/kg, intratracheally) and treated rats were killed h later. lungs of control animals exposed to pma developed increases in lung weight and lipid peroxidation as well as decreases in lung angiotensin converting enzyme (ace) and alkaline phosphatase (akp) activities. pma treatment also caused an increase in myeloperoxidase (mpo) activity in the lung, suggestive of neutrophi] infiltration. pretreatment of pma-treated rats with plain liposomes had no effect on pma-induced injuries. in contrast, pretreatment of rats with liposomal c~-tocopherol, h prior to pma administration, resulted in a significant elevation of pulmonary a-tocopherol concentration, accompanied by a concomitant reduction in mpo activity and reversal of pmainduced changes in lung edema, lipid peroxidation, ace and akp activities. these results appear to demonstrate that the intratracheal administration of a liposome-associated lipophilic antioxidant, such as a-tocopherol, can significantly ameliorate the toxic effects of reactive oxygen species, released from pmastimulated pulmonary target cells and infiltrating neutrophils. jk wojcik, g palasiewicz, w roszkowski immunology department,institute of tuberculosis and lung diseases~ warszawa, poland, m~larhospital, eskilstuna, sweden. introduction:the critical point in neutrophil migration to the alveolar space in the course of ards is the attachment between giyeoproteins of neotrophil membranes(sialyl lewis x carbohydrate epitope containing u-l-fucose) and lectin domains of endothelial p and e selectins (gmp- ,elam-i). a potential beneficial therapeutic strategy may be designep to suppress neutrophil recruitment to the lungs by preventing their rolling and attachment to the pulmonary endothelial cells. objeclive:to investigate if tz-l-fueose prevent experiments pulmonary hypertension in ards as effective as metylpredniselone. methods:only healthy rabbits (n- ) weighing .d- . kg oaselinepao> kpa and mean pulmonary arterial pressure (mpap)<i. kpa were included in this study. anaesthesia was induced with thiopental - mg/kg bw and "blind" jntubation was performed. a f swan ganz catheter was introduced via the left jugular vein into the pulmonary artery. pma, as was used in our experiments activates neutrophils and produces acute respiratory failure with pulmonary hypertension and pulmonary edema. eight rabbits serving as control animals received pma ug/kg bw iv only. sixteen other animals were divided into two groups receiving either ~-l-fucose mg iv or metylprednisolone mg iv min before pma admininstration. results:after pma administration notable physiological changes including marked increase in mpap( . -+o.~ kpe ..lere found. the increase of npap was observed to be completely blocked in both groups of animals which received ~-l-fucose or metylprednisolone. conclusion:in aur rabbit model ards cz-l-fucose pretreatment prevents pulmonary hypertension after pma administration. the effect is comparable with high dose metylprednisolone. the possible explanation is that g-l-fueose molecules block iectin domains of gnp- or elam-i preventing the adhesion of the neutrophils to the pulmonary endotheliom. bartens c, elmadfa i, steltzer h, fischer m, druml w introduction: various micronutrients and vitamins are particulary effective in modulating immune functions and host defense. the nutritive ant±oxidants vitamin c, e and b-carotene, as well as selenium lower the burden of reactive free radicals and protect the structural integrity of cells and tissues of the immune system, as well as other systems in the body. certain cells of the immune system like polymorphonuclear leucocytes (pmn's) use free radicals as a weapon to destroy invading pathogens. these reactive molecules, when released into the surrounding area, mediate lipid peroxidation and tissue injury. there is growing evidence that pmn's are activated in vivo by complement or immune complexes in disorders such as ards. the respiratory host defense mechanisms of patients with adult respiratory distress syndrome (ards) may be defective. the aim of this study was ta evaluate the status of the free radical scavengers and their activity in ards and to investigate the respiratory burst of ards patients. methods: seven ards patients ( sepsis, trauma) with an fie of . + .( , a peep of . ± . , and a murray score of . ± . were included in this study. healthy adults served as controls. superoxide anion production in granulocytes was measured photometrically, and the hydrogen peroxides by fluorimetric assay. vitamin a, e, and g-carotene concentrations were assessed by hplc, and plasma vitamin c photometrically. plasma selenium was determined by dectrothermal aas. plasma lipid peroxidation pruducts, expressed as malondialdehyde (mda), were determined by thiobarbituric acid assay and hplc. results: mda-plasma (/xmol/l) . ~: . * . ± . *= < . , **=p< . condusion: ards patients showed significantly decreased plasma concentrations of vitamin c, e and g-carotene, as well as selenium. these nutritive ant±oxidants are consumed during increased oxidative stress. mda, a final product of lipid peroxidation, is increased. however, a difference in rates of release of hydrogen peroxides and superoxide-anion of pmn could not be detected. therefore, oxygen radical accumulation is more likely a result of excessive inspiratory oxygen concentrations (f.io ), pro-oxidant drugs, and a high settlement of pmn in the lungs, and not an increased release of free radicals of the single pmn. kd glycoprotein secreted by the alveolar type ii cells. recent study showed that sp-a exists in the sera from normal healthy adults and that the significantly elevated serum sp-a levels were observed in the patients with interstitial pneumonia and pulmonary alveolar proteinosis. these findings means there may be a mechanism that the sp-a produced in the alveoli escapes into the bloodstream. here we examined the serum sp-a levels in the patients with critical illness including sepsis and ards. ]clinical subjects & methods] a total of serum samples were collected from patients hospitalized in the division of critical care medicine(icu), sappom medical college hospital. serum sp-a levels were measured by an enzyme-linked immunosorbent assay using monoclonal antibodies to human sp-a. ]results] there was no significant difference between the septic (n= ) and non-septic (n= ) patients. patients with ards (n= , . + . ng/ml) and with respiratory disease other than ards (n= , . +- . ng/ml) showed significantly higher levels of serum sp-a than those with non-respiratory disease (n= , . _+ . ng/ml). as to the ards patients, it was likely that the serum sp-a levels were getting higher in their clinical courses. however, there was no significant correlation between the serum sp-a levels and the pa%/fio ratio. ]discussion] at the present time, the exact mechanism of the escape of sp-a into the bloodstream remain to be unclear. our results may suggested that there was some relation between this leakage of sp-a and the alveolar-capillary permeability because of the higher sp-a levels observed in the ards patients. however it is also likely that higher serum sp-a level represents the proliferation of alveolar type ii cells as the regeneration of damaged lung. further studies are now being done. neutrophils contain a number of enzymes within intracellular granules,potentially damagingto lung tissue.release of these enzymes into the lung tissue from the sequestred activated neutrophils is felt to play significant role in lung injury in the course of aros. using -hours acute animal model of aros the activity of cathepsins,beta-glucuronidase and acid phosphatase was determined in the lung tissue. results of this research were compared with neutrophil proteases activity in serum and broncho-alveolar lavage.also hemodynamic,respiratory and biochemical investigations were performed before beginning of experiment,and in a two-hours time intervals of its duration.after hours was determined total and free activity of cathepsins,beta-glucuronidase and acid phosphatase in full homogenate of the lung tissue,mitochondriallysosomal fraction and the final supernatant. in the course of our experiment we observed an increase ( .i- . %) both total and free activity of neutrophil proteases in all fractions of the lung tissue.generally accepted current pharmacological treatment of aros only attenuated this increase but never caused reversion to the level before beginning of our investigations. the presence of aros was histologically proved.an activity of acid phosphatase in serum and the lung tissue fractions was compared with histochemical pictures of the lung. results of our research indicate that neutrophil proteases are a very important mediators in aros and they are a cause of the lung injury. in addition neutrophil-derived proteases can amplify the inflamatory process by enzymatitally activating of many other mediators and they also may to increase an oxidant induced injury by imparing of antioxidant defenses. oepartment of general surgery, sk~odowskiej a - ~ia~ystok, poland, tel/fax + . in vitro studies demonstrated that paf activates polymorplionuclear leukocyte (pmn) - ipoxygenase, but the generation of leukotrienes (lts) is critically dependent on exogenous arachidunic acid (aa) disposal (f. grimminger et at., mol. pharmacol. : , ) . we investigated the features of paf-evoked lt synthesis in a model of pulmonary microvascular leukostasis, in the presence and absence of intravascular n- -and n- -prescursor fatty acid supply. human neutrophils were infused into isolated, ventilated and perfused rabbit lungs to achieve microvascular sequestration of ligand-responsive leukecytes. leukotrienes (lt) and hydroxyeicosatetra(penta)enoic acids (het(p)e) were quantified by itplc techniques. intravascular application of paf ( um) or arachidonic acid (aa;ioum) provoked the generation of limited quantities of -series lts and -hete (total sum of - ipoxygenade products rd. and rd. pmol/ml.; both in pmn-preloaded and non-preloaded lungs). combined administration of pat r and aa caused amplification of - ipoxygenase product formation with predominance of cysteinyl-lt synthesis both in lungs without (total sum rd. pmol/ml) and, much more strikingly, with pro-application of neutrophils (total sum rd. pmofml). eicosapentaeooic acid ( um) elicited exclusive generation of -series lts and -hepe (total sum rd. pmol/mi). dual stimulation with paf and epa provoked amplification of epa-derived - ipoxygenase product formation, again with predominance of cysteinyl-lts, in lungs without (total sum rd. pmul/ml) and in particular in those with preceding microvascular pmn entrapment (total sum rd. pmol/ml). we conclude that the paf-evoked - ipoxygenase product formation in the neutrophil-harbouring lung capillary bed is critically dependent on intravascular precursor fatty acid supply, with epa representing the preferred substrate as compared to aa. pmn-related transcellular eicosanoid synthesis is suggested to underly the predominant generation of cysteinyl-lts. these findings may be relevant for lipid mediator profiles provoked by infusion of n- -versus n- enriched lipid emulsions in diseases with pmn-related inflammators events. adult respiratory distress syndrome (ards) involves damage to the alveolar epithelium and microvascular endothelium. products released from neutrophils (pmn) are thought to be among the chief causes of this damage, while the role of mononuclear cells (mnc) is uncertain. we studied patients at risk of or with acute ards. we measured the concentration of myeloperoxidase (mpo) and elastase (el) within circulating pmn as an index of pmn activation, elastin degradation products (edp) in the plasma as an index of tissue damage, as well as the cytotoxici~y of pmn and mnc to endothelial cells (ec) in vitro. cells and plasma were prepared from venous blood of healthy controls; or systemic arterial blood of patients on ventilators in intensive care but not at risk of ards; at risk of ards because of sepsis; at risk because of multiple transfusion/major trauma; or with acute ards. lung injury, multi-organ failure and apache h scores were recorded. to measure cytotoxicity, human umbilical vein ec were labelled with cr- , incubated with either pmn or mnc for hours, and the supernatant counted. the adherence of the pmn and the mnc to the ec was also measured. standard assays were used to measure mpo and el in the pmn, mad edp in the plasma. the mnc cytotoxicity did not differ between the groups. the pmn cytotoxicity was higher in the transfusion/trauma patients compared to each other group, which did not differ from each other. there was no correlation between cytotoxicity and adherence for any group. the mpo and the el concentrations were significantly decreased in the pmn from each of the patient groups, including the patient controls, compared to healthy controls. the edp were only increased in patients at risk of or with ards. thus pmn degrannlation occurred in patients not at risk of ards, but tissue damage as measured by increased edp only occurred in patients with or at risk of ards, suggesting that factors additional to pmn activation and degranulation are required for the progression to ards. there was no correlation between the parameters measured and the indices of disease activity, or outcome. these measures of pmn and mnc activation and function are not of value as prognostic indicators in patients with or at risk of ards. the liver is made up of several different cell types which subserve distinct functions in vivo. in addition to the different functions of the distinct cell types, it is now evident that even within the population of hepatocytes substantial functional heterogeneity exists. this heterogeneity occurs in a very organized fashion in the normal liver based upon the position of the hepatocyte in the acinus. although it has been proposed that the acinar heterogeneity of hepatocytes arises from migration of immature hepatocytes from the periportal region to the perivenous region where they become senescent and die, many of the heterogeneous responses can be accutely reversed by reversal of the oxygen gradient via retrograde perfusion. under normal conditions in which the acinus is exposed to unidirectional flow, the periportal hepatocytes are exposed to relatively high levels of oxygen, substrates and hormones. as these substances are extracted along the aeinus their concentration decreases leaving relatively low concentrations for the perivenous hepatocytes. in the normal liver, the heterogeneity of response is attenuated by extensive communication via gap junctions. the major liver gap junctions are made up of hexamers of connexin (cx ) which forms channels between cells capable of pas.~ing any molecule smaller than d. coupling is sufficient to allow diffusion of molecules such as atp or camp from one hepatocyte into > adjacent hepatocytes within seconds. during stress conditions such as endotoxemia or zymozan inflammation, expression of cx is markedly decreased while the secondary gap junction protein cx is either unchanged or even increased. while cx readily effects electrical coupling, molecules > d pass only very slowly. this would result in restriciton of transmission of moecules the size of atp or camp. since inhibition of gap junctions also attentuates metabolic response to hormone or nerve stimulation, it is evident that modulation of hepatocyte hetereogeneity by gap junctions must be considered in determining the mechanisms of metabolic alterations during stress. already minor haemorrhage decreases portal venous blood supply to the fiver and the reduction in portal blood flow becomes more pronounced with more profound btood loss. severe hacmorrhagic hypovolemia also reduces hepatic arterial blood supply which, however, is maintained over a vide range of haemorthage. the net effect of blood loss is a reduction in liver oxygee supply and this reduction is in proportion to the vulume iossed. however, oxygen supply to the liver exceeds the demands of the normal liver and this is the ca~ stilt following reduction of % of blood volume. the situation in sepsis is more complicated. po~l venous supply to the liver is redur.~i fairly early following normovolemic sepsis while hepatic arterial blood supply is maintained at le,~t initialiy, oxygen saturation might be maintained in arterial blood but may also be slightly reduced during sepsis, oxygen saturation of portal venous blood is significantly reduced during sepsis due to increased extraction of the intestines. therefore oxygea delivery to the liver during sepsis becomes sigalfkzntly reduced. at the s,~ne time and for mai.v.ly unknown reasons the need for oxygen becomes significantly increased in the ~-~ptic liver. as a consequence liver oxygen consumption becomes flow dependent and the liver is likely to suffer from ischemia during septic conditions. $ although liver failure is well recognized in sepsis, it is generally thought to be a late complication following pulmonary and renal failure. jaundice, hypoglycemia, encephalopathy and bleeding secondary to low levels of liver-synthesizing clotting factors are, however, signs of rather severe end-stage hepatic failure. furthermore, elevated liver enzymes (sgot and sgpt) represent hepatucyte damage and not hepatocellular dysfunction. in view of this, a more sensitive indicator of hepatic function is desirable in order to detect early hepatic abnormality. in this respect, indocyanine green (icg) is a tricarbocyanine dye that possesses several properties which makes it particularly valuable inthe assessment ofhepatic function. this dye is bound m albumin and is cleared exclusively by the liver through an energydependent membrane transport process and is nontoxic at lower doses. we propose that maximal velocity (vm~,) of icg clearance is a valuable measure of active hepatocellular function, since the total concentration of functioning receptors is directly proportional to vm~. we have utilized a fiber optic catheter and an in vivo hemoreflectometar to continuously measure the administered icg in vivo and consequently determine its clearance without the need of blood sampling. using this technique, we have found that in the early stages of sepsis (i.e., and h following cecal ligation and puncture), the vm~ and kinetic constant (k=) of icg clearance was significantly depressed. it should be noted that at this stage of sepsis, there was no elevation in serum enzyme levels. furthermore, hepatic blood flow and cardiac output increased at the above mentioned time points. thus, the extremely early depression in active hepatocellular function in sepsis, despite the increased hepatic blood flow and cardiac output, may form the basis for cellular dysfunctions leading to multiple organ failure during sepsis. additional studies indicated that following hemorrhage, active hepatocellular function was markedly depressed. this returned to prehemorrhage levels after ringers lactate resuscitation, however, this function was not maintained and decreased significantly after fluid resuscitation. nevertheless, the depressed active hepatocelinlar function following hemorrhage was markedly improved by post-treatment of animals with either atp-mgci , peutoxifylline or diltiazem. thus, the use of icg clearance provides an early sensitive indicator of hepatic abnormality during sepsis and following hemorrhage and this method should be used, not only experimentally, but also in the clinical arena for the early detection of hepatocellular abnormality. although multiple organ dysfunction syndrome (mods) remains a major cause of mortality and morbidity in intensive care units, very little is known about the mechanisms that precipitate its development. since an episode of inadequate tissue oxygenation is considered to be the trigger for mods, we have proposed that a primary localized injury such as ischemia/reperfusion may be sufficient to cause a change of gene expression of remote and apparently unaffected organs. such modulation of remote organ gene expression may decrease the organ's tolerance to a subsequent stress contributing to the development of mofs. to test this hypothesis, rats were subjected to hepatic regional ischemia by clamping the blood flow (hepatic artery and portal venous inflow) of the left and median liver lobes. intestinal congestion was prevented by allowing flow through the smaller right and caudate lobes. after minutes of ischemia, the clamp was removed and the blood flow restored. the animals were allowed to recover for , and hours. kidneys were removed, total rna was isolated and poly(a) ÷ selected by affinity chromatography on oligo(dt) columns. message was in vitro translated using rabbit reticulocyte iysates in the presence of radioactive amino acids. the gene products (radiolabeled polypeptides) were fractionated by two dimensional gel electrophoresis, and visualized by fluorography. analyses of the two dimensional fluorograms indicate that there is a dramatic change in the electrophoretic pattern of in vitro translated products in samples corresponding to kidneys obtained after minutes of hepatic ischemia and hours of reperfusion with respect to kidney samples obtained after sham operation or from control rats. the latter were not subjected to any surgical manipulation. these studies suggest that the gene expression of the kidneys is specifically modified after a remote organ injury (hepatic ischemia/reperfusion). we speculate that this change of gene expression in kidneys after an indirect injury may be part of the early events leading to the development of mods. a priming event, e.g. local ischemia, in combination with a second insult, e.g. sepsis, may amplify a host's response and lead to multiple organ failure. to better understand the mechanisms involved in the pathophysiology, male fischer rats were subjected to min of hepatic ischemia followed by reperfusion (rp) and injection of . mg/kg salmonella enteritidis endotoxin (et) at min of rp. et injection potentiated the postischemic liver injury as indicated by histopathology and an increase of plasma alt activities from + u/l (i/rp only) to + u/l at h rp. inhibition of kupffer cells (kc) with gadolinium chloride ( mg/kg) attenuated liver injury in this model by %, however, monoclonal antibodies (cl , wt ) directed against adhesion molecules ( integrins, cd ) on neutrophils had no effect on the injury despite the substantial accumulation of neutrophils in the liver at that time ( + pmns/ hpf; baseline: + ). isolation of kc and neutrophils from the postischemic liver indicated a -fold increase of the spontaneous superoxide formation only in the kc fractions [ . + . nmol o -/h/ %elts (kc ); . _+ . (kca) ] at h rp compared to control cells. in addition, stimulation with phorbol ester or opsonized zymosan revealed a substantial priming of kc for reactive oxygen formation. in contrast to the short-term experiments ( h), the antibody wt ( mg/kg) attenuated liver injury by % at h of rp and improved survival. conclusion: liver injury during the early rp phase is mediated mainly by kc generating excessive amounts of reactive oxygen while neutrophils are primarily responsible for organ damage during the later rp period. (es- and gm- ) tumor necrosis factors (tnf) are cytokines which are cytotoxic towards some tumors in vivo and certain tumor lines in vitro. moreover, these polypeptides are powerful immunomodulators and have been found to be distal mediators in several models of septic shock and septic organ failure. one of the best-characterized experimental systems is the hepatitis caused by lps or tnf in galactosamine (galn)-sensitized mice. here we describe a cell culture system, in which the direct toxicity of tnf towards mouse hepatocytes was examined. the toxicity of tnf, as determined by ldh-release or formazan-formation, was dose-and time-dependent. the threshold of toxicity was ng/ml, which corresponds to serum concentrations found in mice after lpsinjection. toxicity was only observed in hepatocytes sensitized with transcriptional inhibiters such as galn, actinomycin d (actd) or cxamanitin. sensitization was neither observed with different translational inhibitors nor with various other metabolic inlaibitors or toxins. inhibitors of protein synthesis or protein processing such as cycloheximide, puromycin, tunicamycin and ricin protected actdsensitized hepatocytes from tnf-induced cytotoxicity. tnf induced apoptotic changes and dna-fragmentation in sensitized hepatocytes which is in line with the above findings that cell death is dependent on protein synthesis. thus tnf may be a trigger of programmed cell death during inflammatory organ damage. with the purpose of studying the role of complement activation in tissue injury after ischaemia and reperfusion we blocked the complement cascade in a model of rat liver isehaemia and reperfusion, either by administration of soluble human complement receptor type (scri), mg/kg iv after vascular occlusion (n= ) or by depleting the complement system using cobra venom factor (cvf), . mg im, and hours before ischaemia (n= ). non-ischaemic rats (n= ) and ischaemic non-treated rats (n= ) were used as controls. the experimental procedure consists of the temporary interruption of arterial and portal blood flow to the left lateral and medial lobes of the liver during minutes, followed by reperfusion, recording the liver blood flow and haemoglobin saturation with a laser doppler flowmeter and photometer during one hour after declamping; alt levels were assayed and immunoperoxidase stainings for c and c were performed. there were statistically significant differences between the experimental ~roups and the untreated ischaemic control group in terms of post-isehaemic blood flow (p< . ) and haemoglobin saturation (p< . ). c and c were present in the endothelium of the ischaemic control group. no deposits of c or c were found in the cvf group. few c and no c were found in scri treated rats. these results show that the effect of reperfusion injury in the rat liver is ameliorated either by depleting complement with cvf or by regulating complement activation with scri. hepatic dysfunction, a major cause of mortality following hemorrhagic shock, has not yet been well characterized. the present study was designed to assess the effects of liver blood flow and cytokine levels on hepatic function following resuscitation from severe hemorrhagic shock in normal and cin-hotic rats. methods: aftor pentobarbltal anesthesia, control and cirrhotic sprague-dawley rats were subjected to severe hemorrhage to reduce their systolic blood pressure to + mm hg. this level of hypotension was maintained until the skeletal muscle transmembrane potential (era) depolarized by %.; the animals were then resuscitated with ringer's lactate solution in three times the volume of the shed blood. serial blood samples for tumor necrosis factor (tnf) determination (a modified flow-cytomeuic wehi cell bioassay) were obtained at baseline, during hemorrhage and following resuscitation. liver blood flow measurements by low dose galactose clearance (glc) and functional bepatocyte mass (fhm; defared as galactose elimination capacity [gec] from the zero order portion of the plasma disappearance curve following an intravenous galactose bolus [ mg/kg], divided by liver weight) were measured before shock and after resuscitation. results: higher survival rates (p < . ) were observed in control as compared with cirrhotic rats. shock produced a significant reduction in gec (to < . ); fhm ( < . ); and liver blood flow (p < . ) in normal and cirrhotic rats. decreases in gec and fi-im were greater (p < . ) in cirrhotic rots. tnf levels were higher (p < . ) in cirrhotic rats at baseline and during induction of shock. pre gap junctions provide pathways for metabolic signals between cells. in the liver, the majority of gap junctions are composed of connexin (cx ) polypeptide subunits, and are regulated by gluconeogenic hormones. since sepsis and other inflammatory states alter hepatic glucoregulatory control, we have evaluated the contribution of gap junctional conductance to the metabolic dysregulation in the liver. an acute inflammation was induced in rats by injection with e. coli endotoxin (lps lmg/kg). northern blot/hybridization analysis of total rna isolated from livers after endotoxin injection show a decrease in the steady state transcript levels of cx to % of sham controls. immunostaining of liver sections using anti-cx revealed punctate fluorescent staining on the plasma membrane at regions of call-cell contact in saline injected animals, whereas, staining was only observed in cytoplasmic vesicles hrs after animals were treated with lps, suggesting the internalization of cx without replacement on the cell surface. the staining was quantitated and expressed as % of pixels above threshold. at hr post injection . % ofpixels exceeded threshold, compared to . % in sham controls. functional gap junctional communication was assessed by dye coupling using lucifer yellow in an isolated perfused liver under intravital fluorescence microscopy. dye diffusion was markedly decreased hr after endotoxin injection. this suggests that decreased metabolic coupling after lps injection results from decreased gap junction abundance. the present data suggest that metabolic dysregulation during sepsis may arise in part from changes in intercellular communication caused by a decrease in gap junctional expression and communication. given the marked metabolic heterogeneity of hepatocytes with respect to acinar location, metabolic signaling via gap junctions most likely serves to moderate this heterogeneity, contributing to a coordinated metabolic response. altered cellular ca ÷ regulation might be a critical step in organ dysfunction during sepsis and ischemia/reperfusion events. the aim of the present study was to evaluate hepato-ceuular ca ÷ regulation in isehemiah'eperfusion after hemorrhage and to assess effectiveness of tnfc~-monoclonal antibody (tnfo~-moab). methods. male sprague-dawley rats ( g, n>_ /group; pentobarbital mg/kg) with hemorrhage for rain at mm hg. reperfusion by ringer's lactate ( x maximal bleed out/ min) and % of citrated shed blood. tnfcz-moab (tn , ceutech, mg/kg in . % nac ) infused during flrst min of reperfusion. at baseline, end of ischemia and min of reperfusion, hepatecyte isolation by liver collagenase perfusion. " hepatocyte incubation ( mg w.w./ml) with caci ( . + + + mbq/ml) for rain (ca influx [slope, /mini; ca uptake [nmol ca /mg protein]) w/ and w/o epinephrine (epi, nm). hepatecyte resuspension in radioisotope-free medium and farther incubation (exchangeable ca + (ca +ex) [nmol ca +/mg protein]; ca + membrane flux [nmol ca +/mg protein'min]). during incubation, aliquots ( ~tl) were centrifuged through oil/lanthanum gradient and acivity measured by scintillation counting. statistics: anova. mean + sem. results. hepatocyte ca +ex and membrane ca + flux were significantly increased at both, the end of ischemia ( . +. ; . +. ) and reperfusion ( . +. ; . +. ), as compared to sham-operated animals ( . +_. ; . +. )( <. ). tnfc~-moab treatment significantly prevented reperfusion-induced increase of ca +ex ( +. ) and membrane ca + flux ( . +. )(p<. ). fast ca + influx was significantly increased by epinephrine in hepatecytes from sham-operated rats ( . +. vs. epi: . +. , p< . ). this hormone effect was not observed in isehemia ( . +. , epi: . !-_. ) or reperfusion (untreated: . +. , epi: . +. ; tnft~-moab: . _+. , epi: . +. ). conclusion. the present study clearly demonstrated hepato-cellular ca + overload in ischemia and reperfusion as a result of hemorrhagic shock. analysis of membrane ca + fluxes and hormone ca + mobilization suggests disturbances of membrane ca + transport mechanisms, e.g. through ca +-atpases. reperfusion-induced oxygen free radical generation which affect exchange kinetics of cellular ca + buffering compartments might also be operative. prevention by tnfct-moab indicates the pivotal role of tnf as an early inflammatory mediator of hepatocellular alterations in signal transduetion mechanisms and cellular homeostasis. although the precise mechanism has not yet been elucidated, bacterial translocation and endotoxin absorption have been frequently shown after burn, and have been postulated to be one of the underlying processes of sepsis. the purpose of the current study is to define the hemodynamic response of the liver to endotoxin release in burns, in correlation to bacterial translocation. twelve female minipigs, weighing - kg, underwent a laparotomy & transition time ultrasonic flow probes were positioned on the portal vein, the common hepatic artery, and the superior mesenteric artery. . fr catheters were inserted in the superior mesenteric vein and the left hepatic vein. a jejunostomy was also performed. after five days all animals were anaesthetized and randomized to receive % of tbs a third degree burn. eighteen hours after burn. gg/kg e. coli lps was intravenously administered over rain. ali animals were studied for additional hours and then sacrificed. several recent data suggest that in severe injuries, such as shock state, the gradual activation of kupffer cells and the excessive release of destructive and immunosuppresive products from macrophages may contribute to the development of "multiple organ failure". in in vivo experiments in mice, the effect of kupffer cell phagocytosis blockade on the correlation between the tissue distribution of lps, endotoxin sensitivity and lps-induced tnf production was investigated. to depress the activity of the kupffer cells, gadolinium chloride (gdc ) or carrageenan was used. th~e studies indicate the dissociation of tissue localisation of cr jllabelled endotoxin and endotoxin lethalithy. both gdc and carrageenan depressed kupffer cell activity, but endotoxin sensitivity was enhanced only by carragenan treatment. however, there was a close correlation between the sensitivity to lps and lps-induced tnf production as measured in the serum, since lpsinduced tnf production was enhanced only by carrageenan treatment. on the other hand, gdc pretreatment significantly increased tnf production in the spleen. these results support our earlier findings that gdc -indueed kupffer cell phagocytosis blockade leads to activation of the spleen, and may explain some of the immunological effects of gdc . inositol(l, , ) triphosphate (ip ) has been proposed as a second messenger for calcium mobilization. the addition of ip at low concentration has been shown to cause calcium release from intracellular microsomal store in rat hepatocytes. the effects of sepsis on the ip binding from microsomal fraction of rat hepatocytes during sepsis were investigated. sepsis was induced by cecal ligation & puncture (clp). control rats were sham-operated. three microsomal fractions (rough, intermediate and smooth) were isolated from rat liver. study of ip receptor binding was performed with tridium label ip . the results shewed that the ip binding was significantly depressed by - % (p< . ) during late sepsis ( hrs after clp), but not in early sepsis ( hrs after clp). the ip binding depression during late sepsis was most significant on rough and intermediate endoplasmic reticulum (p< . ), but not on smooth subfraction. since ip binding plays an important role in the regulation of intracellular calcium homeostasis in hepatocytes, an impairment in the calcium release due to depressed ip binding on smooth and intermediate endoplasmic reticulum during late sepsis may have a pathophysiological significance in contributing to the development of altered hepatic metabolism during septic shock. septic organ failure is currently recognized as an overactivation of the nonspecific immune system by bacterial stimuli giving rise to proinflammatory mediators. little is known about the mechanisms of the resulting cellular injury. here, a synergism is described between tnf as a major mediator of septic organ injury released by macrophages and hydrogen peroxide (h ) as a representative of reactive oxygen species as formed by e.g. neutrophils. rat hepatocytes are only slightly sensitive to either agent alone. when treated with a conbination of tnf and h# a stronq synergistic toxicity was found, especially w~e~ tnf-treatment preceeded challenge with h~o~. we have recently described a coculture model bfzrat liver macrophaqes and hepatocytes where lps induces hepatocyte cell death partially mediated by macrophage tnf release. when h was also employed in fhis more complex cellular system a similar synergism was found: the ecc~ of lps was consecutive patients with liver cirrhosis admitted to the department of surgery over a year period from january to december were studied for their complement profiles in relation to other parameters of liver function, the aim of the study was to determine if a direct correlation existed between low complement levels and end stage liver cirrhosis. cirrhotic patients were divided into child's a, b and c categories using child's classification. complement levels (c , c ) were measured and functional assay for complement (ch ) were performed in each of these groupings in addition to normal blood donor controls. these results show that the qualitative c , c and the functional chs complement assays have good predictive values in assessing deteriorating liver function• in particular, the functional assay for complement (ch ) showed marked impairment in child's c patients (p< . ) confirming the impaired immunological status of these patients. sera from this group of patients (child's c) were titrated with pig red blood cells (rbcs) in a haemolytic assay. the results showed that there were significantly less haemolysis of pig rbcs in these patients (p= . ) as compared to the controls. this findings strongly support an impaired immunological status in child's c liver cirrhosis and may explain the high incidence of sepsis as a terminal event in these patients. aim:kupffer cells(kc) have an importamt play to cause hepatocellular injury in sepsis, because these cells release many kinds of substances. we reported that oxygem radicals released by kcs stimulated by lipopolysaccharide (lps) caused hepatocellular injury. aim of this study is to investigate the relationship between imtracellmlar calcium(ca) concentration of cultured rat kcs stimulated by lps and release of oxygen radicals, and effect of prostaglandin e~ (pge~) on imtracellular ca concentration. production of acute phase proteins (c-reactive protein, crp, transferrin, tf) and £erritin (f) in rat hepatocytes (hps) and its dependence on extracellular matrix components were studied. hps isolated from the liver by collagenase perfusion were cultured at ~o per . ml medium fi +dmem ( : ) with % fetal calf serum for days on uncoated or type i collagen coated plastic surface or in the presence of dextrane sulphate in the medium. hps were stimulated by conditioned medium (gm) from i~ia-p or e. coli lps preineubated human blood mononuclear cells. production of crp, tf and f by hps was detected by elisa. it was found that both cms decreased tf synthesis in hps by - % (p<o.os). the level of f synthesis didn't change or only slightly decreased. the addition of cms led to the enhancement of crp synthesis more than . times. the most reproducible results were obtained when plastics had been coated with collagen. dextran sulphate markedly increased crp synthesis. thus using this model of an acute phase reaction in vitro we found the enhancement of crp synthesis and the decrease of tf synthesis. our data correspond with nublished materials on the acute phase in vivo and point to relevance of the proposed model. metabolism of hepatocytes under traumatic illness has not been sufficiently investigated. therefore we have applied absorption and fluorescent cytophotometry techniques to study the content of rna, glycogen and its fractions in hepatocytes of patients with severe mechanical trauma, both with and without endointoxication at various stages. for these purposes slides were prepared from the repeated aspiration biopsy material according to special techniques (kudryavtseva et al., ) . slides were stained by gallocyanin-chromalum to measure rna or underwent fluorescent pas-reaction to measure glycogen and its fractions (kudryavtseva et al., (kudryavtseva et al., , the ability of metabolites derived from the xanthine-xanthine oxidase system to inhibit mitochondrial function was examined using freshly isolated rat liver mitochondria. under uncoupled conditions, mitochondria exposed to free radicals exhibited a significant decrease in consumption supported by nad+-iinked substrates, but showed almost no change in consumption in the presence of succinate and ascorbate. the activity of electron transfer complex i (nadh oxidase and nadh-cytochrome c oxidoreductase) and the energy-dependent reduction of nad+ by succinate were unaltered by oxidative stress. exposure to free radicals also had an uncoupling effect at all three coupling sites. the degree of mitochondrial swelling was closely correlated with the inhibition of state oxidation of site i substrates and with the increase in state oxidation of succinate. the immunosuppressive agent cyclosporin a (cya) completely prevented the mitochondrial damage induced by oxygen free radicals (swelling, ca + release, sucrose trapping, uncoupling, and selective inhibition of the mitochondrial respiration of site i substrates). the same protective effect was found when ca + cycling was prevented, either by chelating ca + with egta or by inhibiting ca + re-uptake with ruthenium red. these findings suggest that the deleterious effect of free radicals on mitochondria in the present experimental system was triggered by the cya-sensitive and ca ÷-dependent membrane transition, and not by direct impairment of the mitochondrial inner membrane enzymes. correspondence should be addressed to: naoshi takeyama the aim of this study was to clarify the critical role of reduced glutathione (gsh) on the progression of lipopolysaccharide (lps)induced liver damage of mouse. the conditions of gsh-depletion and -richness were produced by intraperitoneal administration of buthionine sulfoximine (bso), a specific inhibitor of gsh synthetase, and of gsh-monoethyl ester (gsh-me), respectively. gsh-me, which was esterified the caboxyl group of the glycine residue, is readily transported into cells and is hydrolyzed intracellularly; this leads to greatly increased the cytosolic and mitochondrial levels of gsh. bso and gsh-me were administered intraperitoneally mmol/kg and mmollkg, respectively, and lps ( mg/kg) given h later. hepatocytes were isolated by in situ perfusion of the liver with collagenase h after lps injection. the degree of hydrogen peroxide (h ) synthesis and mitochondrial membrane potential were measured by flow cytometry using fluorescence probe dichrolofluorescein diacetate and tetrametyl rhodamine ethyl ester, respectively. the degree of mitochondria membrane permeability transition (mmp) was assessed by [ ]sucrose entrapment. we found that lps treatment results in a decrease in hepatic gsh level and mitochondrial membrane potential, and an increase in h synthesis and mmp. lps administration to bsq-pretreated mouse worsened at[ these parameters. in contrast, gsh-me pretreatment ameliorates. all together, gsh may acts an important role in cellular defence against lps-mediated liver damage, and mmp may result in the decrease in mitochondrial membrane potential. it has been shown, up to now, that disturbances of enzymatic processes in the cell organella are the basic factor of the changes taking place during endotoxin shock it has been observed that lysosomes are biochemically changed as result of the effect of lipopotysacharides of gram negative endotoxic bacteria. the purpose of the experiment was: .evaluation nfthe course of the ees due to the biochemic changes .determination of the influence of the ees on the activity of lysosomal enzymes in liver cell .deterrmnatian of the influence of h and d on the activity of some lysosomal enzymes in liver cell during ees material and method: examinations ware carried out on dogs. the shock was evoked by i.v. administration of endotoxin e.coli. the dogs were divided into groups: icontrols, i[ -dogs with untreated shock, iii-dogs in shock treated with h, ivdogs in shock treated with d, v -dogs in shock treated with h and d. the following parameters were determined: .activity of acid phosphatase in the venous blood serum. - .total and free activity of acid phosphatase and catepsins in the full liver cell homogenate, in mitochondrial-and-lysosomal fraction, and in the superuatunt (all after hours of the experiment). conclusions . essential increase of activity of lysosomal enzymes was observed in the ees. . increased activity of lysosomal hydrolases in the liver cell homogenate corresponds, as a result of the endotoxin effect, with increased enzymatic activity in the peripherial blood. extensive investigations from our laboratory of the pathophysiology of hepatic no-flow ischemia ( min) -reperfusion injury demonstrated substantial kupffer cell activation with reactive oxygen formation during the first few hours of reperfusion as indicated by increases in plasma glutathione disulfide (gssg) levels in vivo (am. j. physiol. : g , ) and enhanced superoxide formation by kupffer cells (kc) isolated from the postischemic livers (free radic. res. commun. : , ) . the early kc-induced injury initiated the later, primarily neutrophilmediated reperfusion injury (faseb j. : , ). to test whether or not similar mechanisms are operative during hepatic ischemia induced by hemorrhagic shock, male fischer rats ( - g) were subjected to rain of hemorrhage (mean arterial pressure mm hg) followed by resuscitation (rs) (reinfusion of shed blood). hepatic atp levels declined from . + . txmol/g to . _+ . ( min shock) indicating severe ischemia, and recovered to . -- . at min rs. to test for potential oxidant stress during rs, plasma gssg conc. were measured. although gssg levels increased by % compared to baseline levels ( . !-_ . i.tm), there was no significant difference to shamoperated controls. spontaneous superoxide formation of isolated kc was . + . nmol o -/min/ ecells (kc ) and . + . (kc ) in controls and did not change significantly after shock and rain rs. addition of phorbol ester or opsonized zymosan to isolated kc did not indicate a priming of these cells. conclusion: in striking contrast to our previous findings with hepatic no-flow ischemia, there is no evidence for a significant kc activation after min of hemorrhagic shock and up to rain of resuscitation. objectives-this study investigates morphometric changes in kc nltrastmcture which might account for this diminution in phagacytosis. materials and methods -three groups of wistar rats were studied: control, sham-operated [sham] and bile duct ligated [edl] . after weeks animals were sacrificed and livers were "perfusion fixed" with % glntaraldehyde and processed for transmission electron microscopy and image analysis. results -in the the bdl group kupffer cell numbers were greatly increased. biliary ductular proliferation was evident and sinusoidal spaces were compromised. eleven nuclear and cytoplasmic parameters were measured and statistically significant results are summarised in the results: ascorbic acid levels were slightly elevated after the hs and returned to basal values after rain. glutathione concentrations were increased significantly after the hs and the gsh levels kept rising continuously to as much as -fold of basal levels at the end of min. mda showed no significant variation before and after the hemorrhagic shock. plasma concentrations of ratine, teucine, isoleucine, phenylalanine, proline, threonine and serine showed significant increase over basal levels during the whole ischemic period. glutamic acid was slightly elevated at the onset of hs and remained the same for the rest of ischemic period. hydroxyproline was significantly below the basal value at the mid-point of ischemic period. alanine, glycine, histidine and aspartate did not change significantly throughout experimental time course. conclusions: ( ) oxidative stress might not be severe in the systemic hemorrhagic shock for pigs since no significant variations were observed for ascorbic acid and mda ( ) the increase of gsh might be that it was released from hepatocytes when the animal was under systemic ischemia. ( ) celzain amino acids might be acting as transmitters in the event of ischemia. however, fm"lher investigations are needed to clarify the detailed mechanism in regard with antioxidants and amino acids. dr. fang-ku p'eng taichung veterans general hospital talchung, taiwan , r.o.c. jia shi yong, huang zhi oiang and men xian jun. in patients underi~ent major hepatic surgery,obstructive jaundice has been implicated with fnoreased susceptibility to sepsis and liver failure. jaundice was said to he associated with derangement of iamune function and result in expression of pr,:.inflar...aatory cytoki~es that cause hepatooellular damage. this study is ~.o investigate the effects ,.,t lip,~polysaccharide(lps)rats. jaundice were produced in healthy ~istar rats of either sex weighing - m~ by common hi l~ duet l igation(bl)l).seven days post l igation, rats were given lps( .gg. ) . rag/kg intraperitoneally. at the end ,:,f l,gand hours after lp$ ehanllenge, liver were removed and prepared for forzen sections immediately. i)emonstration of inf in liver parenchyna were performed by method of abu i~munohistochemistry using r~onoolonal antibody against tnf, leve of mrna for tnf ~ere measured by in-situ hybridization using biotin-labeled edna probe. results sho'~ed that tnf stained granules appeared in kup~'fer eell~ and polymorphonuclear leukocytes(pnnl,but not in hepatoeytes nor endothelial eel is. they ~'ere located within cytoplasms and peaked at - hours after lps ohal lenge. there was vocomitant tnfmrna expression but peaked earlier hour post lps challenge. tnfmrna vcere detected notably in necrotic area and barely in bdl rats ~ithout lps challenge. it is therefore postulated that production of tnf by inflammatory effeetor cells-kupffer cell and phn in site, in the obstructive jaundice rats during sepsis may atribute to the hepatocellular damage. it also provide evidence for the beneficial effects of early release of biliary obstruction. in the present study, an animal model of a c in wlstar rats was developed by tigatlng the common bite duct and injecting d. mt solution of e. goli % b, (g× ' efm/mt) into the bite duct. the mortality rate was ~ at h after aoc. at , , , h after aoc, kcs were isotated and cultured atone or cocuttured with hepatocytes to evaluate the modulation effect of kgs on hepatoeyte protein synthesis. the results showed that tactodehydrogenase leakage was increased progressively as the injured k~ function and structure developed. tnf and il-i tn the supernatant were detected with the peak values at h after aoc. at h after aoc, ~-teueine incorporation was obviousty decreased in the normal hepatocytes eocuttured with stimulated kcs compared to the uormai hepatocyte cultured group (p< . ), but it was slgnificantiy increased in the group cocultured with normal kcs. in the a c group, 'h-teuclne ineorporatien was decreased progressively in the injured hepatoeytes cocuttured with stimulatedkgs and it was markedly elevated when cocuttured wlthnormat kcs at h after a c (p< . og). it is concluded that the impaired hepatocyte proterin synthesis was directly mediated hy the stimulated kc function during aoc. such a mechanism possibly may be involved in the patho ensis of hepatic dysfunction and m f following h . " the project supported by nsfc. in the past few years it has become evident that cytokines are implicated in various pathophysiological mechanisms. therefore measurement of cytokines and their potential inhibitors in biological fluids may be helpful in diagnosing and monitoring of diseases. however, dependent on the type of assay used investigations performed in different laboratories have often yielded conflicting results. in order to assess reliability and reproducibility of cytokine measurements two comparative studies for the determination of cytokines in biological fluids were launched by several investigators interested in this field: one national austrian ~tudy and one european study in the context of the european workshop for rheumatnlogy research. serum and synovial fluid samples were distributed by the organisers, and participants had to measure one or several of the following cytokines in all samples: il- , il- , l- , i , tnf-alpha, ifn-gamma, gm-csf, and the soluble receptors for il- and tnf; both commercially available immunoassays and home-made assays were allowed. so far, the main conclusions emerging from these preliminary studies are: ( ) the same immurzoassay (elisa) yielded comparable results in different laboratories; ( ) immunoassays from different manufactureres usually measured the highest concentrations in the same samples, yielded similar relative values but disparate absolute values; ( ) assays for soluble receptors yielded less discrepant results; ( ) some assays seem to be more suitable for measuring cytokines in biological fluids than others. the mean retrieval of exogenous recombinant human cytokines was approximately % for most cytokines tested. however, it must be borne in mind that natural and recombinant cytokines may behave differently in immunoassays. this raises the question as to the necessity of setting up international standards for all cytokines. possible interferences by serum components such as (lipo)proteins, complement, rheumatoid factors, etc., which may either decrease assay sensitivity or yield false positive results, must also be considered. in addition, natural cytokine binding proteins (e.g. soluble receptors) might interfere with cytokine determination in immunoassays. the problem of immunoassays versus bioassays has not yet been approached, but is without any doubt worth indepth investigation. thus, these studies are a promising first approach to deal with the difficulties of cytokine analysis in biological samples, and it is hoped that they will help to overcome some of the major methodological problems in the near future. tumor necrosis factor (tnf) is a pleiotropic cytokine which plays a key role in a number of immunologically mediated disorders like septicemia or cachexia. tnf receptors are found on the surface of a variety of cells, where they provide molecular signals for the cytokine effect. there exist two types of soluble tnf receptors (stnf-rs), tnf-r p and tnf-r p . these stnf-rs can compete with the cell surface receptors and block their activity. the expression on and shedding from the cell surface of stnf-rs is enhanced by interferon gamma. increased concentrations of stnf-rs can be found in patients with infectious as well as malignant disorders. in patients undergoing immune stimulatory therapy with interleukin- and interferon alpha a simultaneous increase of tnf and its soluble receptors can be seen. in patients with hiv infection a strong correlation exists between the levels of stnf-rs and markers of immune activation like neopterin or beta- -microglobulin. likewise patients with hematological disorders show elevated stnf-r levels. patients with weight loss have higher concentrations than patients with stable weight. the final value of stnf-rs within the complex network of cytokines is not yet clear. however, there exist striking parallels between infectious and malignant disorders pointing to a key role of endogenous immune activation. biochemicatly, d-erythro-neopterin derives from guanosine triphosphate. in vitro studies show that large amounts of neopterin are produced by human monocytes/macrophages stimulated with interferon-j (ifn-j). neopterin is biologically stable, and its halflife in the blood seems to solely depend on renal excretion. specimen for neopterin determination can be stored without special precautions. increased concentrations of neopterin have been described in body fluids of patients suffering from diseases which are apparently associated with an activated cellular immune response and with enhanced endogenous formation of ifn-~', e.g,, ) increasing neopterin levels predict rejection episodes in allograft recipients ) virus infections induce increased neopterin concentrations, and the degree of neopterin elevation predicts prognosis in these patients which is particularly true in hiv- infection ) in autoimmune disorders such as systemic lupus erythematosus or rheumatoid arthritis neopterin levels reflect activity of the disease ) increased neopterin concentrations in patients suffering from certain types of cancer indicate poor prognosis. significant associations between changes of neopterin and decrease of hemoglobin as well as the development of weight loss and cachexia, e.g., in cancer patients and in patients with hiv- infection, support the concept that endogenously formed cytokines such as ifn-~" and tumor necrosis factor-~( are involved in the pathogenesis of such symptoms. in conclusion, neopterin monitoring is a sensitive tool to detect the activation status of the cell-mediated immune system in vivo. repair and healing or perpetuation of acute inflammation is characterized by a complex network of interacting cellular and humoral defence mechanisms. of the numerous inflammatory mediators/effectors investigated hitherto, the proteolydc lysosomal enzyme pmn elastase has turned out to be highly destructive when released extracellularly thus contributing considm:ably to organ dysfunctions in severe posttraumatic and postoperative courses. besides various cytokines, elastase in complex with its main antagonist c¢ -proteinase inhibitor (a pi) is also supposed to induce the shedding of intercellular adhesion molecules from inflammatory cells (pmns, monocytes/macrophages, endothelial cells). these soluble adhesion molecules may modulate the inflammatory process in many different ways, e.g. via acting as chemotaxins, blocking neutrophil activation or competing with the membrane-bound forms in cell-cell adhesion. thus, measuring circulating or local levels of elastase-a pi and soluble adhesion molecules (icam, e-selectin,-pselectin, l-selectin) may be a helpful tool in judging the severity of an acute inflammatory process. in several clinical studies on surgical patients suffering from multiple trauma and/or sepsis we could demonstrate that the measurement of these parameters in consecutive plasma samples and local body fluids was highly valuable for early diagnosis and prognosis of multiple organ failure. prof. dr. m./ochum, institut fdr klinischechemie und biochemie, lmu miinchen, nufibaumstrage , m nchen, germany procalaitonin (proct) a aa peptide is dramatically increased in the blood of patients with various sepsis and infections. the increase begins as soon as hours after the andoto:edn release and readied maximal level with a to b-fold increase h after li~ edrmrdstration. prcc, alcitorfin response was temporally different from these of tnf~ and ii- , that reached peak levels at h and h respectively. at the opposite of eytokine (tnfcz, ild, j, is), proct is a very stable molecule. the half iife of proct in ~he blood is surprising if we consider the half llfe (about nine mirtute) of mature ¢alcitonin (co. we have found that it is due to the binding of proct with a protein on the n-termktal part. thin complex of about daltons is unable to cross the kidney and the c_n barriers and the half life is at least elghteen hours. this long half llfe is very useful in the evaluation of a sepsis. a very sensitive and specific sandwich in'ununoassay has been developped. the results cart be delivered in two hours. at time, we know that in the healthy adults, the values are less thau . ng/ml. it is also clear that proct is not increased ~n patients wlth inflammatory dleeasea without lnfectlon. for instance, proct is not signlffcat vely increased in purpura rhumatom, arthritis, crohn's disease, rectocolitis, also in various cancer patients with inflammatory components. am other interesting finding, is the absence of increase or a very low increase in the viral infections. at the opp site, in all the patients with bacterial sepsis or in the malaria pat/ants, progt was dramatically increased, from i to fold. p~oct can be useful to the follow up of patients with sepsis. actually, we don't know the origin of this proct production, in the united states, will also be discussed. the septest portion of this study will eventually enroll over patients tentatively diagnosed as septic. the results of septest will be compared with commonly accepted symptoms and criteria associated with sepsis in order to determine the clinical utility of this endotoxin assay. preclinical results of patients and normals be presented as well as data on the time course of endotoxemia and clinical outcome of selected septic patients. preparation of dna libraries clifford w. schweinfest, ph.d. a fundamental tool of the molecular biologist today is the ability to work with purified dnas representing genes of interest with respect to the investigator's field of study. originally applied almost years ago to the genetic dissection of simple organisms such as viruses and bacteria, molecfllar cloning was rapidly applied to study the more complex genetics of the mammalian cell. today, virtually any study of cell physiology which depends upon specific gene expression is approachable using the tools of the molecular biologist. therefore, stress induced gene expression (such as the heat shock gene, hsp ) or the regulation of the nitric oxide synthetase gene or the induction of cytokines and growth factors as a result of trauma or injury lend themselves to investigation at the level of the gene. during these workshops, we will discuss the means by which cdnas and genes are isolated, amplified and identified. we will discuss the strategies and methods for cloning cdnas and genomic dnas, for organizing such cloned libraries, for finding specific genes and for characterizing those genes. this speaker will focus on the techniques and considerations involved in the synthesis of cdna libraries. topics include rna isolation, mrna quality, reverse transcription, choice of cloning vectors and library quality. genomic dna library synthesis will also be discussed with respect to the vector/host systems available and applications which are specific to genomic dna. finally, polymerase chain reaction (pcr) will be discussed briefly with regard to its impact on dna cloning. the identification of the genes or gene products that have a role in cellular processes is fundamental to our understanding of genetic control and methodologies to achieve this aim are currently available. all levels of the various signal transduction pathways can b~ molecularly analyzed to define the mechanism by which critical steps in each pathway are achieved. the questions that are unresolved in each area of investigation serve to direct the scientist towards analyses of gene products or gene regulation of the gene itself. thus, selection of the type of library (genomic or cdna) to be used is dependent upon the specific goals of each investigator. to facilitate resolution of this question, an overview of the uses for the different types of libraries will be presented. at least four methodologies are currently available for screening a library, which are dependent upon specific interaction between nucleic acids, nucleic acids and proteins, antibodies and antigens or between different proteins. the use and advantages of each of these methodologies will be discussed along with a description of probe preparation. sequence methodologies required to begin characterization of gene clones will be presented. hopefully, the participants in the workshop will help define areas of emphasis and allow time for directed interaction to discuss specific applications based upon their own experimental systems. alterations of physiological conditions, such as those occurring after shock and sepsis, induce changes in gene expression of cells composing the major organ systems. the challenge is to detect and characterize these changes in geae expression and relate them to the injury. the development of cloning techniques has emerged as the methodology of choice. changes in gene expression are usually characterized by variations in the concentration of cellular messages because synthesis of the final product "the polypoptide" is usually proportional to the concentration of mrna. due to the rapid regulation of gene expression the cellular concentration of messages changes very quickly. this is commonly referred to as steady-state levels, a balance between transcription and degradation. steady-state levels of mrna can be detected in a single cell (in situ hybridization) or in total rna isolated from cells or organs and separated in agarose gels (northern blots). although analysis of mrna steady-state levels are very useful, they do not provide information about the mechanisms that regulate gene expression. changes in gene expression primarily occur at the level of transcription; characterization of the rna species being synthesized at a given time is performed by the nuclear run-off technique. when there is no a priori information about the gene that may be regulated after a particular situation such as sepsis, the total pool of messages present in cells at given time can be characterized by a combination of in vitro translation of the cellular messages and fractionation of the in vitro translated products by two dimensional gel electrophoresis. such approach permits the visualization of the general pattern of gene expression, a "finger print", of the physiologic state. in summary, researchers now have access to a great variety of techniques to identify and characterize genes expressed in response to a physiological condition that may be utilized as "molecular tools" to study the organism's responses to shock and sepsis. the acute phase proteins are a set of plasma proteins with greatly increased plasma concentrations during acute inflammations and after tissue trauma, e.g. after major surgery. the proteins counteract the source of injury, facilitate clearance of infectious particles by phagocytes, assist immune responses and initiate wound healing. the corresponding genes are expressed in liver hepatocytes and regulated by the inflammatory mediators interleukin and interleukin (ill, il ). class acute phase genes are mainly controlled by ill and by combinations of ill plus il ; class genes mainly by ii, . the human c-reactive protein(crp), serum amyloid a(saa) and complement c genes will be discussed as examples of class genes, and rat c~ macroglobulin as a prototypical class gene. both classes of genes use different types of ¢ytokine response elements in their promoter-proximal transcription control regions; class genes use the transcription factor nf-il or c/ebp as the key factor to mediate cytokine responsiveness; class genes use a different, so far unidentified factor to achieve responsiveness to il . ongoing efforts to purify this factor, called the il -response factor (il -rf), from rat liver nuclear protein extracts will be described. the il -rf apparently mediates the effects of il in a broad range of cell types, including b lymphocytes and other hematopoietic cells. it is therefore likely to be of equal general importance for gene regulation by il as nf-il . the importance of transcription factors as potential targets for novel bioactive substances and possibly therapeutic agents will be discussed with the help of several recent examples. new methods for altering the germ lines of mice provide powerful tools for understanding the roles of individual genes in normal and pathological processes, and for reproducing specific genetic mutations that result in congenital disease. three approaches will be discussed. conventional transgeulc mice are frequently constructed using artificial transgenes that express genes from a promoter other than the normal gene promoter. this paradigm is used to produce very high levels of a gene product, for example, with a viral promoter, or to attempt to regulate gene expression using an inducible promoter. alternatively, normal promoter sequences can be hooked to a gene whose expression is lethal to the cell (e.g., diptheria toxin a chain) to ablate all cells expressing that gene. another approach uses an intact gene with its normal regulatory sequences. here, an elevated level of the gene product is delivered from the correct cells in the correct tissues at the correct developmental stages or in response to natural signals. this approach has been refered to as "genetic pharmacology," and provides a precise delivery of the gene product to the target. however, to be most effective, the transgene should contain arl regulatory sequences as welt as the entire genomic segment containing gene coding regions. the introduction of conventional transgenes is limited to roughly kilobases, while genes containing all regulatory sequences frequently stretch over dozens or even hundreds of kilobases. to overcome this problem, procedures have been developed recently to introduce yeast artificial chromosomes (yacs) into mouse embryonic stem (es) cells. yacs can include over mb of human dna, large enough to encompass the largest known human genes. es cells are also useful for targeted gene deletions and mutations. homologous recombination can be targeted to any known gene in es cells. when these modified cells are injected into a mouse blastocyst, they can be incorporated into all tissues of the resulting mouse, including germ cells, so subsequent generations will pass the genetic modification as an inherited trait. assessment of the effects of a null allele on development can provide valuable insights into its normal role. ultimately, these technologies may be adapted to human cells -not for embryonic intervention, but to provide modified stem cells for various tissues (e.g., gut, eye, hematopoietic system) which could then be applied to somatic therapies. with major illness/injury that respirswy faihne fi'equently followed sepsis, tilney el al nse, d the term "soqueutial syste~ failure" for patients with renal failure after solmir of ruptured abdominal aortic ~aeurysms, i then reviewed our experiences after inju~ and oporstion and suggested that multiple, progsesslve or sequential systems or organ failure was a syndrome to be reckoned with in the, 's. eiseman et al then wrote about "multiple organ failure", especially with liver failure. polk el m found that renmte orgau failure often signalled occult anita-abdominal infection. fry et al ampbasized the role of uncontrolled infection in organ failure, border et ai described metabolic alterations with mof and used the term multiplesystems organ feilmo (msof). other early conltibutots to our knowledge of mof include faist, trunkey and miller, marshall and dimic&, cassone, catlleo, meakins and marshall, (}otis et at., mater and many others. mof or msof were used eommoifly. cerra coined the terms "post-trsumatic septic sfndromc" and "hyper metabolism otgau failure complex", and border et al, used lhe ex ~ression "gut origin seplic states" to illdioate important eurrem aspects of abe gt.'nerlc problem of organ failure and death, other terms include acute organ-system failure, multiple organ injury syndrome, post-traumatic multi-system organ failure nod post-~aumatic organ system infection s~dmmc (fi~sis), i bdieve the latin "maltiple organ failure" is clean, neat and says it all, now there is a proposal for a new set of torminolugios -mods and sirs. will they be helpful in the study and esro of patients? our speakers in this session will review thcsa proposals and the evidence as we strlvo for eoasensns. it has been well demonstrated that the administration of pro-inflammatory cytokines, and especially tumor necrosis factor (tnf) can result in a picture similar to septic shock with secondary multiple organ failure. it is also clear that tissue hypoxia can lead to organ damage. we believe that it is the interaction between the two phenomenons that can lead to mof. on the one hand, the inflammatory response is amplified in the presence of hypoxia. on the other hand, the release of the mediators of sepsis can increase tbe oxygen demand ef the tissues, alter their oxygen extraction and decrease myocardial contractility, and the combination of these elements accounts for the development of septic shock. this hypothesis is supported by two lines of evidence. first, mof is usually preceded by an episode of acute circulatory failure (even though frank circulatory shock may not be evident). second, recent experimental and clinical studies indicated that immunotherapy (especially antibodies to tnf) is particularly effective in the most severe forms of sepsis, associated with circulatory shock. hence, an effective way to prevent mof may be a combination of aggressive cardiovascular management and immunotherapy. development of the multiple organ dysfunction syndrome (mods) in the critically ill follows an heterogeneous group of stimuli including infection, sterile inflammmion, extensive tissue injury, ischemia, intoxication with a variety of substances, and immune system activation. whether the resulting physiologic abnormalities reflect a common pathologic process, or are simply a non-specific manifestation of tissue injury is unknown. moreover, the lack of clearly-defined functional criteria for the characterization of the syndrome on the one hand, and of reliable biochemical markers of its evolution on the other, has made attempts to define its epidemiology and natural history difficult. using a numeric scoring system to quanfimte the clinical severity of mods, we demonstrated that, although mods is more common in patients who have significant infection at the time of icu admission, a much stronger correlation is evident between the severity of mods and the subsequent development of nosocomial icu-acquired infection. furthermore the severity of mods correlates strongly with the severity of the clinical septic response, and with the degree of immunologic compromise evident on delayed type hypersensitivity skin testing. to determine the relative importance of the initial stimulus, and the host response to that stimulus, to the subsequent emergence of mods, we undertook a matched cohort study of critically ill patients admitted to the icu with infection, matched by age, sex, and apache ii score to uninfected controls. organ dysfunction scores were higher in patients admitted with infection, but were also significantly associated with the expression of a septic response at the time of icu admission, independent of the presence of infection. by stepwise regression analysis, the magnitude of the septic response was the most powerful predictor of the severity of mods in both infected and uninfected patients. these data suggest a model of mods in which a stimulus (eg infection) and the host response to that stimulus (eg the septic response) result in a state of altered systemic homeostasis (manifested in this example by immunologic dysfunction). moreover they suggest that the principle determinant of the emergence of mods is the response of the host, rather than the nature of the stimulus, and are consistent with the hypothesis that a stereotypie systemic response to an heterogeneous group of injurious stimuli underlies the pathogenesis of mods. arthur e. baue, m.d, ever since the attorapt build the tower ef babel, as desclibcd in the old testament of the biblc, it has been difficult to got agreement o;x common definitions or language, although mof has served well, there will always he now classifications proposed with good reasons for them, thus mods and sirs are not the final oxpressinns in the lexico~aphic sweepstakes. attcmpts to develop standard animal shock and scpsis models (hemorrhage, endotoxin, foes[ pellets, cecal ligation and puncture, e. colt hlf sioi to evaluate therapy have net been suoca.ssf~. clinical syndromes of mof, sepsis, sepsis syndrome and athers have not been aeacpte.d by all. our problem is that we arc tryittg tu d¢ffino a non-emily. mof or mods or sirs is net a disease or oven a syndrome. it is a series of complications of injury, disease and intensiva care which loads to death for many patients in intensive care units, it is not a fixed entity, but an ewilving picture. we have lumped (ugethet for therapy and definition a number of diseases and problems according to clinical manifestatieos rather than the eause of ihe problem, the search for unified mechanisms has not bean successful. will we benefit oleo from a more precise classification and definition of a non-outjty, a hodgu-podge of human disorders which have charsmeristic.s and manifestations of tissue injury, inflammation and infactian? re.hi clinical trials of potential "magle ballets" suggest that we should go in a different direction--instead of lumpors, we should be splitters, to seek effective therapy, we must fucus on specific disorders such as trauma, specific infections, inflammatory disease and chronic or acute organ damage (copd -renal failure, etc.), i will say more aboet this later ha the me.ethag. thcre is cue potentially important pert of the mods proposal, and that would be do~mcntation of organ dysfunction before fsiiure occurs and before tile need for external supporl dovelope. this could lead to hatter methods of preventing organ failure. preveution is ultimately the only answer to organ failure, m mof, mods and sirs. have wo reached a consensus?--only that we arc dealing wilh a diffl~x:lt probtolr looking for solutlons. acute lung injury (ali) and its most severe form, acute respiratory distress syndrome (ards) characterized by severe hypoxemia, diffuse infiltration of both lungs, a reduction of compliance and a wedgepresure lower than mm hare related to direct or indirect injury. when aliresults from direct injury (toxic agents, lung contusion, pneumonia), the lesions of epithelial barrier and the activation of lung macrophages are the first events leading to the release of inflammatory mediators wh:ch are responsible for alteration of the membranar permeability and for invasion of the alveoli by fluids, proteins and cells. an inflammatory reaction develops, with injury to endothelial cells, adhesion of polymorpbonuclear leucocytes (pmn) and the release in blood stream of intlammatory mediators dispersing the inflammatory reaction to other organs and tissues. the failure of lung function also results into hypoxia in other organs, leading to tissular ischemia, triggering an inflammatory reaction leading to organ dysfunction. frequent complications of direct lung injury are septic pneumonia with endotoxin release, phagocytes activation and cytokine production disseminating inflammation. by this way, direct lung injury can be at the origin of the multiple organ dysfunction syndrome (mods), the frequence of which having been estimated to % and is increased when all has occured in patients alreadypresenting an organ dysfunction (immunodepresslon, cancer...). when ali results from redirect or extrathoraclc injury (trauma, infections, hypovolemic shock, acute pancreatitis...), inflammatory mediators and micro-aggregates released in particular organs or tissues reach the lung via the blood and lymph streams, are filtered in the organ or trapped in the lung capillaries, and are responsible for a local inflammatory reactaon (endothelial cell activation, pmn trapping and adhesion, platelet aggregation, release of mediators). sepsis acts by the way of endotoxiu and sequential eytokines release (tnf, ill,...) while trauma with important blood loss acts especially by the way of hypoperfusionreperfusion phenomena leading to a disseminatedinflammatory reaction and to a possible bacterial transloeation when intestinal hypopeffnsion is present. in these conditions of indirect injury, all (or ards) is a iocal early (often the first) manifestation of a general phenomenon of altered membrane permeability and inflammatory reaction, easily and rapidly recognized by its clin~cai signs. the iung is one of the numerous organs participating to the mods, in these conditions, the mortality rate is high, reaching more than % when sepsis is present or when at least organs are implicated in mods. by direct or redirect injury, lung is so a target organ for mods and injured lung can be the cause of mods or simply a participant to this syndrome. jorge cervts-navarro main determinants for brain dysfunction are breakdown of the blood-brainbarrier and raise of intracranial pressure (icp), in second place decrease of systemic blood pressure, disorders of blood coagulation and respiratory function. the blood-brain-barrier of cerebral blood vessels can be opened by stroke, cerebral trauma, inflammation, convulsions, acute hypertension and changes in the blood osmolarity. the consequence is brain oedema, increase of lop and decrease of the perfusion pressure. a close correlation between intraventricular pressure and the fate of patients with severe brain injuries has been established. regional cbf values of to ml/ g/min are reflected in isoelectric eeg, and values about t ml/ g/min, result in loss of somatosensory evoked potentials. for ionic pump failure the threshold has been determined by values of about ml/ g/min and is reflected in massive release of intracellular potassium. in stroke and in brain trauma when the oedematogenous condition is initially localized the tissue pressure variance within and between the hemispheres lead to tentorial and falciform herniations are the common cause of death even before the critical threshold of intracranial pressure is reached. the increase of the icp over the level of the perfusion pressure leads to the arrest of the cbf. if this persists {or periods exceeding seconds of global brain ischemia loss of conciousness and developing seizures appear. if it exceeds min irreversible injuries of the brain appear. following cerebral ischemia and after severe head injury a tendency to increased coagulation can be detected. vascular occlusion may develop either as a result of local thrombus formation or from emboli caused by circulating platelet aggregates. the formation of microthrombi is triggered by the plateletactivating factor a mediator in central nervous injury also responsible for aggravation of posttraumatic brain edema. acute hemorrhagic leucoencephalitis and brain purpura are known to arise as complications of acute viral infections and following gram-negative septicaemia. institute of neuropathology, free university of berlin, hindenburgdamm , berlin, germany undoubtedly, attempts to quantify as objectively as possible the degree of dysfunction of the various organs is very valuable. however, cardiovascular failure has a peculiar place in the context of sepsis. the development of acute circulatory failure (shock) is of paramount importance as a cause rather than as a consequence of organ failure. it is therefore essential to clearly separate patients with and without circulatory failure. once this has been done, attempts to list the cardiovascular system among the other systems have been unconvincing. in a number of studies, cardiovascular complications are assimilated to a low systemic vascular resistance (svr), but since svr is basically the ratio of blood pressure over cardiac output, and since hypotension is already included in the definition of shock, then a low svr is basically equivalent to a high cardiac output, which is a characteristic rather than an ominous complication of severe sepsis. development of a low cardiac output unresponsive to fluids is usually a terminal event. it is not advisable to list other problems such as severe arrhythmias, myocardial infarction or tamponade as complications of severe sepsis. host defense dysfunction following trauma, shock and sepsis e. faist, g. f. babcock * major accidental, burn and operative injury often precipitates a profound multicentric immunologic depression that is believed to predispose patients to become anergic and thus to develop towards a higb probability of infection. anergy or a lack of immunologic reactivity stands for a total elimination of skin test reactivity and recall antigen responses in the inununocompromised patient. anergy following overwhelming trauma or major septic conditions results from a massive impairment of cell mediated immunity (cmi) together with a whole body malignant inflammationiike state. we and others have demonstrated clearly that the skeration of cmi following trauma is mainly due to the disruption of intact monocyte (moo) / t-cell interaction. within this phenomenon we see a shift of the cell ratio in the compartment of peripheral blood mononuclear cells (pbmc) with a considerable increase of prostaglandin e synthesizing m~ and a simultaneous decrease of functionally competent cd + and cd + lymphocytes. t-cell dysfunction in states of profound stress is characterized by impaired synthesis of two crucial lymphokines -interleukin- (il- ) and gamma-interferon (y-ifn). the inability to produce adequate amounts of il- , most likely attributable to alterations in the transmission of signals from the cell membrane to the nucleus, results in incomplete proliferative t-cell responses to antigenic stimuli, while a lack of ?-ifn results in inadequate m~ antigen processing and presentation. the role of the two functionally distinct t-helper subsets, t-helper- (thl) secreting principally il- and ?-ifn and t-helper- (th ) acting principally in inducing antibody formation with a secretion of il- , il- , il- and tnf-[ has still to be established within the context of major trauma. antibody formation to common protein antigens is impaired, the predominant finding is a shift from igm to igg synthesis. although excessive secretion of prninflammatory cytokines (il-u , tnf-c~, il- , il- ) has been considered to be deleterious for the host in states of major inflammation and infection, in-vitro and whole blood investigation of me function has clearly revealed that there is initially a marked suppression of moo from septic patients to synthesize and secrete proinflammatory cytokines to endotoxin. this probably will result in immunodeficiency of traumatized as well as septic patients, since these cytokines in low concentrations are involved in the upregulation of the essential humoral and cellular immune functions. abnormalities of pmn function noted after serious injury have been interpreted by some investigators as signs of unresponsiveness of this cell population, others have demonstrated signs of pmn byperactivation. latest findings revealed that there is a clear pmn dysfunction in circulating blood: % of all pmn's in this compartment show downregulated or non existent ~-integrins within hours posttrauma -these cells do not phagocytose, have a reduced respiratory burst and appear to be completely degranulated. restoration of these cell functions within days post-trauma is significantly correlated to survival of traumatized patients. other reports however stress increased expression of cr + receptors (cdll/cd complex) on circulating pmn's, increasing the ability of these cells to adhere to intercellular adhesion molecules, thus contributing to play a major role in inducing the pulmonary capillary leakage. our knowledge about the perturbation of host defenses associated with serious injury and sepsis is continuously increasing and represents the precondition for the design of effective therapeutic measures to prevent and counteract the resistance to invading microorganisms. dept. of surgery, klinikum grosshadern, ludwig-maximilians-university, munich, germany. * dept. of surgery, university of cincinnati, cincinnati, ohio, usa lg thijs~ ce n~ck sepsis is the most common cause of acute disseminated intravascular coagulation (dic) and coagulation disorders as well as abnormalities of fibrinolysis are common in septic patients. some clinical and experimental studies indicate that dic is a pathogenetic factor for the development of multiple organ failure. endotoxin and various mediators (tnf, il-i) enhance tissue factor and decrease expression of thrombomodulin on endothelial cells in vitro. also, tpa activity is suppressed and release of pai-i is stimulated. in such a way the endothelial surface becomes procoagulant whereas fibrinolysis is inhibited. following administration of endotoxin to normal volunteers levels of prothrombin fragments (fi+ ) and thrombin-antithrombin (tat) complexes increase, indicating thrombin generation. also the fibrinolytic system is activated as evidenced by a rise of levels of tpa and plasmin-antiplasmin (pap) complexes but this is counteracted by a subsequent release of pai-i. in severely ill septic patients levels of tat complexes are increased and concentrations of the natural inhibitors of coagulation (at iii, protein c) are usually decreased. also, tpa levels snd pap complexes as well as concentrations of pai-i are elevated. the severity of many of these alterations is related to mortality. thus, both coagulation and fibrinolysis are activated in sepsis, but not in a balanced way, thereby promoting coagulation. one of the hallmsxk pathological alterations associated with sepsis is the development of microvascular thrombosis, an entity ~lmre~erizod by microvas~tlar plugbing with leukoeyies (predominately nentrophils) and fibrin deposits. preranably, ischemia remlt~g fibm ve~-'ttlac ow,.luwion contributes sisni.ficantly to end orgen darnaje and consequent dysfatlctlon. p, er~t srldies haw focused pmdominately on the role of adhesion molecules in the pathogenesis of neu~ophil sequestration during infection and s~sis. this preparation will review the mechanisms underlying intravak-'v.ler i~brin deposition and its contribution to organ injury. the normal endothelial cell sure is generally conddered o be anticos~am. this state is maintained by two major anticoag~lam molecules on the cell so,ace: hepax'an su,lfale and thmmbomodulin. studies performed over the past decade have do~mentod a general shii~ towards a procoa~qtlant staw during gram negative hffeodon, aft e~| mediated mainly by changes in the endothalial cell surface. antt-tf antibodies have been shown to be pro~ective during l~'ml endotexemia. in summary, ~erova~'~ler fibrin deposition, in ~rt mediated by ~rcgulation of cellular tf, is a consistemt patholo~cal flndin~ during sepsis and contributes to organ injury. strategies designed to abrogate this event may n~nimjze the magnitude of erg~ dysftm~on. n, v, christou md phd, department of surgery, megill university, montreal, quebec, canada interactions between immune calls and the endothelium vie adhesion molecules serve to modulate immune cell traffic between the blood strum and the extrmvascular space, these families of molecules acting in a cascade and closely integrated with the oytoklna network, blood coagulation and the complement system, are responsible for the homing of leukocytes to areas of inflammation and the realrculatlon of tymphocytes. there are three types of immune ceils that must exit the blood stream into the extravascular space: lymphocytes ; polymorphonuclear leukocytes; and non-lymphocyta mononuclaar cells (monooytes, basophlls, aoslncphils). b lymphocytes exit the blood stream and recircu}ate mostly via the high endothelial venule (hev) in lymphatic tissue, rarely, in chronic }nfectlon=, they may recirqulate vie hev in non-lymphoi:t tissue. t-lymphocyte recircutation on the other hand can occur via hev in lymphoid tissue, as well as, the endothalium of the skin, returning to peripheral lymph nodes via the lymphatic channels. lymphocyte recirculation is the mechanism which allows ¢ontaot between the immune repertoire and pathogens, and homing delivers these cells to the appropriate environment for activation and for effeotor function, pmns exit the blood stream through endotbelium in close proximity to the site of inflammation after appropriate endothelial membrane receptor expression. they must reach the site of pathogen tnveslon quickly in order to be effective. their exudation to the inflammatory site can be modulated by their intravascular pdmlng, which results from appropriate receptor expression. because endotoxin leak from the gut has been postulated as an important trigger mechanism for the systemic inflammatory response syndrome seen after serious injury, the immunologic and metabolic effects of bacterial endotoxin infusion into normal volunteers can be expected to shed considerable light on the validity of this hypothesis. we and ethers have used tbis model to show that endotoxin causes a temporary paralysis in the ability of circulating monocytes to prudce the proinflammatory cytokines interleukin-i (il-i) and tnf-a. endotoxin, however, causes increased production of pge by the same cell population. endotoxin infusion causes significant suppression of circulating t-cell numbers and a profound suppression in the ability of the circulating t-cell population to proliferate and to produce interle~in- (il- ) upon in vitro stimulation. after endotoxin circulating t-cells are also more sensitive to the inhibitory action of exogenous pge . administration of cyclooxygenase inhibitors at the time of endotoxin infusion largely abrogates the effect of endetexin on t-cell proliferation and il- production. endotoxin infusion also causes the release of increased levels of circulating catabolic hormones including cortisol. administration of cortisol alone or cortisol along with endetowin to volunteers has allowed dissection of cortisol effects from those of endotoxin itself. cortisol infusion alone causes a diminution in the circulating t-cell population but the remaining ceils continue to produce il- after appropriate stimulation. cortisol infused along with endotoxin blocks the overshoot in monocyte proinflammatory cytokine production seen - hours after endetoxin infusion. at present, one may conclude that administration of sublethal doses of bacterial endetoxin to human volusteers produces alterations in cytokime production and tlymphocyte activation which are both similar and dissimilar to those seen following serious injury. hemodynamic support is based first on intravenous fluids and second on vasoactive agents. colloids are usually preferred to crystalloids, for their more rapid hemodynamic effects and their lesser passage in the interstitial space. in the presence of hypotension, the pharmacological profile of dopamine makes it the first agent of choice. it is only when high doses of dopamine are insufficient to restore a sufficient tissue perfusion pressure that norepinephrine should be added. even when cardiac output is not decreased, a dobutamine infusion is often indicated to counteract the myocardial depression, prevent vasoconstriction, and increase oxygen delivery to the tissues. the benefit derived from the administration of "renal" doses of dopamine is doubtful, but stimulation of dopaminergic receptors may increase blood flow also to the gut. in any case, none of these catecholamines has been shown to significantly improve the oxygen extraction capabilities of the tissues. agents with antiinflammatory properties but also with some vasodilating properties, such as n-acetylcysteine, prostaglandin el or pentoxifylline represent more attractive options to increase oxygen extraction. cardiovascular support should aim not only at the restoration of a sufficient arterial pressure but also at the maintenance of an optimal oxygen delivery to the cells. it should thus be guided also by measurements of cardiac output, mixed venous oxygen saturation and oxygen extraction, and indexes of cellular hypoxia, such as blood lactate levels, gastric intramucosal ph or vanearterial pc gradients. supranorma[ delivery contributes to the prevention of tissue hypoxia tissue hypoxia is considered to be the common final pathway in the pathogenesis of multipte systems organ failure. it may directly contribute to cellular injury and organ dysfunction as well as enhance further mediator activation and release by a positive feed back mechanism. prevention of tissue hypoxia, is therefore, one of the most important aims in the supportive therapy of critically ill patients, especially in those with sepsis and septic shock. mismatch of cellular o= supply and demand in these patients may resuit from the impairment of the cardiocircu[atory system on all levels. . myocardial depression with a drop in delivery (do~) . redistribution of blood flow between the different organ systems . inadequate nutritive blood flow due to tissue edema and endothelial damage (gic, leucocyte swelling etc.) these pathological changes may go along with increased metabolic needs. cellular and organ supply may therefore be inadequately matched with cellular needs in patients with normal and even supral normal doz. hyperdynamic circulation is often present in adequately volume resusucitated patients. it is most likely that one of the bodys main compensatory mechanisms would maintain cellular o= supply in the face of increased metabolic needs and impaired oz extraction capabillities. this pathophysiology may explain the findings in several clinical investigations that patients with normal or even supranormal doz can have signs of inadequate regional tissue oxygenation. it is also consistent with the results of different studies which demonstrated that the achievement of supranormal doz levels, either spontanuously or due to adequate supportive therapy, resuits in better patient outcome. any attempt to prevent or treat tissue hypoxia in these patients, however, has to take into account the effects of therapy not only on global dgz but especially on regional and microcirculatory blood flow. r. rossaint, d. pappert, k. lewandowski, h. gedach, k. slama, k.j. falke klinik for anaesthesiologie und operative intensivmedizin, ukrv, freie universit §t berlin, germany important contributory factors to the high mortality of severe acute respiratory distress syndrome lards) are the aggressive therapies required, such as mechanical ventilation with high inspiratory oxygen concentrations and airway pressures. as specific therapies for reducing or preventing the general inflammatory reaction of the lung resulting in severe hypoxemia is unknown, today's therapy is limited to procedures which predominantly support or maintain pulmonary function, i.e. pressure limited ventilation with peep and permissive hypercapnea, avoiding or treatment of fluid overloading, and positional maneuvers. extracorporeal lung assist combined with low frequency positive pressure ventilation has been recommended, when conventional therapy fails. today, extracorporeal gas exchange may be carried out using a system internally coated with covalently bound heparin. this allows for a lower level of systemic heparinzation reducing the risk of severe hemorrhagic complications of extracorporeal respiratory support. from april to august patients, aged from months to years, were transferred to our intensive care unit (icu) for treatment of severe ards. all fulfilled at least the slow entry criteria of the u.s. national ecmo study. due to hypoxemia patients required veno-venous extracorporeal membrane oxygenation (ecmo) immediately after transfer to our icu. the other patients were first treated with pressure controlled mechanical ventilation, permissive hypercapnea, prone position, and dehydration, if necessary. in out of these patients, in which the gas exchange did not improve in the following days, veno-venous ecmo with heparin-coated systems was additionally performed. heparin was given to achieve a partial thrombin time between - s and an activated clotting time between - s. if surgery was performed during ecmo, heparin infusion was interrupted. no severe bleeding complications related to anticoagulation for the extracorporeal bypass could be observed, however, in some patients, after three weeks of ecmo thrombi in the drainage cannula were observed. a problem of of membrane leakage shortened the life span of the membrane lungs to a mean of about four days. in the conventionally treated group % survived and in the additionally with ecmo treated group % survived, representing a % survival rate in patients whose risk of death is considered more than %. on the basis of these experiences, we conclude that the described strategy, including veno-venous ecmo with heparin-coeted systems, may improve the survival in patients suffering from severe ards. abnormally high skeletal muscle po in septic patients and its normalization during recovery: evidence against tissue hypoxia but for impaired oxygen metabolism of skeletal muscle? p. boekstegers, k. werdan department of medicine i, gro hadern university hospital, munich, germany a pathological oxygen uptake supply dependence was suggested to indicate tissue hypoxia in sepsis-a hypothesis which is discussed controversially. because the detection of reduced oxygen transport to tissue and &tissue hypoxia would have important implications for therapy, skeletal muscle oxygenation was studied in patients with sepsis. intermittent and continuous determination of skeletal muscle po by polarographic needle or catheter probes provided no evidence for skeletal muscle hypoxia even in severe stage of sepsis (boekstegers et al., crit care med ) . in contrast, mean skeletal muscle po was found to be abnormally high in patients with sepsis ( _+ , mmhg, n= ) compared to patients with limited infection ( , + , mmhg, p< . , n= ) , to patients with cardiogenic shock ( , + , mmhg, p< . , n=ls) and to healthy subjects ( , _+ , mmhg, p< . , n= ). furthermore, serial measurements in patients with sepsis showed that skeletal muscle po was higher ( , _+ , mmhg) on days with severe sepsis than on days with intermediate state ( , _+ mmhg) and than on days without sepsis ( , _+ , i mmhg) . thus, a decrease of abnormally high skeletal muscle po was related to improvement of sepsis. this was also demonstrated by comparing the decrease of abnormally high skeletal muscle po with the decrease of apache ii score or elebute score as well as interleukin- serum levels in a separate study (boekstegers et el., shock, in press). in summary, our data provide no evidence for skeletal muscle hypoxia in patients with sepsis but support the assumption &impaired oxygen metabolism in severe sepsis. neutropnlic emigration from the vascular space into the extracellular matrix is important for the response to tissue injury or contamination by providing a large recruitable pool of tissue-based phagocytes. the consequences of neutrophil exposure to intravaseular chemoattractants, likely relevant for il- and c a in sepsis, trauma, and in burn injury, are suppression of neutrophil attachment to endothelial cells and matrix proteins. it is probable that proteoglycan-bound attractants are of considerable biologic relevance, and may result in enhancement of responses to subsequently encountered cytokines. in the presence of connective tissue proteins expressing integrin-specific binding ligands, neutrophils respond to tnf-cq gm-csf and other cytokines by producing large amounts of hydrogen peroxide. this response is likely important in the digestion of contaminated or injured tissue by facilitating activity of neutrnphil granular proteases and inactivating plasma anti-proteases. this matrix-dependent oxidative response is important in defining potential novel targets for therapeutic intervention. the response appears to involve signalling by integrin-linked tyrosine kinases. the net effect of matrix protein injury through this mechanism is enhancement of the fibrotic response which underlies much of the prolonged ventilator dependence of patients with the adult respiratory distress syndrome. this adherence dependent response has also been implicated in direct hepatocyte injury, and may represent an early component of the syndrome of multisystem organ failure. study purpose: in this patient (pat.) population with a considerable sepsis morbidity and mortality, parameters proposed for sepsis assessment (elebute sepsis score [ele], sirs) were investigated with regard to their use in the early classification of pop. pat. at risk for developing sepsis. patients and methods: in a previous observational study on consecutive pat. after elective open-heart surgery, we had determined ele daily for at least pop. days (in pat. with a longer stay: until icu discharge). after publication of the newly proposed sirs definition, these criteria were retrospectively calculated and compared to ele. results: on the total of n = patient-days, both ele and sirs showed significant (p< . ) correlations with parameters reflecting the general and sepsis-related severity of the pop. clinical course. compared to sirs, the ele correlations were better (icu mortality: . vs. . ; icu treatment days: , vs. . ; days on mechanical ventilation: , vs. . ; days with vasopressor requirement: . vs. . ; number of microbiological findings: . vs. . ), the optimal classification criteria for the mainly sepsis-related outcome gave maximal youden indices of . for ele (ele >_ on >_ days, accuracy: %) compared to . for sirs (sirs present on > days, accuracy: %). accordingly, ele roc curve areas for both overall ( . ) as well as sepsis-related prognostic evaluation ( . ) were significantly (p< , ) larger compared to sirs ( . and . , resp.), this higher overall accuracy of the ele criterion was primary due to a more valid assessment already on the first and second pop. day, where sirs still had a high false positive classification rate ( % and %, compared to % and %, resp.). conclusion: in the early postoperative course after cardiac surgery, the sirs definition displayed a high false-positive classification rate (low specificity) for subsequent sepsis-related mortality compared to better classification results obtained by the elebute sepsis score. from the departments of medicine i and of "cardiac surgery, grosshadern university hospital, marchioninistr. , d- munich, frg. correlation between physiological and immunological parameters in critically ill septic patients. ma rogy, h oldenburg, r trousdale, s coyle, l moldawer, sf lowry a relationship between physiological parameters of severe sepsis and immunological function has not been established. in an effort to assess such a relationship we prospectively evaluated nine severely ill septic patients. physiological risk was assessed by the apache iii score , while one component of immunologic function was evaluated by peripheral blood mononuclear cells (pbmc) eytokine production after in vitro lps stimulation . four of the nine patients died. apache iii scores at h were lower in survivors (s) than in non-survivors (ns), ( -+ vs -+ p< . ), while apache iii scores at admission were not significant different between s and ns ( -+ vs -+ ). down regulation of cytokine production by pbmc upon lps stimulation was a transient event in s. while s demonstrated an fold increase of tnf-a bioactivity with[r~ hours, ns did not demonstrate any increase at all. a similar pattern was demonstrated for il- [ and il- immunoactivity. tnf was measured by wehi bioactivity, il- [~ and il- immunoactivity were determined by elisa. the sensitivity was pg/ml for tnf, pg/ml for il-ll and pg/ml for il- , respectively. in conclusion, both physiological as well as immunological functions of severe critically ill septic patients demonstrate predictive value for ultimate survival. while patients biological status seems to be more predictable by apache iii at day , p< . , the pattern of cytokine production by pbmc upon lps stimulation over the first h might be a reliable predictor as well. introduction: therapy of sepsis and its sequelae depends largely on its early recognition. many studies have investigated the change of certain mediators during sepsis and their potential to predict multiple organ failure and outcome. it was the objective of this study to investigate whether the onset of sepsis can be predicted by alterations of levels of interleukin- (il- ), tumour-necrosis-factor (tnf), pmn-elastase and c-reactive protein (crp). materials and methods: over a one year period, polytraumatized patients were prospectively studied (mean age y, % male, iss ). serum and edta-plasma samples were taken in h intervalls until the patient left the icu. il- , tnf, elastase, and crp were determined immunologically. sepsis was defined according to the criteria of 'systemic sepsis' (veterans" administration study, ) with at least of clinical signs: ( ) tachycar-dia> /min, ( ) temperature > , °c, ( ) blood pressure < mmhg, ( ) mechanical ventilation, ( ) leukocytosis > . /ml, ( ) thrombocytopenia < . /ml and ( ) presence of an obvious septic focus. clinical parameters, sepsis severity and serum levels were documented on a daily basis, beginning on day after trauma. results: of patients developed a systemic sepsis ( . %), and died. all mediator levels were elevated under septic conditions. the clinical severity of sepsis correlated well with the respective levels of mediators. in patients, who developed a sepsis the following day, il- ( vs. ng/l; p= . ), crp ( vs. mg/l; p= . ) and tnf ( vs. ng/l; p= . ) were significantly increased as compared to those patients who remained non-septic. elastase levels were considerably elevated but did not reach the level of significance. we conclude that il- , tnf and crp appear to be sensitive markers for prediction of septic complications in polytraumatized patients. objectives of the study: the assessment of liver function in polytraumatized patients who are at risk of developing mof is too inaccurate and late by using conventional biochemical parameters. methats: the injury severity of the patients (n= ) was determined by the injury severity score (iss). lidocaine is given at a dose of mg/kgbw over rain. i.v. and is metabolized in the liver by a cytochrome p- mechanism to monoethylglycinexylidide (megx). the metabolite is measured by a fluorescence polarization immunoassay. serial determinations of the test were performed between the ~t and the ~ day after trauma and were compared with other liver function tests (bilimbin, gldh, alt, ast). the systemic inflammatory response syndrome (sirs) is still a challenge concerning early diagnosis, therapy and prognosis. therefore, evaluation of inflammatory and disease activity becomes more important. c-reactive protein (crp) is a well established acute phase protein in chronic inflammatory diseases. recent reports suggest an induction of crp by interteukin- (il- ), a cytokine involved in the mediator cascade of sirs. on the other hand, tumornecmsisfactor alpha (tnfcx) is a very early released mediator in sirs removed very rapidly from circulation. in addition, soluble tnf receptors (stnfr~ , stnfr ) are released into circulation in the acute phase response. this study examines the kinetics of five acute phase proteins (crp, il- , tnfot, stnfr , stnfr ) in patients suffering from sirs. eighteen patients entered the study after diagnosis of sirs. blood samples were drawn every six hours during the first two days and every twelve hours thereafter. crp was measured in an routine turbimetric assay. il- was detected in an biological assay using the/l- dependent -cell line / . detection of tnfc~ was performed in an elisa system using a monoclonal antibody" for tnfo~. soluble tnf receptors were also measured by elisa. crp levels were elevated (> mg/l) in all patients and at all time points. crp values did neither differ significantly in patients with ( ± mg/l) or without ( a: ) multiple organ failure (mof) nor in survivors ( ± ) or non-survivors ( :t: ). in contrast, l- was elevated in patients wilh mof (mean pg/ml, range - pg/ml). il- levels correlated especially with lung dysfunction. tnf(x levels were consistently elevated in patients with mof. crp, il- and tnfoc did not correlate with each other. in contrast, levels for both stnfr showed a positive correlation (r= . ). patients could be divided into two groups by values for stnfr~ and stnfr : the group with higher soluble tnf receptor levels showed increasing values combined with a poor prognosis. the group with lower levels of soluble tnf receptor consisted of patients surviving mof or without mof. in conclusion, crp does not monitor the course of sirs adequately. in contrast, il- correlates with mof and episodes of high disease activity. high stnfr levels may indicate poor prognosis. klinik f r an/isthesiologie and operative intensivmedizin der cau kiel, schwanenweg , kiei, germany. ch. waydhas, md; d. nast-kolb, ivid; m. jochum, phi); l. schweiberer, mi) objective: to evaluate the irfflarranatory response after different types of orthopedic operations and compare them with the systemic effects of accidental trauma of varying severity. patients: in consecutive patients with multiple injuries (iss . ) the inflammatory response to trauma was prospectively studied. the patients were divided into groups according to their iss points. additionally, the alterations after secondary operations (> hr) were determined (msteosynthesis of the femur (n= ), pelvic girdle (n=ll) and spine (n= ), facial reconstruction (n= ), smaller osteosynthesis (n= ) and others (n= )). methods: specific and unspecific parameters of the inflammatory response were determined in the trauma patients every h, beginning on admission of the patient to the emergency room for a period of hr, and in the operative patients on the morning of the operation, at the end of the procedure and every hr during the first two days. results: lactate, neutrophil elastase, heart rate, po /fio -ratio, and other parameters discriminated significantly between the injury severity groups during the first hr (kruskal-wallis-test, p<. ). the degree of postoperative changes differed significantly (kmskal-wallis-test, p<. ) between the types of operations for lactate, heart rate, po /fio -ratio, nitrogen excretion and showed a strong discriminating tendency for neutrophil elastase and c-reactive protein. the extent of changes were highest after operations of the pelvic girdle, followed by procedures on the femur, spine, smaller bones, and the facial region. the postoperative changes after osteosynthesis of the femur or pelvis were comparable to the alterations noticed after smaller (iss to ) or moderate (iss to ) accidental trauma for neutrophil elastuse, heart rate, po /fio -ratio and parameters of the coagulation system. conclusions: there is a considerable inflammatory response to operative procedures that varies with the type of surgery. large operations cause changes in the body homeostasis that resemble those after multiple injuries. it remains to be established whether the inflammatory sequelae of surgical trauma are additive to the changes caused by accidental trauma. objective of the study: we retrospectively compared characteristics of elderly patients (~ years) and yeunger patients admitted to a surgical {sicu) and a medical intensive care unit (micu). we further studied the relations between advancing age, chronic disease, sepsis, organ system failure (osf) and mortality in the elderly group. material and methods: during a -year period, patients were consecutively admitted into the icu; and during a -year period, patients were consecutively admitted to t~mich. criteria for chronic disease, sepsis, osfsi.e. cardiovascular (cf), pulmonary (pf), renal (rf), neurological (nf), haematological (hf), hepatic (lf), and gastrointestinal failure (gf)-were derived from the literature. results: patients from the sicu and~cu were similar in age, number of osf, and length of stay. however, when compared to sicu patients, micu patients had more cf (p<o.o ), sepsis (p<o.o ), and mortality rate ( % vs. ii~, p<o.ool). in contrast, sicu patients had more hp and nf, and prior chronic disease (all, p<o.o ). of the total group of , patients, there were ( %) patients years of age or older. elderly and younger patients had comparable length of stay in the icj, but elderly patients had significantly more chronic disease, sepsis, and number of osf (all, p<o.o ). all osfs, except hf and nf, were more ~o~mon i~ mdeljl, eompard to you-ger patients. ~he mortality is also higher in elderly patients ( % vs. % in younger patients). after multiple logistic regression, only number of osf increased mortality by a factor of . ( % confidence limits, . - . ), age did not increased [odds ratio . (i. i.i )], while admission to the sicu reduced risk of death by a factor of . ( . - . ). conclusions: based on these results, we conclude that age does not have any impact on icu outcome in the elderly. the only prognostic factor is the extent of acute disease, as measured by the number of osf. hence, prevention of oaf may influence outcome in elderly patients with critical illness. the lower risk of death in sicupatients may be explained by the large proportion of postoperative elective patients with relative mild chronic disease, and the lower incidence of sepsis. department of surgery, free university hospital, de boelelaan , ~v amsterdam, the netherlands. septic shock and low output syndrome h.miyakawa, t.noguchi, s.hattori, a. mizutani, m. mori and n.honda objectives: cytckines are thought to cause the acute phase reactions under several critical conditions. we had investigated the relationships between cytokines network which included il- , l- ,acth and cortisol,and the outcome of the patients with septic shock or low output syndrome (los). materials and methods: in the septic group and los group,nine and four patients were enrolled respectively. furthermore, the patients in the septic group were divided into two groups,survival (n= ) and non-survival group (n= ).tn these patients,ll- , l- ,acth and cortisol had been measured every day after diagnosis of septic shock or los.the total number of measurements were points in survival septic group, l l points in non-survival septic group and points in los group.statistical analysis was used student's t-test to compare the mean of each group,and the changes were reported as clinicat significant if p< . . results: il- levels in non-survival septic group were higher than in both survival septic and los group.ll- levels in non-survival septic group were more significant than in both survival and los group.otherwise,there were no differences with respect to acth and cortisol among three groups. conclusions: we assumed that los would make several organs dysfunction as well as septic shock. but our results showed septic shock, especially non-survival,had different cytokins network mechanism for organs failure from los. lasson ,~, g/ ransson j, jijnsson k. eady diagnosis of complications after trauma is imperative to decrease morbidity and mortality. for this purpose an easy, cheap and fast diagnostic method is needed. the aim of this study was to analyse if complications after surgical trauma of various extent could be diagnosed earlier using preoperative or daily postoperative measurements of various plasma proteins than by using climcal signs of complications. material and methods: two acute phase proteins (c-reactive protein and antichymotrypsin), lbur main plasma protease inhibitors (alpha- -maeroglobulin, c estemse inhibitor, antithrombin ill and alpha- -antiplasmin) and one collagen precursor (procollagen iii peptide) were measured preoperatively and then once dally for days postoperatively. for the plasma protease inhibitors immunorcactive as well as functional levels were measured. haemoglbin, albumin and the white blood cell count were also measured. measurements were done preoperatively in patients and continued postoperatively in patients, % of the patients were operated on for malignancy. resulls: preoperative plasma c-reactive protein levels were higher in patients developing postoperative complications. this discrimination increased when plasma was sequentially analysed postoperatively, when a remaining high level ora second increase in plasma levels depicted a complication - days earlier than clinical signs. high levels were seen both in patients developing local as well as in patients developing general complications. there was no clear correlation between plasma protease inhibitory levels and complications, neither pre-nor postoperatively. procollagen iii paptide levels were slightly (but not significantly) higher postoperatively in patients developing complications. contusions: the acute phase response, especially concerning c-reactive protein, predicts postoperative complications better than both plasma protease inhibitors or collagen precursors. preoperative plasma c-reactive protein levels indicate the risk of postoperative complications, while daily postoperative measurements more readily depicts a complication, usually preceeding the clinical signs of complication by - days. dept. of surgery m'alm general hospital, s- i malmr, sweden. mof is a major threat to the extensive burned patients and associated with a high mortality rate. the role of endotoxemia in the pathogenesis of mof in burned patients remains controversial. in this study, we examined the relationship of plasma endotoxin levels to development of mof, and outcome in patients with thermal injury. methods: a prospective cohort study of patients admitted with burns covering more than per cent of body surface area was undertaken. circulating endotoxin concentrations were measured by modified limulus amebocyte lysate assay in serial samples of plasma. results: out of burned patients developed mof according to multiple criteria. the plasma endotoxin concentrations of patients with mof were . -- . eu/ml, significantly higher than that of patients without mof ( . - . eu/ml) on , , and days postburn (p< . -- . ). significantly more incidence of positive endotoxin test (>_ . eu/ml) was found in patients who developed mof as compared to that of non-mof during the observation period (p< . ). as the mean endotoxin levels increased, the prevalence of mof and death also increased (see table below), persistent endotoxemia carried a poor prognosis. conclusions: the present investigation provide further evidence that endotoxemia in severely burned patients commonly occur. cimulating endotoxin has also been found to be strongly associated with development of mof and mortality following major burn injury. multiple hemostatic changes occur in sepsis mad multiple organ failure (mof). to evaluate the role of platelcts in patients with sepsis and mof, we examined changes in surface glyeoproteins on circulating platelets of t patients with suspected sepsis and mof. the severity of sepsis and mof was assessed by eiebute and apache i scoring system, respectively.using flow cytometric techniques and platelets specific monoclonal antibodies, platelet surface expression of fibrinogen receptor on gpiib-iiia, ofvon willebrand receptor gpib, and of granula glycoproteins (thrombospondin, gmp- , and gp ) was measured. receptor density of gpiib-illa mad gpib on circulating platelets was not affected by sepsis or mof. in septic patients surface expression of activated fibrinogen receptor (libs expression) was significantly elevated (p< . ) and correlated well with severity of disease (f . ). no significant change in surface expression ofthrombospondin, gmp- or gp was noted in septic patients. in contrast, degranulation ofgraanle glycoproteins was significantly elevated in mof (! < . ) that correlated well with severity of mof (gmp- , r= . ; thrombospondin, r= . ).we speculate, that platelets in sepsis circulate in a hyperaggregable (fibrinogen receptor activation ) but still reversible state that results in increased risk of microthrombotic events. in the course of the disease, irreversible platelet degranulation might occur and may play an important role in development of mof. abdominal sepsis is still associated with high morbidity and mortality. the present study aimed at evaluating patients with abdominal sepsis treated at our surgical intensive care unit during a -year period with the aim of identifying potential prognostic factors, bacteriological cultures, diagnostic procedures, treatment and outcome. during the period - i patients with abdominal sepsis were treated at the icu at our university hospital. patients were women and men with a mean age of ( - ) years. in cases, the abdominal sepsis occurred as a postoperative complication. the patients were scored according to apache ii and bacteriological cultures and the occurrence of organ failure were noted. the patients were hospitalized in median for (- ) days out of which (- ) in the intensive care unit. out of patients ( %) died in median after ( - ) days. the primary cause of mortality was multiple organ failure ( / ; %). apache ii scoring could not predict a fatal outcome. abdominal bacterial cultures were dominated by bacteria of enteric origin ( %) and in % cultures grew multiple bacteria. patients bad organ failure and multiple organ failure. / patients ( %) had abdominal sepsis due to diffuse peritonitis despite a morphologically intact gastrointestinal tract and the absence of localized abscess formation. mortality in this group was significantly higher as was the percentage of positive blood cultures and the occurrence of multiple organ failure. abdominal sepsis is still associated with a high mortality, predominantly caused by multiple organ failure. abdominal culture findings are dominated by bacteria of enteric origin. in about / of patients with severe abdominal sepsis a diffuse peritonitis with intact gastrointestinal tract without localized abscess formation was found. in this group the mortality was increased as well as the risk of developing multiple organ failure. during the period from january to september patients, mean age + years were referred to our department of resuscitologywith the diagnosis of eclampsia. all the patients were delivered by cesarian section and were mechanically ventilated for . _+ . days. diagnosis of sepsis was confirmed in cases by clinical and microbiological methods. patients were divided in two groups: lnon septic patients, -patients with sepsis, the control group consisted of patients after cesarian section without symptoms of eclampsia or infection. we determined plasma concentrations of immunoglobulins a,g,m(a,g,m), complement factors (c ,c ), alphal-antitrypsin (aat), trausferrin (trf) and albumin (alb) using beckman (usa) analyzer,protein concentration, using kone (finland) analyzer. a(mg/dl) g(mg/dl) m(mg/dl) c (mg/dl) c (mg/dl) k +- + _+ + +- -+ " -+ * _+ " -+ ' _+ " +_ '* -+ ** -+ "* -+ "* _+ " in a prospective study we investigated serum of severly traumatized patients withdrawn directly after admission at our hospital (tr i). follow up controls were taken daily until day ten after trauma (tr ii). two control groups were performed: serum of healthy volunteers (co, n = ) was investigated as. well as serum of patients undergoing elective herniotomy (n= ) hours before (op i) and hours after operation (op ii). serum bactericidal index (sbi) was determined using a hemolytic e.coli strain :k :h . / suspension with a final concentration of - cfu were incubated with l oopl serum. after overnight incubation sbi was calculated according a special formula. results: co . _+ . opi . _+ . opii . _+ . * tri . _+ . "* trii . + . ** (*:p< . ; **:p<o. ) sbi represents a simple and reproducible method to detect immunobiological alterations after trauma and elective surgery. patients undergoing elective surgery showed slight but significant diminuation of sbi h after operation. deterioration of sbi was observed in serum of traumatized patients directly withdrawn after admission at our hospital. ten days after trauma significant improvement of sbi was found. further investigations have to be done to proof sensitivity and prospectivity of this simple but reliable test. a sepsis like syndrome (sls) occurs in i % of our patients following cardiac surgery. sls is characterized by a severe decrease in systemic vascular resistance requiring the use of vasopressors to maintain adequate hemodynamics in the presence of negative blood cultures. in order to determine whether preoperative factors predict the occurrence sls we retrospectively studied patients with sls (group i: age . ~ . years); they were compared to control patients (group : age ± . years). treatment of sls consisted of aggressive fluid replacement and norepinephrine infusion. rydrocortisone ( mg/ hrs) was given on the first day. antibiotics were switched prophylactic to cover gramnegative bacteria in pts. preoperatively pts in group revealed a significantly lower cardiac index ( . ± i/min/m ) compared to group ( . ± . i/min/m ; p < . ) higher left atrial pressure (group i: . ~ . mmhg; group : . ~ . mmhg; p < . ) and lower ejection fraction (group i: . z . %; group . ± . %; p < . ). bypass time, minimum and mean blood pressure on bypass and aortic clamp time were not different between the groups. immediately postoperatively (pop), the white blood count was elevated (group i: , ± , /ui; group : , ~ , /ui; p < . ) and core temperature hours pop was higher (group i: . . °c; group : . ~ . °c; p < . ). serum lactate was already elevated on arrival on the icu pop (group i: , z . mmol/l, group : . ~ . mmol/l) but dropped within hours (p < . ). icu stay (group i: . ! . ; group : . ± . days; p < . ) and mortality over months (group i: . %; group : . %; p < . ) were significant higher in group i. sls is observed more frequently in patients with preoperative cardiac congestion and results in longer icu stay and higher mortality. although intraoperative hemodynamics are similar in both groups, the white blood count and serum lactate levels suggest an intraoperative cause for sls. further investigations will focus on possible intraoperative causes of sls. the objectives of the study were to estimate the problem of stress ulcers in critically ill patients and to compare ranitidine and omeprazole to determine their efficacy in the prophylaxis of stress ulcers. patients who were admitted to the intensive care units between january and july ' with polytrauma, sepsis or those requiring ventilatory support for more than hours were selected for the study. the patients were randomized into groups to receive ranitidine, omeprazole or a placebo. the changes in gastric ph were monitored hourly and the patients underwent an upper gi endoscopy hours after the start of the study to look for stress ulcers and hemorrhage. the drugs were withdrawn one week after the start of the study. of the patients selected for the study, had undergone cardiac surgery, had polytrauma and had sepsis. the change in average pre and post drug gastric ph was + . in the omeprazole group, + . in the ranitidine group and -). in the placebo group (p < . ). endoscopic evidence of stress ulcers was seen in % of patients not on prophylaxis, . % of those on omeprazole and . % of those on ranitidine. while all the patients in the placebo group who had stress ulcers showed endoscopic evidence of hemorrhage, % of the patients with ulcers in the ranitidine group and none of the patients with ulcers in the omeprazole group showed hemorrhage (p < . ). in critically ill patients the incidence of stress ulceration is high. an alkaline gastric ph is protective against stress ulcers. omeprazole when used for prophylaxis against stress ulcers in critically ill patients or those on short term ventilation will reduce the incidence of formation and hemorrhage from stress ulcers. the early and accurate diagnosis of sepsis is of key importance for critically ill patients survival. many studies have shown that tumor necrosis factor ~x (tnf ~) and interleukin- (il- ) are mediators of the inflammatory response in sepsis. bacterial antigens interact also with antigen specific t cell receptors and the activation of t ceils takes place. activated t cells release soluble interteuldn- receptors (sil- r). the aim of this study was to evaluate: the significance oftnf c~, il- and sll- r in the diagnosis of bacterial sepsis and to evaluate the correlation of clinical and laboratory parameters with serum levels of tnf ~x, il- and sll- r. we examined patients with clinical signs of sepsis treated in the intensive care units of university medical centre ljubljana. venous blood was drawn from each patient within hours after the first clinical signs of sepsis. clinical data (body temperature, blood pressure), laboratory dam (peripheral white blood cell count with differential, platelet count, c-reactive protein), and quantitative blood cultures were recorded. serum levels of tnf c~, ,- and sil- r were measured in septic patients and in adult healthy controls. tnf ct, il- and sil- r serum levels were measured by commercially available ria and elisa (amersharn and eurogenetics) kits. the differences in serttm levels of tnf ~, il- and sil- r between healthy control and patients and correlation between clinical and laboratory parameters were calculated. we found that only sll- r serum levels were significantly (p< . , student t test) increased in patients in comparison with healthy controls. of all indicators of sepsis that we compared, only hypotension was significantly correlated with tnf ~x levels and leukocytosis with ] ,- levels. we conclude that only the increased serum sil- r levels were predictive of bacterial sepsis within hours after the first septic signs. tnf c~ and il- levels were not significantly increased at that time in lifts small group of patients. in order to create high precision prognostic system for patients with sepsis and septic shock we have made prospective and retrospective analis of cases of sepsis. patients were included in this analis according bone's criterions of sepsis. comparing with apache-h, we have excluded such phisiologic variables as:temperature,na+ ,k+ ,}it, ph,which had a little influence on prognos of illness. we have added the other, more important variables: biilirubin, plateles,pti. we took into account: the seat arrangement, methods of respiratory support, comorbid conditions as: caneer, diabets,obersity. in general new score has headings: -physiologic variables, -age, -seat arrangement, -chronic comorbid conditions, -methods of respiratory support. roc -analis have showed a greater precision of our score, compared with apache-ii score. there is significant difference between the roc-curve of apache-ii scare. the k.p.tit~v.,i.e.gurmanchuk. objectives of the study. sepsis is a severe complication of the local infection, th e fever and the systemic inflammatory response syndrome may take place in such a case as manifistations of the inflammation induced by bacteria. the systemic fever observed in infection is known to develop due to the action of certain cytoldnes. other systemic manffistation of inflammation are the production of acute phase reactants, acute phase proteins, the activation of the complement system. ivratertals and methods. we observed children with light and children with severe course(l- class of serionuess) of the sepsis. the ftmetional activity of the complement system (ch , level of c -c , factors b told d, c a), level of c-reactive protein (crp} and tumor necrosis factor (tnf) were investigated, results. the level of crp was increased in the children with more severe class of the septic process in both group ( %- st and ioo%- nd}( with light and hard eours of disese) of patients. parameters of the complement system -the activity of cl, c , c components, activity of b and d factors-were increased in the seram of children with light course of sepsis. in children with severe course of sepsis these parameters were signffieantty decreased, especially in the group of chiidrellwith higer level of crp. we found the negative correlation of the tnp-alfa concentration with the functional activity of classical pathway components (cl~ ) and the positive onewith the funfional activity of the alternative pathway factors b-and d of the complement system. conclusions. thus, in children with different course of sepsis certain changes in levels and functional activity of an acute phase o[ inflammation proteins -crp and the complement system ones -&ire characteristic. the relationship between the tnf-alfa level and the activity of classical and alternative pathways proteins indicates on its role in the complement proteins genes expression. schr der j, braun j, rennekampff ha, schr der dw various alterations of the immune response are known in trauma, but the course will not be complicated by multiple organ dysfunction syndrome (mods) in all patients. phenotyping of cells offers a rapid system of evaluation certain aspects of the immune response. different subsets of lymphocytes and neutrophils were determined to evaluate their prognostic role in developement of mods. in trauma patients with an injury severity score (iss) > (mean iss = ; mean age years) lymphocyte and neutrophil phenotypes cd (t-cells), cd (t-helper cells), cd (t-suppressor cells), ratio cd /cd , cd b (receptor for cr ) and cd (fcriii) were measured on day , , , , and post trauma. the expression of class ii histocompatibility antigen (hladr) on monocytes (hladr+ cd ) and il -receptors on t-helper cells (cd /cd were determined as well. the percentage of cells was monitored by immunofluorescence using monoclonal antibodies and three color cytometry. the percentage of hladr+ cd were significantly lower an day , , and in patients who developed mods (p< , ) compared to patients without mods and a healthy control (p<o,o ). the expression of il receptors on cd was significantly different only on day . no differences could be measured in lymphocyte phenotypes cd , , and cd /cd -ratio as well as in expression of cd b and cd on neutrophils. class ii histocompatibility antigen (hladr) on monocytes offers the best ability to reflect cellular immunosuppression in trauma. this parameter allows the best differentiation of patients with and without mods. we retrospectively studied the relative importance of age, prior chronic disease, sepsis and organ system failure (osf) to determine outcome in critically ill patients with acute renal failure (arf). arf was defined as serum creatinine > /zmol/i, a twofold creatinine rise in prior renal insufficiency or the need of acute renal replacement therapy. definitions for prior chronic disease and other osfs -i.e. cardiovascular (cf), pulmonary (pf), neurological (nf), haematological (hf), hepatic (lf), and gastrointestinal failure (gf)-were derived from the literature and described previously. of the consecutively admitted patients to a surgical and a medical intensive care unit during -ye r period, ( %) had arf. arf mortality was %. ninety-eight percent had other osf. overall, cf, pf, gf, and nf was significantly more common in nonsurvivors than in survivors (all, p<o, ). although both the number of osf before and after arf was higher in nonsurvivors than in survivors (p< . ), the number of osf before was higher compared to after arf in both groups of patients (p< . ). furthermore, age, cf and pf before the ontset of arf, nf thereafter, and renal replacement therapy were related to mortality (all, p< . ). however, prior chronic disease was not related to mortality and chronic renal insufficiency was inversely related to outcome (p< . ). after multiple logistic regression, advancing age, cardiopulrnonary failure and sepsis before arf, and nf after arf remained significant. these results show the high prevalence of arf in critically ill patients and that arf rarely occurs alone. the prognosis of arf in critically ill patients is poor, especially if associated with advancing age, additional osf, particularly cardiopulmonary failure and sepsis before arf, and nf after arf. hence, prevention of cardiopulmonary and sepsis before the outset of arf may influence outcome in arf in patients with critical illness. the search cominnes for a magic bullet ta help critically ill petienta, bat recent elini ',.ml rials of agents that showed ixomise in animal studies raise questions about such trials. expcrlmemai uvidan~ :in anlmats and human volanteet~ for concepts, mechanisms and treatment of inju~ ur illness can be substentlal, l~rauasive and exciting but the positive effects of potential therapy suggested by such animal and ctinieal research may be difficult to prove in sick patients. efficacy of a new txeatment can be difficult to prove became elinie.al situations, hi spi~e of important biologic phenomena, are v~iable and conrplex. there is redundancy and overlap of mediators ~d problems of timing of therapy. a majt~r cause of this dilemtns is not with the trials or hypotheses, but rather the promem of the cause or the causability of the human dise~.se that is trebled. this is/hu "causa nets" or '*specific cause" as described by stehbens, when prevention or tre.atmcnt is based em the sauna nero, extinetiem of the disease is ix~ssible as with saul/ pox. only elimination of the cause wl cure the disease. careful animal studit~s evaluate single pcrturbmiuns for survival or other changes. an ldso preparation may be infiuancad aignificantly by a ~mall clangs which may be insignific~lt ht pstiants, most human experiments ate carried out in normal volunleers with a single porlurbation, such as a low-level, non-lethal dose of a substance. such studies are huportant in defining mechanisms attd mediators of disease, in our world of injm'ed, operated, infected and inflslned patients, there are many diseases, mof is not one of lhem. it isn't even a syndrume, it is the final pathway for a number of diseaaes~ each of which has a cause. mecormock believes thal a "multi-causal" etiology is a euphemism for ignoranc# or a synonym fo~ unknown etiology. admission iv sn icu, a high apache seer% the sepsis syndrome, mof, muds, or sirs and having predictors indicating potential mortality, are not diseases. the inmpors are getting negative results in trials of agents on eiek or septic icu patients and aru now becoming splitters, dafining subgaoups at higher risk for death. such an approach may produce positive results if the diseases are identified and the treatmeul is specific for them, a major challenge in deterraintng the efficacy of new therapies for sepsis nnd shock is identifying patients whose e#temtc inflammatory response is appropriate from those in whom the mediator| are contributing to end organ system damage end death, traditional and recently revised categorical patient descriptions such as sepsis syndrome, sepsis syndrome with shock, multiple organ system failure, or the recently proposed systemic inflammatory response syndrome (sirs) may not be sufilcient since they identify individuals at varying levels of risk for short term mortality, the efficacy of new lmmunotherapy may be directly related to the patient's severity end risk of mortality at entry to the study. we recently reported (jama ; : z - ~ ) a comprehensive risk assessment approach for patients with sepsis syndrome, a common eategarlcal description used as an entry eriterlon for many trials. by screening s database of , recent admissions to hospitals in the united states and western europe, we identified , patients who met sepsis syndrome criteria but were not enrolled tn clinical trinh, we then developed a survival model end severlty assessment method to estimate their g.day mortality risk. k..ente physiologic abnormalities were the most important prognostic factors ( % of total chl square) influencing outcome. the specific disease resulting in ice admission and the days the patient spent in the hospital and icu before qualification were independent risks, as were age and a clinical history of cirrhosis. the predictive model was cross-validated within the original , patients with a receiver d_perator characteristics (roc) area of . and in two independent databases, the first independent database contained hospitalized patients with gram-negative infection meeting criteria for sepsis syndrome (roc= . ); in the second, the placebo patients withtn the recently completed phase ill e~aluatlan of il- ra (rocffi . ). in all databases the risk model was able to accurately risk stratify patients throughout the range of risks that varled from a very low % to a very hlglt %. by drawing on the ready avatlabillty of large clinically aeuurate, current databases and using the power of modern statistical techniques to model the bodfs response to sepsis, we are able to produce very aeettrate pre-treatment risk estimates, these prospectively defined and continuous risk estimates reduce reliance on multiple subgroups and data dredging that can compromise a stady's integrity. they cart provide a nnlform method for patient description across clinical trials of different attempts at immmlotherapy. risk calculations can also be useful in developing entry criteria for phase ii evaluations in order to initially test efficacy on a limited number of high risk patients, fonowing sueeessinl completion of a definitive trial, the risk estimates can be used to develop specific |ndlcattons for s drug's use and can monitor the impact of both new and multiple compounds on patient outrome, when dealing with therapeutic trials for the treatment of sepsis, there are ways of checking the comparability of the groups (placebo and treated groups) -to use several description items such as age, sex, preexisting disease, number and nature of organ failures, physiology score, such as saps il ( ) -to use a model for risk of death either from a score (apache ii, lii, ( ) saps ii) or directly (mpm ii system ( )) before using the model for risk of death in septic patients, is it mandatory to validate it (by calibration, i.e. goodness of fit, and discrin'dnation, i.e., roc curves) first on a data base using the same definition for sepsis as in the trial and secondly on the placebo group of the trial ? or is it better to use a specific model for each trial ? the general models usually do uot fit for septic patients. there are methods to make them fit : either to add variables to the original score (model for sepsis using the apache iii system ( )) or to customize the model. for saps ii the customization is applied to the equation regression, using the same saps ii score. for mpm i each component of the model can be customized. several remarks : only one model is published to be applied at the icu entry ( mpm ii ) before any therapy. -most of the published scores are calculated from the lsl icu day. applying these scores to the let day of sepsis could have a very different significance. -is the accp classification of sepsis useful at the bedside to select oatients ? ( the pathophysiology of sepsis involves a dynamic interaction between the host and the infecting microorganism(s). a multitude of biochemical and hemodynamic interactions occur which function in concert to determine the ultimate outcome of the septic episode. the complexities of the septic process preclude outcome analysis by in vitro systems or computer models, animal studies have become indispensable in evaluating new therapeutic agents in the treatment of sepsis. these studies provide valuable information on safety, pharmacokinetics, relative efficacy and dosing strategies for potential therapeutic agents in the treatment of sepsis. there are three basic types of animal models: ( ) toxicity models with injection of bacterial endotoxin or exotoxins; ( ) live or killed bacterial challenge models; ( ) actual infection models. all models employ some form of external manipulation under controlled conditions to induce sepsis and to analyze potential therapeutic efficacy. these experimental requirements may limit the ability of animal models to accurately predict the clinical value of new agents in human sepsis. four major end points are analyzed in the various animal models: ( ) hemodynamic parameters; ( ) modulation of host-derived inflammatory mediators; ( ) resolution of end organ injury; or ( ) lethality. each animal model has certain advantages and limitations. species-specific differences in physiologic and immunologic features make it difficult to directly extrapolate the results of animal experiments into clinical medicine. while no ideal animal model exists, consistent benefit of a new immunotherapeutic agent in multiple animal systems provides the most compelling preclinical evidence of its therapeutic potential in septic patients. consensus-assisted development of a study protocol on sepsis: an important difference from previous randomized trials there have been several, and perhaps too many metaanalyses of cliuical trials on surgical infections, but their results have only rarely been incorporated into the design of new randomized trials in sepsis. metaanalysis is retrospective. it seems more important to analyse and to criticize the design of tria/s before they are ongoing. incorporation of that into development of a study protocol is the aim of the following procedure: the time-schedule of about two years should include further cell culture and animal experiments after the first successful studies showing effectiveness. exhaustive evidence for a dose-dependent cost-banefit and near complete explanations of the pathomechanism should not be awaited for development of the protocol of the clinical study. however, a discussion forum of experts should be performed in a recently published, almost perfect trial in order to see the frontiers of the present research in cell and molecular biology, clinical pharmacology, statistics and decision making. this should be followed by a metaanalysis of at least study designs on sepsis with methods of formalized medical decision making (decision tree). clinical algorithms -developed by objective methods including nominal group processes -should be developed to standardize any concomitant treatment in the centers considered for a multinentre trial. the latter is usually necessary in the field of sepsis. finally, a pilot study should be performed to demonstrate not only feasability, but to learn about all possible types of interventions which modify endpoints as response variables. especially mortality is not free from such effects. the time for the individual phases of this consensus-assisted process of protocol development have to be shortened by their temporal hiterloeldug. due to the fast discovery of new chemical factors in sirs it wilt otherwise be impossible to come up with results of randomized trials which are fascinating enough to be incorporated in daily routine treatment. severity scoring systems are intended to provide a population-based estimate for the risk of an unwanted outcome resulting from some disease process. in the area of infections and the "septic" response, this has routinely been defined as death. for anti-infective trials, there has been a reasonable correlation of severity (apache ll) with outcome measured as persistent or recurrent infection, but this is not as robust as the association with mortality. it is expected that non-lethal failure would not immediately correlate with disturbed physiology: the basis for antiinfective failure depends on a variety of factors not measured in severity scoring, such as type of infecting organisms, density and susceptibility to administered antimicrobia[s, and anatomic features of infection (e.g., pancreatic). severity scoring is important in differentiating these "categorical" variables from continuous (physiologic) variables. there are, additionally, a series of problems related to the cause of death in relation to severity scoring. in those tdals in which cause of death is analyzed, high severity scores did not routinely predict death as an immediate sequelae of sepsis/septic shock. many of the predicted deaths occurred remotely of progressive background diseases. other important problems with severity scoring have to do with lead-time bias: hew long patients were ill before entry into the study. statistical techniques for condensing various categorical and continuous variables, as well as factoring in information requiring the pharmacodynamics of agents which affect outcome, are being developed to further refine deviation from predictive equations as an outcome measure. stepwise logistic regression analysis has identified the presence of shock, intm-abdominal or unknown source of infection, hospital acquired infection, age greater than years, neutropenia and inappropriate antimicmbial therapy as independent variables associated with increased mortality in sepsis. maldistribution or" these variables is a concern in targe randomized clinical studies. it should be noted that only the selection of antimicrobiai therapy could be addre.~'sed and altered at the time of enrollment in a sepsis clinics] trial. inappropriate antimicrobial therapy has been noted in %- % of septic patients. well designed, randomized sepsis trials do not assure the absence of imbalance between treatment and control groups with regard to inappropriate antibiotic therapy, especially with subgroup analysis. statistical manipulation to correct for any imbalance is appropriate but avoiding imbalance is ideal. selection of antibiotics in septic patients requires such considerations as clinical setting (history, physical examination and underlying disease), appropriate laboratory tests (such as gram stain), identification of source and associated bacterial flora, antibiotic susceptibility patterns for that hospital and likelihood of resistant organisms. determination of inappropriate antibiotic therapy is made retrospectively after culture results are available. in some circunmtances the organism and antibiotic sensitivities cannot be predicted, while in others it can. leibovici et al identified hospital acquired infection, antibiotic treatment before a bacteremic episode, endotracheal intubetion and thermal trauma as independent variables which predicted isolation of a multiresistant organism. the same authors developed a predictive index for resistant organisms, which when compared to prescriptions of attending physicians, improved antibiotic selection in critically ill patients. including a standard antibiotic regimen for all septic patients in a clinical trial is impractical. there is too much interhopsital variability in flora and antibiotic susceptibility. in addition, the aggressive broad spectrum coverage necessary for some patients is inappropriate for others. a protocol which guides a prescribing physician through a logical chain of reasoning might improve antibiotic selection in critically ill patients and could be included in the design of a clinical trial in sepsis. although this approach might minimize potential for maldistribution of inappropriate antimierobial therapy, it would likely create multiple problem areas. will the patient's physicians agree to the protocol choice? what is the availability of speciftc antibiotics at a participating hospital? what is the aplpiieability of study results in typical clinical situations? if there is agreement that thin is an appropriate antibiotic protocol, should it not be used in all seriously ill septic patients in the hospital? in other conditions such as ards, the success of protocol therapy is dependent upon measurable goals such as pao and highest plateau pressure, while measurable goals are not as clear in choosing antibiotics. based on the above confounding issues, a complex and extensive algorithm covering many potential possibilities of error and specific antibiotics seems impractical; however, an algorithm focusing on three to four major common errors in antibiotic selection and dealing with classes of antibiotics is plausible for inclusion in sepsis clinical trials. in this session we will attempt to outline the methodology of such a future study, emphasizing the immense difficulties involved in its proper conduction including: design, selection of patients, surgical considerations, supportive treatment, the "human factor" and ~nd points. only a close cooperation between a few dedicated surgeons, obsessively studying a large number of well selected and stratified patients over years, could make such a study possible. algorithmis have frequently been mistaken for the graphic format in which they are presented. however, an algorithm is neither a flow chart nor a list of instructions; it is a step-by-step approach to solving a problem. likewise, a clinical algorithm is a step-by-step approach to solving a clinical problem. cas are deterministic, which does not mean that they are rigid. they are practical rather than mathematical algorithms, that tan be used only with clinical judgment, and must be tailored to each patient. there are a number of types of, or uses for, cas that can improve sepsis management, including: diagnostic or severity scorm cas, a management ca for managing sepsis constructed according to recently published standards for use in teaching research protocol algorithms that must be used to collect data or guide implementation of a clinical trial aimed at validating one or more dicisions in the management ca; finally, protocol-style cas drawn from the management ca and should be validated using matching outcome studies. organisational problems peculiar to multicentre trials the organisation of any randomised clinical trial is fraught with difficulties, and that of a multicentre trial particularly so. there are problems associated not only with the principles on which the investigation is based but also with the detailed organisation and analysis. are all the participants truly unbiased about the relative merits of the regimens being studied? is like being compared with like -are all the end points and the standards for measuring them clearly defined so that they cannot be misunderstood? are all eligible patients being studied, and their results reported? is truly informed consent being sought that will satisfy not only the patient's right to choose what happens to him, but also the law of the land? and, finally, how can the participants be sure that the trial will be stopped at the right time, to ensure that no treatment is given to any patient that might be harmful? these questions may seem insoluble, but until we tackle them we shall never be certain. dr.m. ev~s, scar~mu~ hospital, scarborough, nonhyo~s~ y ql, u.k. increasing knowledge of the pathogenesis of sepsis and septic shock has led to the development of many new therapies and technologies capable of preventing, blocking or even reversing the deleterious cycle of events. recent results of subsequent multicenter trials testing some novel therapeutic drugs, however, did not confirm the promising sometimes overwhelming effects obtained experimentally. it is postulated that this is largely due to inappropriate design and conduct of multicenter trials as currently performed. one of the shortcomings emphasized in this paper is the "treatment mix" problem. multicenter trials in sepsis are performed because no single center is able to recruit the necessary number of eligible subjects within a reasonable time. each single center (icu) has its own individual policy which cannot be standardized for the trial (treatment mix). even if we ascribe that each icu did the "best" for their patients, it is highly probable that the outcome differs between the icus. this translates to the effect of the new therapy under investigation. ]t is therefore worthwhile to consider that icus must first demonstrate a certain standard based on the patients' outcome (audit) before becoming accepted as a participating center. this prerequisite ensures comparable quality between participating centers, led to the reduction of "noise level" and increases the probability of positive study results. the riyadh-icu program based on standard mortality ratios is recommended as an audit instrument. during the last decade most clinical trials of potential therapeutic agents in systemic sepsis have failed to demonstrate benefit from the drug under study. although in many instances it is entirely possible that the agent in question does not have clinical efficacy, an equally plausible explanation for the multitude of negative results is that the studies were improperly designed and thus could not show therapeutic benefit, if it existed. problems which have been identified in these various trials include inappropriate or unrealistic definitions of response to the drug; inadequate sample size, with attendant insufficient statistical power to demonstrate a difference, if it existed; insufficient standardization of customary therapeutic maneuvers in septic patients; imprecise criteria for patient entry into the study, which creates unacceptable inhomogeneity between control and treatment groups and invites unjustified post-study subgroup analysis; the lack of a formal sequential monitoring procedure for interim data analysis, which could potentially affect patient safety; and a primary analysis of study results that excludes protocol deviants and is not according to intent-to-treat. these and other problems have impacted upon the validity of the various trials conducted to date and may well have prevented the resolution of controversies surrounding the use of certain agents in the treatment of septic patients. the complexity of bacterially-induced septic shock involves a cascade of events that evolve over time, beginning with the proliferation of offending organisms and followed by the release of toxic mediators from the bacteria. endotoxins [e.g. lipopolysaccharides) from gram-negative bacteria initiate septic shock by precipitating a systemic inflammatory response syndrome (sirs) through release of a broad spectrum of hostderived mediators. over the last century, hundreds of these endogenous mediators have been proposed to serve as pathophysiological substances in this "alphabet soup" of cytokines, eieosanoids, biogenic amines, kinins, peptides, ions and hormones. an evaluation of the literature on septic shock leaves the investigator with a sense that, although many pieces of the septic shock puzzle have been presented, no clue was provided to indicate how these pieces fit together, in an attempt to assess objectively the causal role of individual mediators, we recently completed a collective meta-analysis of mediators that were individually reviewed and subjected to koch-dale analysis of causality by distinguished authorities in the field ( ). in summary, our attempt analyze available evidence to support a cause-and-effect relationship for putative mediators of septic shock revealed that only eight of the mediators analyzed could be strongly inferred as playing a causal role in septic shock. evidence supported the involvement of endotoxln, endorphins, complement, interleukins, tumor necrosis factor, eieosanoids, platelet activating factor and calcium. other mediators either lacked adequate supportive evidence or were not conclusively involved. posttraumatic outcome may be reduced by an amplified stress response mediated by neural and humoral stimuli. the classical hormonal catabolic response is predominantly mediated directly or indirectly by neural stimuli, while most changes in inflammatory responses such as leukocytosis, acute phase proteins and changes immunofunction are mediated by humoral mediators. clinical experience from controlled studies suggest afferent neural blockade and modification of stress response to improve organ function and postoperative outcome, and limited experimental studies also suggest neural blockade to be of beneficial value in shock states. of special value may be the improved gastro-intestinal motility after neural (visceral) blockade. no outcome studies are available from patients with major truma, multiple organ failure or sepsis, conditions where humorai mediators may be more important to modify than neurally mediated responses. future studies should investigate the clinical outcome effect of combined neural and humoral mediated blockade, as well as the potential role of an initial neural blockade in elective trauma (first hit) to improve the metabolic scene and outcome if a postoperative complication (second hit) should occur. neutrophil elastase is the predominant protease of the human neutrophil. this enzyme, and a variety of other enzymes, including neutrophil collagenase, are released by activated neutrophils in the setting of high concentrations of reactive oxygen metabolites. in addition, in this extracellular environment, the normal antiprotease defense mechanisms of the organism may have been severely inactivated oxidatively especially along capillary endothelial cells. accordingly, release of neutrophil elastase which mediates inflammation and degrades most extracellular matrix proteins, including elastin, fibronectin and many forms of collagen, may contribute to tissue injury and organ failure in a variety of diseases ranging in severity and acuity from pulmonary emphysema to the adult respiratory distress syndrome (ards). as a result, significant efforts by the pharmaceutical industry have been directed not only toward the development of human neutrophil elastase inhibitors, but also toward their characterization in a variety of animal models of neutrophil mediated diseases, and their evaluation as potential therapeutics for the treatment of a variety of human clinical conditions. data from animal models of organ injury and failure along with data collected from a series of patients at risk for ards and with ards will be presented and discussed as a rationale for inhibition of neutrophil elastase. parameters that need to be monitored to obtain success in future clinical studies will also be presented in this context. have turned out to initiate and maintain organ dysfunctions in severe posttraumatic and postoperative courses. such proteolysis-induced disorders are especially rendered possible by the concurrently arising consumption of inhibitory regulators (e.g. a vproteinase inhibitor=a pi, antithrombin iii=at iii) via cofnplex formation and/of proteolytic/oxidative inactivation. besides the well-known destructive potency against protein substrates, proteinases such as elastase or thrombin (active or in complex with the serpin inhibitors ~ pi or at iii) are also supposed to increase the inflammatory reaction by inducing cytokine release or shedding of soiuble adhesion molecules from various inflammatory cells (pmns, monocytes/macrophages, endothelial cells). those cell-derived mediators may provoke further cell activation through an autocrine/paracrine loop thus increasing significantly the proteinase burden at the inflammatory focus. therefore, this noxious circle might be interrupted by a convenient proteinase inhibitor therapy to ameliorate the inflammatory process. to verify this hypothesis, high dosis of at iii (mean plasma levels up to %) were applied in first controlled randomized studies on surgical patients suffering from multiple trauma or severe sepsis. in control patients we could clearly demonstrate the sequential appearance of proteinase/serpin-complexes (fa pi, tat), cytokines (il- , il- ), and soluble intercellular adh sion molecules (icam, elan, p-selectin) in the circulation. these factors turned out to be a helpful tool for early diagnosis and prognosis of forthcoming organ dysfunctions. interestingly, m at iii-treated patients a significantly reduced release/production of inflammatory mediators became obvious concomitant with the improved clinical course in comparision to an increasing deterioration in control patients. soluble mediators of inflammation are cytokines (e.g. il- , il- and tnfe) as well as breakdown products of complement proteins (e.g. c a and terminal complement complex). therefore, attenuation of both, release and generation of these synergistically functioning mediators together with stimulation of release of antagonists including soluble forms of receptors are potentially beneficial in all kind of inflammatory diseases. intravenous immunoglobulins (ivigs) are known to have an anti-inflammatory effect in humans (nih consensus conference on wig, ) . the mechanism of action becomes more and more clear. in single cells stimulated by anti-cd mab wig was able to down-regulate production of il- , il- , ifn% and tnfj~ significantly. igg coated solid-phase stimulates release from monocytes of interleukin- receptor antagonist (il-lra) but not of il- ; this observation is very much in contrast to the effect of endotoxin in the same in vitro system. furthermore, naturally occurring anti-cytokine antibodies can be demonstrated in apparently healthy individuals and in wig prepared from plasma pools. some of these antibodies can be detected by antigen/antibody reactions in fluid phase (anti-ll-le, anti-il- ), some only by solid-phase detection systems (anti-ll- , anti-ifn% anti-tnfc . infusion of wig to patients suffering from inflammatory disorders have resulted in a decrease in il- in circulation. during infusion wig might induce an acute but transient rise of tnfo~, il- , and il- . self limitiation of this process might be due to demonstrable instant release of il- ra and soluble tnfo~ receptors. in vitro ivig has also been shown to attenuate complement activation via the classical pathway. furthermore, acid haemolysis of erythrocytes in paroxysmal nocturnal haemoglobinuria could partially be prevented by ivig. ivig was able to attenuate forssman shock in guinea pigs. we have seen a patient with congenitally elevated turnover of alternative pathway of complement who repeatedly showed an increase of haemolytic titres after administration of ivig. thus, wigs apparently have multiple potencies including attenuation of soluble mediators of inflammation and might therefore be of benefit in trauma, shock, and sepsis. significance of sinusoidal liuing cells and of humoral factors on hepatic function following sepsis and major surgery hirata k, katsuramaki t, yamaguchi h, mukaiya m, yamashiro k. regeneration of the liver after hepatic necrosis or partial removal has been extensively studied, but uncontrolled mechanisms to irreversible hepatic failure following sepsis or major surgery of liver or with hepatic dysfunction have so far not been well documented. we suggested the importance of the intrasinusoidal aggregation between sinusoidal lining cells and intrasinusoidal running ceils in the mechanisms of hepatocyte dysfunction. thus, the purposes of this study was to investigate the changes in each sinusoidal lining cell during this process and the effect of cytokine on hepatocyte under various oxygenation. [ materials and methods ] ( ) clinical study : thirty two patients with histologically proved malignant tumor underwent major hepatectomy were devided in two groups, i_e. the cirrhotic liver group and the non-cirrhotic [aver group. most of the former were the patients with hepatocellular carcinoma and most of the latter were the patients with metastatic carcinoma of colorectal cancer. five patients were complicated septic conditions with hepatic failure. following operation in each patient, a verous blood sample was taken for measurement of serum il- , il- , tnf and c-reactive protein concentration. and hepatic biopsies were sometimes undergone in patients with anomalous hepatic function. ( ) experimental study : kupffer ceils, sinsoidal endothelial cells and hepatocytes were separated from mouse ( c hhen ) liver. and also polymorphonuclear cells and platelets were purified from blood and peritoneal macrophages were from peritoneal cavity of mouse. co-cultures between or among these cells with iipopolysaccharide were performed. cytokine concentrations in media and hepatocytic function were compared. [ results and conclusion ] our findings in above experiments demonstrated the cleanly different concept for the mechanism of hepatocyte dysfunction following sepsis or major surgery. namely, the effect of hepatoeytie function by cytokines or superioxide were significantly affected under low oxygenation, but not significant under good oxygenation. hirata m.d.,nishi ,hokkaido,japan $ immune complexes as .mediators of sepsis and immune dyafumcffon laa k horn, chxistof birkenmaier, and greg h mon departmen~ of surgery, san frandsco general hospital, urdversr , of calif(~rrda, san frandsco. immune complexes (ic) a;:e commonly found circulating in parians during infection and sepsis; and following traumm, bums, and massive l~ensfusion. clearance of c occurs by phago~'tmsis of esll-bou_nd or opsonized p~tlcles. monocyte activation du~jng phmgocytos/s could lead ~o release of cytokilies ieletexiot~ to the hosh to examine tb/s phenomenon, we formed insoluble ic by precipitating iow-endotoxin bovine serun~ albumin (bsa) with rabbit ant/-bsa igg. we have ~town that these ic are ingested by monocytes and concomitantly stimv/ate re~pizatory bu~t activity measuxed by assay of in%racellul~ peroxldaffon. we have shown that ic ingesffon produces signlqcant el,era,lore in the monoey~e phenotype. spedacally, cdi is down-regu/ated, along wl~ cd and cd . thus responsiveness to lipopolysacchmdde ( ) a~xd i=m~unoglobulin fe st~mu/mtlon is reduced. in cert,+rest, the complement rote.p tot cdc is u~-regulamd, indicaling mcremsed re~ponalx=~ness to opsonized pat,rotes, we examined monocyte superna~n~s for production of hzmor necrosis factor alpha (tnfg) following ic stimulation and showed that ic are capable of provoking ~elaase of hrmaunl)reac~ve tni~. j[c also increase mono=yte produchon of prnstaglandin e . in summary, ~/~ese results demonstrate lhmt ic are capable of indudng production of ¢ytokines and the imrau-nosuppressive prostaglandin pge . ic also allez ~he surface expression of important receptors involved in actlvaffon by lp~ and phagocyiosis. thus, ic aze competent for indud/on of the mepl/e s! otlse. by examining m n cyte phenotypms, it may be possible to d~mrmkne extent ohn'u~u~e complex activation and predict immune depression iu criffcally ill pa~ents. a great deal of experimental work has focused on preventing and/or treating sepsis and organ failure following injury. many of these strategies have tried to attack mediator substances released during the systemic inflammatory response following injury. sugermann has demonstrated the improvement of pulmonary function, but not eappillary leak using [buprofen in the porcine model. in a clinical trial, faist demonstrated the effectiveness of indomethacine in amelierating the post trauma of cellular amenity using in vitro parameters. morbidity and mortality, however, were not different between control and treatment groups. baue und chaudry have suggested that atp magnesium chloride may have protective effect in renal failure um kupfer cell dysfunction seen after shock. pentoxiphyllin has been found to be effective in improving tissue oxygenation and oxygen consumption following hemorrhage, and there may be promise for this drug in the ischemia reperfusion injury. monoclonal antibodies against endothxin and inflammatory mediators seemed promising at first glance; however, preliminiary clinical data of the treatment of sepsis with either ha-ia or e monoelonoal antibodies against bacterial cell wall have been disappointing. initial studies with il-i receptor antagonist also appeared encouraging, but no difference was seen in the most recent trial. currently studies are ongoing with monoclonal antibodies to tumor necrosis factor which may have more efficacy given the fact that it is a macrophage mediator released by endotoxin. although we seem closer to understanding and preventing the problems of sepsis and organg failure after trauma, we must continue to appreciate the complex interrelationships and delicate balances inherent in the host defense system. overzealous attempts at restoring immunity in the absence of understanding pathophysiology may be just as dangerous at post-traumatic immlmospremsion. severe acute pancreatitis was caused by different etiologic factors, but once pancreatic tissues were infected, patients show a similar pattern of aggravation and develop organ failure. remarkable elevation of serum il- was unexceptionally observed in patients with severe acute pancreatitis. the serum levels were more than pg/ml (normal: less than pg/ml) during the first one or two days after onset. there was a significant correlation between the peak serum il- level and the number of organs showing failure (r= . ). tnf-a production by isolated peritoneal macrophages following lipopolysaccharide (lps) stimulation was significantly increased in cerulein-induced pancreatitis rats. serum tnf-a activity was elevated following intraperitoneal administration of lps as the septic challenge both in pancreatitis rats and in control rats, being significantly higher in the former (p< . ). histological findings and liver function tests revealed that lps induced more severe liver damage in pancreatitis rats than in control rats. these results indicate that increased tnf-a production by peritoneal macrophages in acute pancreatitis augmented lps-induced liver injury. organ failure in severe acute pancreatitis could be caused, at least in part, by increased cytokine production. it is clear now, that in mods, organ injury is not directly due to exogenous factors, such as bacteria or toxins, but instead is largely a consequence of the host's own endogenously produced mediators. there is an extensive body of literature on the inhibition of mediator production, release and action in different cascade systems by glucocorticoids. they can serve as a host protection against overactive defense reactions if used adequately. a new understanding of the regulation of cytokine synthesis, especially tnf, may lead to an insight of the conflicting findings between the benefits of glucocorticoid therapy in animals and its current failure in recent clinical trials. glucocorticoid shares its role with other novel therapeutic approaches also shown to be successful only in experimental settings. a mete-analysis of steroids in sepsis, however, revealed a beneficial effect in the subgroup of patients with gram-negative infections. there is now a series of arguments to reevaluate the indication for steroid thera-py and/or prophylaxis in mods and sepsis. honjo i- - , kumamoto , japan in septic shock j. briegel, m. halter, h. forst, w. kellermaun, m. bittl, k. peter imrodnetlea and methods: hydrocortisone (hc) at an infusion rate similar to the maximal secretory rate of cortisol in man improves hemodynamics in human septic shock ( ). we hypothesized that the hc-induced hypercortisolemia prevents a harmful overshoot of immune reactions. to test this hypothesis we prospectively investigated patients admitted to the icu in refractory septic shock. after resuscitation (mechanical ventilation, fluid resuscitation, titration of vasopressors, and initiation of antimicrobial therapy) hc was started with a loading dose of mg/ rain, followed by a continuous infusion ( mggh). with hemodynamic improvement (dopamine < gg/kg/min) the infusion rate nfhc was tapered over a period of days. phospbolipase a (pla ), c-reactive protein (crp), and elastase-proteinase inhibitor complex (e-pi) were deierminated daily. results: according to our previous results hemodynamics improved during hc infusien. after days dopamine requirements decreased to less than gg&g/min in all patients. this corresponded to an attenuation of the systemic inflammatory response syndrome (sirs) indicated by the abrogation of fever and the decrease in heart rate and inflammatory mediators. pla activity and e-pi concentrations decreased to near normal values and crp concentrations decreased as well. after cessation of hc infusion (between day and ) a reinforcement nfthe sirs was observed despite cortisol levels within the normal range. this was first indicated by e-pi, followed by fever, increases in heart rate, crp, pla , and finally by the relapse of septic shock in four patients on days , , and o. a second infusion of hc again resulted in shock reversal and in a decrease in pla , crp, and e-pi in the patients under study. discussion: there is growing evidence that the endogenous steroid hc and proinflammatory cytokines integrate a complex immunoregulatory feec~ack circuit. the elaboration of tnf, il- , il- , and il- is attenuated by- rag hc prior to endotoxin challenge in humans ( , ) . cytokines like tnf, il- , il- , and il- are potent proinflammatory signals for acute reactants (--, clip), neutrophil degranulation (--, e-pi), and pla synthesis and secretion. our data provide evidence that hc at an infusion rate similar to the maximal secretory rate of cortisol in man attenuates the systemic inflammatory response in human septic shock. to evaluate the feasibility of a nigh-dose regimen of antithrombin iii (at iii) treatment in patients with multiple injuries regarding blood levels of antithrombin iii and undesired side effcts and to analyse effects of the initibitortherapy on the systemic inflammatory response. patients and methods: patients with an iss nf more than points who could be treated with at iii administration within rain after trauma were randomized to receive either at iii or placebo. at iii was given to reach an antithrombin iii inhibitory capacity in plasma of % by using the following calculation: at iii to administer = ( % -at iii measured) x body weight. at iii was given every six hours for a period nf hours and on the th day. patients were followed up throughout their stay in the icu but at least days. in this abstract the data of the first patients are included. results: the patients' median injury severity score was points with a median age of years. the patients were equally distributed between verum and placebo groups with respact to age , iss, prehospital treatment, blood pressure, hemoglobin and at nmevel on admission, and time from the accident until the test solution was given. the patients of the at iii group received , units of the inhibitor on average during the first days. with our regimen, the at iii levels could be kept between % and % of normal, whereas control patients an at hi concentration of % to % was observed. patients with at ni treatment required less red blood cells bur received the same amount of ffp and fluids. there were no differences with respect to platelet count, partial thromboplastin time, l~rothrombin time and prothrombim. we did not observe bleeding disorders or any other side effect with peak concetrations of up to % of normal. white blood count, pmn--elastase, interleukin and and c-reactive protein tended to be lower in the at iii group. there were no differences with respect to renal and hepatic function parameters but the duration od mechanical ventilation was shorter in the at ii group ( . vs. . days) conclusions: we conclude that our treatment protocol (a) was able to restore at iil levels to the desired range of %, (b) did not lead to coagulation disorders, (c) did not increase transfusion requirements, (d) did not reveal other undesired side effects, and (e) showed a tendency towards reduced posttranmatic inflammation and mechanical ventilation requirements department of trauma surgery, essen, germany antithrombin-lll (at-ill) acts as an inhibitor of thrombin, further proteases and the alternative pathway of the complement system. inhibiting thrombin, at-ill works as a functional antagonist of paf~ therefore, in state of hypevolemic-traumatic shock, continuous supranormal serum -and tissue -concentrations of at-ill may be efficient to reduce the local posttraumatic reactions resulting from complement and pmn-activation. patients with severe multiple trauma ( treatment [at-ill] -- controls [c]) were investigated. study cdteda were age > and < years, injury severity (iss) > points and glasgow-coma-scale > points; randomization and treatment has to be started within hours after trauma. permission for the clinical study was given by the local ethic committee. bradykinin (bk) and related kinins are potent inflammatory peptides which possess the ability to induce, vasodilation, increased vascular permeability and hyperalgesia. cp- , a novel homodimer bk antagonist has previously been shown to increase survival in rat and rabbit models of lethal endotoxin shock and is now in clinical trials for sepsis. we have now evaluated the effect of cp- in other models of inflammation. male rats were precannulated with a catheter in the carotid artery. h later bk was injected ia and the pain score ranked from (no responses) to (vocalization). cp- at . umoles/kg completely inhibited the pain responses for a period of . - h. cp- at . umoles/kg s.c. was also found to inhibit the increase in paw volume and hyperalgesia induced in rats over a - h period by an intraplantar injection of . % carrageenan. the abdominal constriction response o an intraperitoneal injection of kaolin was inhibited in a dose-dependent manner by cp- . when ul of . % formalin was injected into the paw of a mouse a characteristic licking response was observed which was biphasic in nature. cp- significantly inhibited both the first ( - min) and second ( - min) phase responses. ]n a rat burn model, where the hind paw is immersed in water at °c for sec the increase in paw volume was significantly reduced by pretreatment with cp- , . umoles/kg s.c. finally cerebrai edema was induced in rats by applying cold (- °c for sec) to the dural surface following a craniectomy. cp- at . umoles/kg s.c. produced a significant reduction in the amount of edema compared with sham controls h later. these data suggest that bk is an important mediator of inflammation and hyperalgesia and that the bradykinin antagonist, cp- , may be useful in the treatment of such inflammatory, hyperalgesic disorders. partial hepatectomy in humans is associated with a considerable morbidity due to hemodynamic and metabolic derangements, which increase the risk for organ failure and mortality. we hypothesized that endotoxemia may play a pivotal role in these complications. we therefore, investigated whether peri-operative infusion of rbpi , a recombinant protein of the human neutrophil bpi with bactericidal and endotoxin-binding capacity, could prevent postoperative derangements following partial hepatectomy. male wistar rats ( - g.) received a % liver resection (phx) or a sham operation (sh), and a continuous intravenous infusion of either . mg/kg/hr rbpi (phx-bpi, n= ; sh-bpi, n= ) or the (iso-electric, iso-kd) control protein thaumatin (phx-con, n= ; sh-con, n- ). various parameters were measured h after the resection or sham operation. mean arterial pressure, cardiac output and heart rate were significantly decreased in phx-con rats compared with sh rats, which effects were not observed in phx rats treated with rbpi . blood ph was significantly decreased in the phx-eon group, whereas the leucocyte count, hematocrite and il- levels were significantly increased compared to sham levels. in the phx-bpi group, these parameters were restored to near sham levels. in vitro experiments with rat plasma and human mononuclear cells (mncs) revealed that plasma of phx-con rats is highly capable of activating mncs, accompanied by the release of cytokines. this activation is attenuated with phx-bpi plasma. in vitro added acd or polymyxin b was able to reduce the activation by phx-con rat plasma to the levels of phx-bpi rats thus, these data suggest that systemic endctoxemia, possibly of gut origin, is a major cause of postoperative hemodynamic and metabolic derangements following phx and that rbpizz can prevent these changes. more recently we reported a transient appearance of both endotoxin and tnf in the circulation of rats subjected to the haemorrhagic shock (hs) already at - rain. similar to bpi, recombinant bpi was found to bind lps and inhibit tnf formation in vitro. the aim of this study was to investigate the effects of rbpi (kindly provided by xoma corporation, berkeley, ca) against haemorrhage related endotoxemia and mortality in rats. method: a prolonged hs was induced by blood withdrawal to a mean arterial pressure of - mmhg for rain followed by reinfusion of shed blood (sb) and resuscitation with two times of sb volume of ringer's lactate over rain. rbplg. was administered at a total dose of mg/kg i.v. ( . mg/kg at the -eginning followed by two doses of . mg/kg each at end of shock and the end of resuscitation). the control group was treated similar to the bpi group but received thaumatin as a protein control preparation at the same dose as rbpi . results: imrffe?diately after resuscitation ( min) the detected plasma endotoxin levels in the control group (mean = , range = - pg/ml) were almost neutralized by rbpi treatment (mean = , range = - pg/ml) . plasma tnf levyis were not significantly influenced by rbpi treatment at the two time points and min of experiment (means: and in bpi vs , pg/ml in the control group). the -hour survival rate was improved from / ( . %) in the control to / ( %). conclusion: these data suggest that haemorrhagic shock may lead to bacterial translocation and/or transient endotoxemia with concomitant cytokine formation that may play an important role in the pathogenesis after shock and trauma, rbpi might be a useful therapeutic agent against endogenous bacterfal/endotoxin related disorders in hemorrhagic shock. morbidity and mortality after hypoxia of the vital organs had been correlated to the production of oxygen radicle which is mediated by xanthine oxidase activity, in this study we have evaluated the survival rate after allopurinol. rabbits weighed + grams divided into two groups. group i included tabbits were treated with allopurinol mg/kg for seven days before induction of haemorrhage. group ii as a control included rabbits. all rabbits were subjected to % arterial blood loss through the central ear artery for one hour then resusciatation was done by the heparinized withdrawn blood through a marginal ear vein. during the experiment blood pressure and heart rate were monitored through the central ear artery. also uric acid, lactic acid, glutathione activity were estimated. animal survival was followed for days. postmortem vital organ histochemistry and histopathology examinations were done. in group i the survival after three days was out of while in group ii it was two out of . our conc|usion, allopurinol had increased the survival in aiiopurinol pretreated rabbits which may indicate the value of allopurinol premedication for patient prepared for elective bloody surgical intervention . h receptor antagonists are commonly used for stress ulcer prophylaxis, but their actions on the septic response are largely unknown, in an experimental model, pigs were first anesthetized, then injured with joules of energy to the posterior thigh, then hemorrhaged - % of their blood volume. after i hr of shock, all the shed blood plus x the hemorrhage volume as lactated ringers was infused. following resuscitation, ranitidine ( . mg/kg iv twice daily) or saline placebo was begun. the treatment group was randomly assigned in a blinded fashion. after hrs, a septic challenge was administered ( bg/kg of e. coil endotoxin (lps)). serial gastroscopy, gastric ph, hemodynamics, abg's, physiologic dead space ventilation, leukocyte counts, and tumor necrosis factor (tnf) levels were recorded for min. baseline values and units were cardiac index _+ ml/min/kg (ci), arterial po + mmhg(pao ), base excess . -+ meq (be), physiologic dead space fraction +_ % (pds), and tnf . + . units/ml. baseline gastric ph was . -+ . and . _+ . in the placebo and ranitidine groups, respectively. the gastritis following hemorrhage was marginally attenuated in the ranitidine group. following lps infusion the following were obtained: ci pao * be* gastric* pds* peak* rain rain rain ph min tnf ranitidine _+ _+ - . ± . bum injury results in hypermetabolism, fever and nitrogen wasting. endotoxin (lps) has been proposed to mediate these effects, either directly or via activation of macrophages to produce cytokines such as interleukin- (ii- ). this study was designed to clarify the role of lps and - in the metabolic response to bum injury. twenty-five burn patients ( -+ %; + % ft bsa burn; _+ years old) were studied serially for three weeks post bum. patients underwent partitional calorimetry to assess metabolic rate and compartmented heat loss. nitrogen was assayed using chemiluminescence. lps and i - were measured with limulus amebocyte lysate assay and elisa. patients were excluded if they suffered smoke inhalation, showed any sign of sepsis or failed to rapidly meet their nutritional needs via the enteral route. ten patients received intravenous polymixin b ( , u/kg/day to bind lps). these patients did not differ for the remainder. all patients were hypermetabolic and febrile in proportion to the size of their bum wound but were not endotoxemic ( . +_ . pg/ml; normal < pg/ml). i - did demonstrate a significant correlation with cole temperature (tr~ = . + . ogi - , p= . ) and with nitrogen excretion (nou t = - . - . ogi - + . tr, p= . ). administration of polymixin b had no effect on metabolic rate, temperature or i - levels but did reduce nitrogen excretion resulting in more positive nitrogen balance ( .t grn/day vs. - . gm/day, p= . ). although bum injury does not produce an obligatory endotoxemia, i - does appear to play a role in the fever and nitrogen wasting seen with such injuries. the effect ofpolymixin b on nitrogen excretion suggests that lps may play a role either locally or in the portal system. introduction: there is substantial evidence that release of inflammatory mediators by activated kupffer cells contribute to the course of a systemic inflammatory process, e.g. after shock or lrauma. besides the systemic effects of mediators such as tnf, paf or interleukines, local actions on hepatic microvasculature and hepatic inflammatory response have to be considered. our aim was to assess the role of tnf and paf by blocking their effects using anti-tnf monoclonal antibody, pentoxifylline and a paf antagonist. methnds: in anesthetized sprd-rats, hemorrhagic shock was induced by withdrawl of arterial blood within rain and shock state was hold for h at a map of mm hg (cardiac output of %). following adequate resuscitation with % of shed blood and twice of this volume as ringer's solntion, animals recovered to map > mm hg and co > %. hepatic microcirculation and sinusoidal leukocyte-endothelium interactions were examined by intravital epi-fluorescence microscopy at , , or hours after resuscitation. in a blinded fashion, a rat-specific monoclonal anti-tnf antibody [ mg/kg, celltech, uk) , pentoxffylline (ptx, mg/kg, hoechst, d), and a paf antagonist (web , boehringer, ingh., d) were given either as pretreatment or at the time of resuscitation (n= - group bolla. k*., duchateau, j., hajos, gy., mbzes, t., hern~di, f. prevention of temporary/secondary immune deficiencies or reduction of their severity and/or duration as well as the reduction of the perifocal inflammatory processes belong to the rational targets of posttraumatic/pedsurgical medication. such a targeted medication can result in less frequently occurring nosocomial infections, and in reducing the duration of the intensive care and convalescence period. the results of in vitro studies performed with the amino acid sequence - of thymopoietin, i.e., with thymocartin in whole blood and peripheral mono-nuclear celi(pbnc) cultures clearly show some characteristic effects of this immunomodulator. preincubation with the tetrapeptide significantly (p<o.ol) and concentration-dependent reduced the endotoxin(lps)-induced tnfalfa production from , to about pglml, but did not abolish it. the inhibition of the lps( . ug/ml)-induced tnf production occured already in presence of , pg peptide/ml and peaked at the concentration of , ng/ml. higher concentrations did not increase this effect. in contrast to the other two small thymic peptides (tp- and tp- ), thymocartin did not enhanced the pwm-induced pge production in pbmc cultures up to a concentration of ng/ml, inclusive. the selection of thymocartin (tp- ) for perisurgical medication and/or for treatment of trauma-induced temporary immune depression has been strongly supported also by targeted animal experiments. thus, mortality of about % registered in mice infected with pseudomonas aeruginosa after bum injury could be reduced with the tetrapeptide treatment to a level which did not differ significantly from that of the infected non-burned controls. moreover, observations gathered first of all with the inflammatory model of air poach/croton oil grenuloma (selye) clearly showed, that a very definite, antiexudative effect can be achieved with this thymic peptide. as to this effect, thymocartin has been confirmed, e.g., to be equipotent with locally administered fluocinolone acetonide and/or s.c. injected prednisolone. the interim results of two explorative double-blind clinical studies (involving more than patients after polytrauma and hip-fracture untill now, respectively) correspond to the expectations. the treatment significantly reduced the occurence of nosocomial infections, the days spend in intensive care and on antibiotics as well as it shortened the bed-out time and reduced the additional medication. objective of this prospective randomized study was to further delineate the mechanisms leading to these alterations and to investigate the effects of immunomodulatory intervention. patients and methods: patients (pts) formed control group a. group b pts received x mg indomethacin (indo) from the first (dl) to the fourth postoperative day (d ) intravenously to block prostaglandin e induced suppression of cmi response as well as mg thymopentin (tp- ) subcutaneously preop., on d and d to augment cmi reactivity. in vitro investigations preoperatively, on dl and d included measurements of the percentage of cd + t-helper (th) cells, pbytohemagglutinin (pha)induced synthesis of interleukin (il)- as one cytokine primarily produced by thl-cells, and pha-induced synthesis of il- as one cytokine primarily produced by th -cells. delayed type hypersensitivity (dth) skin response to an antigen skin test battery and specific antibody (ab) production following tetanus vaccination preoperatively and on d were used as in vivo tests for thl-and th -induced immune response respectively. results: postoperatively, group a pts showed a persistent significant reduction of cd + th cells, il- /il- ratio, and dth skin response as compared to baseline values (bl), while ab production increased (p< . vs.bl). in group b pts no change in cd + th cells, il- /il- ratio, or dth skin response was observed (p< . vs.group a), and postoperative ab production increased significantly (n.s. vs. group a). conclusions: .these results clearly indicate a significant suppression of th induced cmi response, while th induced response remains normal following ohs. .these alterations may gain clinical significance whenever a postoperative infection requires a th response and may explain the susceptibility to opportunistic microorganisms observed in pts after ohs. the aim of this study was to find out whether the establishment of administration of thymostimulin (tp-i) in jaundiced and anergic rats would return the rats to the state of immunocompetence. material and methods. male wistar rats weighing - g were injected with haemocyanin (klh). all rats with a positive response were included in the study and we evalu ated the t cell subpopulations and il- . they underwent laparotomy and the common duct was ligated and divided. those rats whic become jaundiced and anergic one week after the operation, were divided in two groups: control group ( objective of study. the goal of this study was to prove the necessity of thymus derived immunomodulators treatment in acute period of infantine sepsis, materials and methods. immune status was investigated in o infants. clinical conditions of children were defined by syndrome of multiple polyorgan]c insufficiency. the heaviness nf condition was estimated as the sum of points according to efforts needed to restore of basic living functions -respiration, hemodynamjcs, hemocoagulatlon, metabolism, functions of liver and kidneys. it was expressed in form of clinic condition classes from to . results.it was found that in % of infants with - classes of heaviness immunode[iciency took place simultaneously with ii and iii stages of hemocoagulattve syndrome. amounts of t cells and t helpers were decreased more then times, ratio th/ts was reduced to . or lower. concentration of lgg and igawas reduced almost a hull in comparison to control. phagocytic and metabolic activities nf neutrophils were depressed. complement system state was changed: the functional activity of the alternative pathway factors b, d and the level or c a subcomponent were increased but the level of c , c ,, c and c components of the classic pathway were decreased. during the development of coagnlopathy the direct correlation between chso, levels of plasminogen and antithrombine iii was found. in greater extent the function of immune system was disodered in accordance with point metabolic violations and hemocoagulative disturbances considered as disseminated inmtravaseular clotting syndrome on ii or ili stages. conclusions. the rehabilitation of the immune system functions was promoted by taetivine and thymaline in doses of i- mcg/kg per day and mg/kg per day accordingly during a week in children with - classes el heaviness. aiter - days tactivine had advantage. when eoagulopathy took place thynaaljne promoted restoration of ( - )-~-d-glucan (bgc) is a major cell wall compornent of pathogenic fungi and shows many immunopharmacological activities on experimental animals. lps is also derived from gram-negative bacteria and have in~ttnomodulating activities on immune systems positively or negatively. because of difficulty to cure contaminating lps from bgc preparations, it is very hard to evaluate the exact activities of bgc. in this study, we compared the immunological activities of lps ans highly purified bgc on murine system. materials and methods: c h/hen or c h/hej mice, to wkolds of both sexes were used through experiments. highly purified ( - )-{ -d-glucan (gurdran; bgc)was courteous gift from seikagaku kogyo co. tokyo, japan and resolved in endotoxin-free ultra-pure water. escherichia cell lps was purchased from sigma chemicals, usa. mitogenic activities of bgc or lps on splenic cells were measured by mit dye assay. in vitro activation of peritoneal exudate macrophage (pen) have moniotored by phagocytosis and intraphagocytic killing of pseudomonas aeruginosa (z~b- . induction of cytokine productions from pem or spleen cells induced by bgc or lps were detected by cytotoxic assay. results and (bnclnsions: i ) in vitro cultures of pem with bgc have induced enhanced phagocytic and bactecidal activities in c h/hen and c h/hej mice, whereas lps only induced such activities in c h/hen mice. most effective dose of bgc was ug/ml. ) bgc-dependent proliferative response of c h/hen splenic cells was not detected under the culture condition used. ) induction of tnf~ prodction was apparently observed in bgc-stimulated c h/hej pd cultures, but not in lps stimulated one. these findings indicate that activation mechanisms of pr and splenic cells by bgc are different from that by lps. to investigate the bsc-induced p~ activation, intracellular signaling pathways of p~ by bgc-stimulation are under consideration. yamagami k, uedono y, kawakami k, kitazawa y and tanaka t according to the latest reports of use of il- in a burned-sepsis model, the dose was too high to adjust for human therapy. adoptive transfer of l~ymphokine-activated killer (lak) cells has been demonstrated as a means of enhancing therapy in malignant tumors. we therefore attempt to use lak therapy on burned-infected mice instead of il- . under anesthesia, -weekold male c h-hej mice were subjected to a % scald or sham burn and then resuscitated. sham burned mice served as controls. scald burn mice were subjected to peritonitis by intraperitoneal innoculation of organisms of p. aeruginosa hr after burn. burned-infected-mice were divided into two groups. one group had no further treatment, and the other group received lak cells ( x ) intraperitonelly after septic challenge. the mice were scored for survival daily. on day after burn, using moabs dual-color flow cytometry, we studied lymphocyte expression in mice with use of blood and spleen. simultaneousely we studied the alteration of il- and il- in their serum using immunoassy kits. sham burned animals had no mortality. the mortality of the lak-treated mice was significantly reduced when compared with that of the burned-infected mice. the most consistent changes observed were depressions in percentages of thyl, positive cells and a remarkable depression of nk cells in spleen. after lak cell treatment, those two percentages of cells significantly increased. all the data of assay of ill and [l were not detected on sham burn mice serum. due to burn and septic challenge the levels of illand il (n= ) were raised to . _+ . and _+ pg/ml, while the levels in lak treated mice were reduced to . _+ . and _+ pg/ml, respectively. the results reported here demonstrate that lak therapy is able to improve cell-mediated immunity in burned-infected mice. this is associated with a significantly improved survival rate, since ill has been demonstrated to mediate immune and inflammatory responses. also a cause effect relationship between elevated endetoxin levels and increases of [l has been recently established. the aim of our present study was to investigate the effect of parenteral indomethacin on the immune system of patients under major operations. our study included operated patients, of which received mg indomethacin before and , and days after surgery (group a) and patients received no antiinflammatory therapy (group b). we measured total t-cells helper (cd ), suppressor (cd ), nk-cells and interleukin- and tnf production by pha or endodoxin (lps) stimulated peripheral blood mononuclear cells at day and , and days after operation. in group a we detected a significant (p< . ) increase in cd /cd ratio on day while no differences were ~oted in nk-cells or cytokine production in both groups (table ) . it seems, therefore, that parenterai indomethacin may have a benefitial effect on the immune system of patients under major operations by increasing the t-helper /t-suppressor cell ratio while having no effect on the production of cytokines by peripheral blood mononuclear cells. this study was undertaken td dete~nnine the role of prostaglandin synthesis inhibitor on survival post traulna sepsis. analysis of the effects of prostaglandin synthesis inhibitor on survival of four groups of mice each were made after laparatomy and intravenous administration of live e.coli. post trauma sepsis, group a received no treatment; group b received antibiotics im; group c received prostaglandin synthesis inhibitor im and group d received both antibiotics and prostaglandin synthesis inhibitor im. survival time was longest in group treated with prostaglandin synthesis inhibitor and antibiotics post trauma sepsis. the singular use of either antibiotic or prostaglandin synthesis inhibitor did not alter the outcome on survival. mortality rate was lowest in the group treated with combined prostaglandin synthesis inhibitor and antibiotics. use of this combination showed a reduction in bacterial growth in peritoneal and blood samples, mild morphologic changes secondary to sepsis in the heart, lungs, liver, kidney and stomach and marked enhancement of mean level of activity. the study indicates that addition of prostaglandin synthesis inhibitor in treatment of trauma-sepsis has clear beneficial effects. interferon-? (ifn-y) is a potent immunostimulant which has been shown to be detrimental when administered during septic shock. blockade of this cytokine however is beneficial during the acute septic response. the aim of this study was to evaluate the cellular effects of this cytokine and its blocking monoclonal antibody (moab) in lethal sepsis following injury. female cd- mice were randomized into two groups: septic=lps vs injury=hind limb amputation (hla vs igg. nstats= anova=p< . vs lgg ifn-y was detrimental when given to control septic animals. however its blocking moab was protective (p< . ). conversely ifn-y was proteetive in injured septic animals compared with anti-ifn-? (p< . ). these findings demonstrate that the immune stimulant ifn-? has therapeutic potential in the immunosuppressed injured host predisposed to sepsis, while blockade of this cytokine is required for protection in the septic host with a normal immune response. dept of surgery, rcsi, beaumont hospital, dublin , ireland. oxidants play a role in physiology. the potential noxious oxidant biochemistry is restrained by chemically distinct antioxidants. these antioxidants, which may reside in different cellular compartments, can act synergistically. in normal physiology an oxidant/antioxidant bai&nce exists. unbalance in favour of the oxidants is called oxidative stress. oxidative stress has been implicated in many pathologies including lung diseases(e.g, doxorubicin induced cardiotoxicity), ischemia/reperfnsion damage and central nervous system trauma. transition metals such as iron are involved in the early events leading to oxidative damage in these pathologies. this has been underlined by the finding that postischemic cns pathology closely resembles that caused by a chemical oxidative insult (e.g. iron microinjection). moreover, a protective effect of oxygen-radical scavening agents or compounds that inhibit lipid peroxidation (antioxidants) in brain ischemia/trauma is apparent. some known drugs (e.g. anti-arrhythmics or histamine h -antagonists may act as non-specific antioxidants. howe~er, recently, interesting new membrancespecific antioxidants (e.g. -aminosterdids) have been designed. subt&e effects on iron redox chemistry contributes to the potent antioxidant activity of these aminosteroids. since a few years, one area that greeted enthusimastlcally in clinical medicine is that of reoxygenatlon injury or ischemia-repeffusion, a phenomenon accepted to make a majo:" contribution to organ dysfunction in trauma, shock and sepsis through the formation o( oxygenated free radical species. however, thei detection in vivo always remains a difficult challenge. efforts have been made recently to directly establish the formation of free radicals in biological samples as complex as blood, plasma or tissue with the use of electron spin resonance (esr) spectroscopy. using spin trapping agents, the presence of reactive carbon-and oxygen-centered radicals has been demonstrated in animals blood submitted to heart, renal and intestinal ischemia-repeffusion or to liver transplantation. recently, the in vivo formation of free radicals in the cerebra; extracellnlar fluid during cerebral isehemia-repeffusion has been assessed by the spin trapping technique coupled to brain microdialysis. esr investigations have also been conducted to detect endotoxin-induced free radical generation in rat or baboon liver and oxygen free radicals (ofr), produced both at intra-and extra-cellular levels, seem to play a major role in the pathophysiology of tissue injury and organ dysfunction in sepsis, through induction of lipid pemxidation in cell membranes. oxidative damage can result both to an ofr-overpmduction or to a depletion of endogenous antioxidant defenses, which are represented by scavenger enzymes (e.g. sod), hydrosoluble and liposoluble antioxidants (e.g. ascorbate, vitamin e), and other mechanisms such as metal-ion sequestration. in animal models, oxidative damage has been proved by detection of increased levels of lipoperoxidative products, and a depletion of antioxidant defenses was found both in plasma and tissues. in the few clinical studies a similar results have been reported, and oxidative damage appears to correlate with dic, with organ dysfunction and with red blood cell deformability. in a group of critically ill septic patients we found increased levels of conjugated dienes (cd) (bioproducts of lipoperoxidation) and decreased plasma levels of alpha-tocopherol and coenzyme qlo (coqi )(endogenous liposoluble antioxidants). a relationship between cd and uric acid (p< . ) was found, may be related to xantine-dehydmgenase to xantine-oxidase conversion. antioxidant depletion is due both to overconsumption and to a nutritional deficiency, even if a reduced synthesis can also be present. in fact one more relationship between coqi and plasma cholesterol (p< . ) demonstrates the commun hepatic biosynthetic defect. is there any role for antioxidative therapy in sepsis? can it achives a significant improvement in the septic course, organ dysfunction, and final outcome? several antioxidant drugs, have been evaluated in experimental and clinical sepsis: scavenger enzymes, natural antioxidants, alloporinol, -aminosteroids or lazaroids, have been proved to reduce lipopemxidative damage, to protect organ dysfunction, and in some cases to improve survival. several questions must be addressed in evaluating safety and utility of antioxidative therapy. more specific and standardized methods must be applied to detect and quantify the lipoperoxidative damage. antioxidant drags must act selectively on ofr-production, without interference with other than that are beneficial for the organism. antioxidants must be able to achive in adequate amount the tissue or cellular compartment where their action is required. many antioxidants have also a pro-oxidative effect which can he detrimental in some conditions. the timing of administration, the dosage used and the association wih others antioxidant drugs must be defined. nutrition plays an important role as antioxidative therapy, since it supplies all compounds needed to maintain adequately levels of endogenous antioxidant or to support their synthesis. thiobarbituric acid reactive substances (tbars) concentration in serum has been determined in a large population of healthy subjects and in patients suffering acute hepatitis and chronic cases of hepatitis c, as well as several other processes. the correlation with different physiological and clinical parameters in these populations is also presented. treatment with interferon of the chronic active hepatitis c patients, x u three times a week during two months, led in those patients whose sgpt activity normalized in serum, to a concomitant decrease in serum tbars content. the possible theoretical involvement of peroxidation and antioxidants in this beneficial effect of i~terferon in hepatitis c patients is discussed. the results presented confirm the value of tbars as laboratory test in the management of disease and as a useful tool for the study of pathogenic and/or therapeutic mechanisms. -hydroxyalkenals are among the different substances measured by the tbars assay. these compounds show several biological effects that have been demonstrated mainly in different experimental models. we have studied the capacity of different tissues to conjugate these compounds patients surviving the initial subarachnoid hemorrhage (sah) from a ruptured in~raeranial aneurysm are prone to develop cerebra] ischemia from vasospasm which is associated with significant morbidity and mortality. among the many treatments that have been prol~osed to treat this condition, none has been shown to be satisfactorily effective. recently, a new drug, namely the -aminosteroid tirilazadmesylats, has been studied in a large, prospective, multicentor trial for its effectiveness to improve the outcome of patients with aneurysma! said. the study was conducted in europe and australia in neurosurgical centers and included patients. all patients received presently accepted standard treatment, including nimodipine. patients were randomized to four different groups: placebo and groups of tirilazad in escalating dosage ( . - mg/kg/day). the clinical outcome was compared for these groups and cerebral a~giography was performed in % of patients on day - follovang sah, to study the effect f'the dflf~ off cerebral vasospasm. the study reached its planned endpoint months ago. preliminary results ~how a significant improvement with regardto mortality in those patients receiving the highest tirilazad dose as compared to placebo and the two lower dose groups. additional beneficial effects were seen in the rag/day groups with regard to the occurence of symptomatic vasospasm and good clinical outcome. although the final analysis of all data is still pending, these results suggest that tirilazad-mesylate could represent a major improvement for the treatment of patients with sail. experimentally lipidperoxidation products (lpo) are increased in acute pancreatitis (ap) due to oxygen radicals (or). the purpose of this clinical study was to determine the antioxidant status and lpo in patients suffering from ap and to evaluate the effect of antioxidant treatment with sodium selenite (se) thus improving the function of the se dependant glutathione peroxidase which is the major detoxifying system for or. materials and methods: in z patients sufferin s from severe ap (c-reactlve protein > me/l) we determined on day and day after admission the lpo ma!ondialdehyd (mda), conjugated dishes (cd), reduced (gsr) and oxidized (gssg) glutathione, the vitamins a,c,e and se. moreover the patients were evaluated clinically using the ranson and the apache ii score. i patients were randomly treated with ug/day of se for days. results: all patients suffered from a severe depletion of antioxidants,especially a low concentration of se (only / of normal). thereby the increase in lpo correlated with the clinical course. during se treatment lpo decreased and the levels of antioxidant vitamins improved. se had no influence on leth-slity the lenl or the chan in rs or ap ii. background: since reperfusion injury occurs when oxygen is reintroduced into ischemic tissue, the ideal timing for administration of therapeutic compounds aimed at ameliorating oxygen radical mediated injury is at the time of initial fluid resuscitation. currently used colloid or crystalloid preparations do not provide optimal, or even significant, anti-oxidant protection. systemic iron chelation affords protection against the iron catalyzed components of oxygen and lipid radical mediated tissue injury. the conjugate resulting from chemical attachment of the clinically approved iron chelator, deferoxamine (dfo, desferal ®, ciba), to hydroxyethyl starch (hes) represents a novel approach to colloid based fluid resuscitation. hes-dfo contains % hes and % chemically bound dfo. the polymer-drug conjugate has a lower molecular weight than that of hes in order to allow more rapid excretion. results: preclinical and initial clinical trials indicate that hes-dfo is well tolerated, even at high doses. in animal studies, fluid resuscitation with hes-dfo does not significantly improve central hemodynamic recovery beyond that observed with hes, but hes-dfo seems to afford better protection of microcirculation in organs at risk (lung, liver and gut), possibly by decreasing neutrophil sequestration. in a burn model, total fluid requirements are lower and oxygen utilization higher in hes-dfo treated animals compared to hes controls, suggesting decreased vascular leak and improved tissue perfusion. conclusion: hes-dfo represents a means by which potent antioxidant protection can be administered at resuscitation. iron has been suggested to play a pivotal role in oxygen flee radical mediated tissue injury. in vitro experiments indicated its critical role as a katalyst in hydroxyl free radical generation fenton-reaction). since iron chelator deferoxamine administered in shock alone demonstrated severe side effects, a hydroxyethylstarch (hes)daferoxamine (dfo)-conjugute was used to modulate oxygen free radical injury during the ischemia/reperfi~ion syndrome induced by hemorrhagic shock. methods. female lewis rats ( - g, n> ; pentobarbital anesthesia mgjkg), in hemorrhagic shock ( the aim of the study was to elucidate ( ) whether the generation of or would affect lung and kidneys as primary shock organs in the very early phase of sepsis and ( ) whether dfo-hes could prevent this tissue damage. methods: in rats sepsis was induced by cecal ligation puncture (clp) peritonitis. the animals were randomly assessed to groups: one group was treated with ml dfo-hes ( mg/kg iv), the other rats received solely ml of the carrier starch solution. , , , and min after induction of sepsis respectively, the animals were sacrificed, the organs collected, and tissue contents of glutathione (gsh), malondialdehyde (mda), myeloperoxidase (mpo) and conjugated dienes (cd) determined. plasma samples were obtained for analyses of endotoxin (chromogenic lal test). blood pressure (map) was measured via a carotid artery catheter. results: clp caused sepsis with high (> . eu/ml) endotoxin levels. map in both groups decreased slightly but significantly during sepsis regardless any treatment. in the lungs mpo concentration was increased (p< . ) in the lies group already min after sepsis induction. concomitantly, tissue gsh level decreased and lipid peroxidation was pronounced as shown by elevated mda and cd levels. dfo-hes diminished tissue pmn accumulation and mpo concentration. moreover, at each time point lung mda and cd levels were lower (p< . ). histomorphological examination showed marked micro-atelectases, destruction of the alveolar septa, and splicing of the basal membranes in the lies group. in contrast, in dfo-hes treated rats the alveoli remained well-ventiiated and only some enlarged reticular fibers without splicing were observed. almost similar results were found for the kidneys. mpo levels differed neither within nor between both groups. the slight decrease in gsh levels seen after min in the dfo-hes group seems to demonstrate an oxidative stress to a lesser degree. the most impressive effect of iron chelation, however, was revealed by the lipid peroxidation products. at each time point, mda and cd levels were lower (p< . ) compared to the hes group. light and electron microscopic examination disclosed tubulotoxic and mitochondriat damages while dfo-hes lxeatment prevented that alterations. conclusion: both the biochemical and histological results of this study reveal an early and remarkable generation of or in peritonitis-induced sepsis. thereby, these or obviously cause pulmonary and renal tissue damages, intravenous application of dfo-hes may, however, benefit by preventing early lipid peroxidation of the tissue. the proteolytic irreversible conversion of xanthine dehydrogenase (xd) to xanthine oxidase (xo) is triggered by calcium flux. the aim of our study is to clarify ~he link between intracellular ca + levels and xo activity determined by uric acid release, and to evaluate the efficacy of verapamil, on the generation of hydrogen peroxide associated with reperfusion by assaying lactate & pyruva~e release and the levels of cytosolic free nad /nadh ratio. experimental protocol consisted of :(a) non ischemic/reperfused experiment in which normal cardiac slices of rats were perfusated with oxygenated kreb's ringer phosphate buffer containing glucose ( mg%) and bovine albumine ( gm%) for min at °c.it composed of groups, group aa (control group), and groups ab & ac (perfusate supplemented with verapamil in the dose of loo& mi% respectively). (b) ischemic reperfused experiment in which ischemic cardiac slices were obtained from rats subjected to min ~aemorrhage.lt was also divided into two groups; group ba and bb (verapam~/ mi% added to perfusate}. verapamil stimulated uric acid release from normal rat cardiac slices were % in group ab and % in group ac(dose related). rates of uric acid release is enhanced by verapamil in group bb. moreover, rates of uric acid release in groups ac & bb are insignificant. in verapmil added groups (group ab, ac & bb), increase uric acid release is associated with an enhancement in pyrurate release and with increase levels of cytosolic free nad+/nadh ratio, although it is not evident ~ ischemic group (group ba).it is concluded that the conversion of xd to xo is calcium independent. eicosanoids like thromboxane a , leukotriene b and leukotriene c are known as promoters of initial inflammatory reactions. we investigated whether oxygen radicals (or) are able to induce a release of these eicosanoids in whole blood. blood from healthy volunteers was incubated with xanthine oxidase/hypoxanthine to generate oxygen radicals. after , , , and minutes plasma levels of thromboxane b (txb ), leukotriene b (ltb ) and leukotriene c (ltc ) were determined via elisa technique. another volunteer had taken mg aspirin one day before taking the blood sample (no ). results: txb plasma levels increased from pg/ml at min to pg/ml, pg/ml, pg/ml and pg/ml at , , and min (p< , ) . ltb and ltc plasma levels showed an increase during the first few minutes (ltb : min: llpg/ml, min: pg/ml; ltc : min: pg/ml, min: pg/ml (p< , )) followed by a decrease to normal values at min. in the sample no the cyclooxigenase-pathway was completely inhibited, the txb plasma-levels did not alter at all, whereas ltb and ltc -plasma levels weren't affected. opallogeneic blood transfusion jane shelby, ph.d., and edward w, nelson, m.d, there have been numerous investigations dudng the last two decades examining the effect of surgery, anesthesia, blood loss and transfusion on vadous immune parameters in humans and animal models. there appears to be concurrence among several well controlled studies that transfusion of whole blood (containing leukocytes), has regulatory effects on immune ceil function which include decreased cell mediated immune response, and inhibition of il- secretion. these effects occur following transfusion alone and in con.cart with the distinct immune effects of surgery, trauma and anesthesla, the clinical consequences of this immune modulation by transfusion include decreased allogeneic response to transplanted organs, which has been exploited clinicelly in renal transplant patients. additionally, there is evidence for a strong association with increased risk for infection in transfused patients following surgical procedures. aiiogeneio blood transfusions have been shown to inhibit cellular anti.bacterial mechanisms, causing increased susceptibility to bacterial pathogens, in humans and in animal models. there is also concern that allog~neic transfusion may adversely affect cancer patients, resulting in decreased disease-free survival. several stategies have been proposed to minimize the adverse effects of blood transfusion. there is evidence that the risk of immune mediated infectious complications associated with transfusion may be greatly minimized wlth the use of autologous blood and leukocyte free allogeneic blood.products in surgical and trauma patients, it also appears that the inhibition of cellular immune response and il- productiorl following atlogeneic blood transfusion may be mediated by increased prostaglandin e secretion, and that immune response may be preserved in allogeneio whole blood transfused subjects receiving c lc~oxygenase inhibitors such as ibuprofen. among these are various alterations in immune function. efforts have therefore been made to utilize alternatives to homologous transfusions. these include the use of autologous predonation, supplemental iron therapy, and recombinant human erythropoietin. although initially considered innocuous, these therapies are now recognized to have potential deliterious immune sequelae. erythropoietin, by its ability to lower serum iron levels, can impair both lymphocyte and nk cell activity. autologous donation impairs nk cell function. finally, supplemental iron therapy can stimulate bacterial growth and increase the rate of infectious complications. this talk will present a discussion of these factors as well as a weighting of their importance. r.l rutan, rn;bsn, shriners burns institute and the university of texas medical branch, galveston tx, usa the serious sequelae of homologous blood transfusions have resulted in vigorous efforts at identifying alternate therapies for correcting red blood cell (rbc) deficits. erythropoietin (epo) was hypothesized to exist in the early th century, however the protein was not isolaled until . the human gene was identified and cloned in , which permitted the production of epo through recombinant techniques. the earliest clinical trials were performed in anemic end-stage renal failure palients on hemodialysis. treated patients experienced increases in erythropoiesis with normalization of hematocrit and hemoglobin levels, cessation of lrans-fusion requirements and improvement in general wellbeing. these studies, however, identified side effects of epo treatment such as hypertension, seizures and ee deficiency. volunteer trials have established that the hypertension is not a direct pressor effect but rather the result of abnormally rapid increases in red cell mass in the face of the incompetent volume-controlling mechanisms of the end stage renal failure patient. lower doses of epo and the subsequent gradual increases in red cell mass are associated with significantly lower incidences of hypertensive complications of epo therapy. likewise, seizure activity is not the result of a direct epileptogenie effect but parallels the incidence of hyper-tensive-related sequelae during high.dose epo treatment. in cross-over designed studies, pre-existing iron deficiency has been demonstrated to decrease or negate stimulated erythropoiesis but effective-hess can be restored with appropriate fe supplementation. exogenous epo is effective whether given by iv or sq routes and dose response curves do not vary with route of administration. increases in rbc mass are directly related to the dose of epo, both in amount and frequency of administration although there is a - day time lag between the first epo dose and laboratory indications of its action (i.e. increase in the number of reticulceytes in peripheral wood). epo is currently labelled for use in the treatment of anemias associated with end-stage renal disease and aids. however, its use in the surgical population has been explored because of its unique direct dose-response, epo has been used to effectively increase the blood harvest amounls in autologous pre-donation, significantly increase hematocrils in children following thermal trauma and successfully increase red blood cell mass following essential surgical procedures in patients with religious aversion to transfusion. by blood transfusion in colorectal cancer surgery mm heiss md, ch delanoff md, r stets md, j hofinann, e faist md, kw jauch md, fw schildberg md allogeneic blood transfusions are associated with an increased risk for postoperative infections in colorectal surgery when compared with autologous blood transfusions. attribution of this effect to immunomodulation was suspected in our previous study (lancet ; : - ) . task of the recent investigations was to analyze which specific effector systems were affected in-vivo by this transfusion-associated modulation. for global in-viva assessment of cell-mediated immunity (cmi) multiple recall skin-reactions were applied prior and post-operative. the specific humoral immune mechanisms were investigated by applying tetanus-toxoid one day preoperatively and deterimnating the quantitative igg-response. for indication of macrophage stimulation in-vivo tnf-levels were determinated by bioassay. dth-responses were significantly suppressed (p< . ) in patients receiving allogeneic blood (n= ) or operated without blood transfusions (n= ). dthresponses were not suppressed and tendentiously increased in patients with autologous blood transfusions (n= ). in contrast, specific igg-levels increased sigmficantly (p< . ) in patients receiving allogeneie blood (from . + . to . _+ . ie/ml) whereas in patients receiving autologous blood a smaller increase (from . + . to . + . ; p= . ) was observed. tnflevels demonstrated a similar pattern with a higher increase in patients receiving allogeneic transfusions (l . + . to . + . u/ml) compared to those patients with autologous blood ( . + . to . + . ). in conclusion these data indicate that allogeneic blood transfusions lead to a remarkable macrophage/rhs stimulation. this is corroborated by the boostered humoral igg-response which was initiated before onset of surgical trauma and blood transfusion. concerning cmi this caused a substancial suppression probably due to a stimulated secretion of immunosuppressive monokines. objective: firstly, to analyse the concentrations of the cytokines tumor necrosis factor (tnc), interleukin- (il-i), interleukin- (il- ) and coagulatioo/fibrinolysis parameters in postoperatively retrieved blood from a surgical area, secondly to characterize the correspanding cytokine patters in the patients and thirdly to study cytokine concentrations in the initial portion of drainage blood from a surgical area. materials and methods: blood retrieval was performed in a closed-loop system without anticoagulant during - hours after surgery in patients undergoing arthroplasty ( hips and knee). kf, il- , it- , thrembin-antithrombin complexes (tac) and antithrombin (at) ~ere determined in shed blood. patient plasma tn v, il-i and il- concentrations ~ere analysed at the beginnlqg and end of the - hour blood retrieval period. in a separate study ( hip arthroplasties) f~f, il-i and il- ~ere determined in the initial portion of drainage blood. cytekine analyses ~re performed usiog ipmuooassays. an omidolytic method was used for at determinaf.ion and tac was analysed by elisa. n~n-poram~tric tests was used for the statistical comparison. results: the patient plasma il- coocemtratiems rose from a median value of to pg/ml, p<o. , during the blood ret.rieval period. in c was detectable in patients, range: - pg/ml. il-i was not detectable in the patients. in retrieved blood tag was > mg/ml in all samples (ref:< . mg/ml) and at was . - . units/ml (ref:o. - . ) . the il- concentrations in retrieved blood was > pg/ml in all samples. tn v or il-i was not detectable. in the separate study, (n= ), characterlzing eytokine content in the initial portiere of drainage blood, in= (range: - pg/ml) and il-i (range: - pg/ml) ~re present in all samples but ii- (range:o- pg/ml) was detectable in o.qly one semple. conclusion: theses findings indicate that hypereoagulability and hic~ ccrcentratioos are present in retrieved blood. the cytokine pattern in the initial portion of blood from a surgical area differed from these observed in retrieved blood and in the systemic circulation. to identify the role of both autologous and homologous blood on postoperative infections in elective cancer surgery. materials and methods: patients with colo-rectal cancer submitted to curative elective surgery were prospectively studied. on hospital admission the following nutritional measurements were assessed: serum level of albumin, cholinesterase, delayed hypersensivity response , total lymphocyte count and weight loss, as were age and sex, duration of operation , operative blood loss, amount and type of blood given, pathological dukes' stage of the disease and the attending surgeon were also recorded. results : eighty-four patients ( . %) were perioperatively transfused. thirty-six ( . %) patients were given autologous blood , while ( . %) received homologous blood. no patients received both autologous and homologous blood. twenty eight ( . %) patients developed postoperative infections. non transfused patients had a . % infection rate , those receiving autologous blood had a . % infection rate, whi]e in the homologous blood group the infection rate was . % (p < . ). univariate analysis showed that infections were significantly related to operative blood loss (p< . ), length of operation (p< . ) blood transfusion (p< . ) and attending surgeon (p< . ) . multivariate analysis identified homologous blood transfusion as the only variable related to the occurrence of postoperative infections , while the other variables failed to reach statistical significance. blood transfusion (bt) remains an essential life-saving treatment for surgical patients. however, besides the beneficial short-term impacts, negative longer-term effects are observed, which include various alterations in the immune responsiveness. in surgical patients these alterations may contribute to the increased risk for infections and cancer recurrence. since relatively few data demonstrate immunologic changes occurring in other lymphoid compartments than blood after bt, we studied the effect of et on the frequency and responsiveness of immune cells in bone marrow (bm), spleen (spl) and blood (b) in a rat model. normovalemic, month old rats were transfused intravenously with syngeneic heparinized venous blood ( x ml, every other day), and , and days after the last transfusion bm cells ( leh is an experimental oxygen-carrying resuscitation fluid. since leh is cleared from the circulation primarily by the mps, its effect on the development of sepsis and the nature of its relationship with the mps remain a major concern. preliminary in vivo data from our laboratory failed to show any leh effect on the hemodynamic and hematologic responses to endotoxin lipopolysaccharide (lps) in the rat. in contrast, leh exacerbated the lps-induced tnfa production and early mortality. the exacerbation of early mortality by leh was attenuated by pretreatment with the tnfu synthesis inhibitor rolipram. ex vivo, peritoneal macrophages from rats treated with leh and lps have shown increased il-lg mrna signal as compared to lps alone. also, leh increased tnftx production by peritoneal macrophages in response to lps stimulation in vitro. additionally, recent pilot studies indicate that leh attenuates pma-induced superoxide production from rat peritoneal macrophages and that leh augments fmlp-induced migration of human monocytes. taken together, these data strongly support possible interactions of leh with the mps and therefore the nature of such interactions should be further explored. over the last decade, we have developed liposome encapsulated hemoglobin (leh) as an artificial oxygen carrying fluid, or blood substitute. our efforts have focused on studies to define the safety and efficacy of this resuscitative solutions. leh consists of distearoyl phosphatidylcholine, cholesterol, dimyristoyl phosphatidylglyeerol, and alpha tocopherol in a : : . : . mole ratio and can encapsulate hemoglobins of different origin (bovine, human, recombinant human). leh is fabricated using hydrodynamic shear to create an average particle size of . microns. leh can be lyophilized using disaccharides and stabilized in the dry state and easily reconstituted before administration. histopathology and clinical chemistries indicate that leh rapidly accumulates in tissue resident macrophages in small animals injected in the tail vein, principai y in the liver and spleen. the consequences of accumulation in the reticuloendothelial system are manifest by transient increases in liver transaminases (ast, alt), bilirubin, and bun over - hours with no change in biliary function (ggt, ap) . clearance through the liver and spleen is observed over the course of - -weeks. more recent attention has been focused on secondary consequences of leh administration especially with regard to inflammatory eytokines. leh does not elicit expression of tumor necrosis factor in vivo and in isolated macrophage cultures, but does result in a transient increase in serum il- . we have also examined the interaction of leh with lps in vitro macrophage culture to further understand how this blood substitute may effect the immune system. we have labeled leh with technetium- m ( mtc) to study the biodistribution of leh non-invasively in anesthetized rabbits. rabbits were infused with a % topload of leh ( mg of phospholipid, . g of hemoglobin per kg of body weight) and imaged continuously with a gamma camera. at hours, images were again acquired. animals were then sacrificed and tissue counts obtained, images revealed an initial rapid uptake bythe liver, % at minutes and % by hours. the spleen accumulated activity at a slower rate, % at minutes and % at hours. at hours, autopsy biodistribution studies revealed that approximately . % of the dose is in the blood pool, . % in liver, . % in spleen, . % in lungs, . % in muscle and . % in urine, with trace levels in kidney, brain and heart (< °/o). in a hypovolemic model, rats were % or % exchange transfused with mtc-leh. in the % exchange model, mtc-leh was rapidly taken up by the liver and spleen with minimal activity in the circulation at hours. with the % exchange, % of the leh was in circulation at hours. the interaction of leh with platelets labeled with indium- was also studied. after infusion of leh, the labeled platelets rapidly moved from the circulation to the lungs and liver. over the next minutes, the platelets gradually returned to circulation. this effect was not seen with iiposomes of the same lipid composition but containing no hemoglobin. non-invasive imaging is proving to be a very useful tool for the investigation of leh. the need for a safe, efficacious and commercially viable blood substitute is unequivocal. of the several strategies pursued to invent an adequate blood substitute, liposome entrapped hemoglobin (leh) has been already established as a leading possibility. major advances in liposome technology have already resulted in liposome preparations compatible with clinical use for drug delivery. recent technological advances made by the u.s. naval research laboratories resulted in the capacity to entrap hemoglobin into liposomes in a way which secludes hemoglobin from interacting freely with biological systems. the leh produced has already been tested in in vivo systems and was foun.d to be well tolerated. moreover, the leh originally produced as a solution can be transformed into a lyophilized form which can be reconstituted and delivered as a fresh solution. while important milestones in leh development for a practical blood substitute have been achieved, several issues remain to be explored. most notably, the long term consequences of leh on host defense mechanisms and, in particular, immune cell function. in addition, it is important to understand more fully the metabolic fate and repercussions of leh delivered at clinically relevant dose/schedule regimens. finally, while leh is a highly promising strategy for a blood substitute, the present formulations consist of human hemoglobin derived from human blood, to improve the safety profile, a recombinant preparation for liposome entrapment will be much desired, aa-ginine, a semi-essendai dietary amino acid, possesses several unique and potentially pharmacologic properties. argirdun is a potent secretagogue for pituitary growth hormone and prolacfin and for pancreatic insulin and glueagon; it modulates host protein metabolism by increasing nkmgen retention and enhancing wound collagen synthesis. it also is a potent t call function regulator. ait of these effects coupled with its relative lack of toxicity and safety make it an a~antive nulritionai pharmacologic agem (t). rodents fed supplemeutal arginine exhibit increased thymsc weight which is due to increased numbers of thymic lymphocytes present in the gland. thymic lymphocytes from animals fed supplemental ar~e demonstrate increased blastogenesis in response to coma. and pha ( ) . peripheral blood lymphocytes from humans given supplemental arginine also have heightened mitogunic responses to mitogen or antigens ( ) . in postsurgery padents supplemental arginine abrogates or diminishes the deleterious effects of trauma on lymphocyte responsiveness and restores peripheral blood lymphocyte responses much faster than observed in controls. overall host immunity is also enhanced by arginine. allograft rejection is enhanced and septic animals survive longer when given supplemental arginine ( ) . tumor bearing urginine-supplemented animals have decreased tumor growth and enhanced survival (i). lastly, asgmine can induce t cell maturation and t cell mediated responses in athyrnic nude mice. arginine also has remarkable effects on host nitrogen metabolism post-injury. in increases nitrogen retention in healthy human volunteers and in surgical patients. this beneficial effect on overall nitrogen metabolism is accompanied by a unique effect on the healing wound. supp]emental arginine increases wound collagen synthesis which also translates into increased wound breaking strength ( ) . arginine has no effect ou epithelialization. douglas w. wilmom, m.d. boston, ma gintamine is the most abundant amino acid in the body, but it has long been considered a nonessential amino aeid because it is synthesized in many tissues. fohov~g st,~'vation~ injury or infection, skeletal muscle pmteln inoresses its net tale of degradation and releases amino acids into the blunds~mm at an aocelerared rate. app~o)~mately one-third of the amino nitmgea is ghitamine, which is metabolized by the kidney where it parth:~pates in acid-base homeostasis, is the primly ~ for lymphocytes, mac~optmgcs and untexocyms, and contm'butcs to the synthesis of giumth~une. olmamine degrades slowly while in ~olu~ou, especially at usual room teml~mtums. because giulamine was considered nonessential, it has beer absent r'om nil intravenous and most gluts.mine should be considered a cendittona]ly essential nutrient for individuals with serious ilinesses, uspccially those confoanded by infcctinn and inflammation. over the uc~:t - years, glutamine will be incorgorated into most feeding formulas designed for patients with critical illness. o]~ga- pufa there continues to much interest in the application of the mega- pufa in clinical nutrition. the basic principle has been that the mega- pufa will displace arachidunic acid and result in a decrease in eic san id production. in addition these changes in pufa will after the physical characteristics of the membrane including flujdity, receptor function and transmembrane signals. animal studies have shown that there is omega- incorporation with continuou~ enteral feeding both in control and endotoxic animals within days. this includes the liver, spleen, circulating and alveolar marc phages and the lung. this incorporation resuls in significant changes in the eicosan id production including pgf and ket -pgflalpha. there is improvement in the cardio-vascular reep nse of these animals with ~ecreamed lactic acidosis and improved cardiac contractility. as well there is improved immune function with improved t cell response to mit gens. the ~ of a mumber of pharmacological agents blocking cicosanoid production can enhance the cell effects of mega- pufa. clinical studies using short term entsral nutrition with mega- either alone or with other enteral supplements in a number of clinical settings have shown significant mesa- incorporation and decreased eicosan id production. these positive results must be discussed with the additional evidence that long term omega- supplementation decrease eic san id production but als induce a state of immune suppression that is capable of increasing transplant sunvival. these ng te~ inune effects may benefit clinical conditions including rheumatoid arthritis and cr hn' disease early enteral nutrition instituted i~mediately afte~ injury will decrease the entry of bacteria into the intestinal wall and decrease the number of bacteria that translocate into the portal blood. these reductions are associated with & decreased catabolic response, decreased plasma cortisnl levels, end decreased vma excretion in the urine and prevention of mueosal atrophy. sdecific nutrients also affect the transloeation process. addition of arginlne to the diet significantly improves the ability to kill translocated organisms. however. translooetion across the gastrointestinal barrier is not affected. in contrast, glutamine diminishes the rate of translooation across the imtestinal barrier and also improves killing of the beetarla that do translooate. the omega fatty acids in the form of fish oil slightly decrease the rate of translocation but more significantly increase the ability of the animal to kill translo~ated organisms, all three dietary additives, i.e. argini~e, glu=amine and fish nil. significantly improve survival, hut adding glyoine or medium chain triglyeeridem do not, combinations of srginine and glutamlns, glutamine and fish oil, and fish ell end arginine each improve survival, and to a greater degree than a combination of all three. these studies add further evidence that translocation is an important determinant of survival after injury, early feeding with immunonutrlent enriched dices will improve survival and dsarease transloeation to varying degrees, depending upon the nutrients provided. objectives: we studied effects of supplementing a commercial enteral diet, impact r (imp, sander nutr lnc), with fiber (imp/fib) or alanyl-glutamine (imp/ag, exogenous glutamine (gln) gms/l) on influencing the incidence of bt to mesenteric lymph nodes (mln) in burned mice. fiber has been shown to improve gi integrity under certain stress/treatment conditions. the dipeptide ag is a water-stable source of gln, which is a specific fuel for many cells including enterocytes. traumacal (trcal), a high-protein, high-fat enteral diet (mead johnson iuc), was also studied, as well as rodent chow (harlan teklad inc), which contains very high protein & fiber. methods: anesthetized cf- mice aged - wks received % tbsa fullthickness dorsal burns & were resuscitated with cc ip saline. diets were allowed ad lib; caloric intakes were comparable in all gps except fasted gp (fast hrs, chow hrs). at hrs postburn mln were sterily removed, homogenized and plated on heart brain infusion agar; cfu/g mln tissue were determined. bt was analyzed by fishers exact test, cfu/g by anova-bonferroni. * p< . , ** p< . compared to imp and burn-fast gps. background. infectious complications following trauma, major operation, or critical illness adversely affect hospital cost and length of stay (los). some key nutrients have been shown to possess immune enhancing properties. this multicenter trial was conducted to determine if early administration of an enteral formula supplemented with arginine, dietary nucleotides and fish oil can decrease los and infectious complications in icu patients. methods. this was a prospective, randomized, double-blind study of adult icu patients who required enteral feeding for > days. patients entered the study within hr of the event, were stratified by age and disease, and were randomized to receive either the supplemented formula (impact®) or the conventional formula (osmolite ® hn). feedings were initiated at full strength and advanced to at least ml/hr by hr after event. results. both groups tolerated administration of formula well. for patients fed > days, the median los was % shorter (p=o.ol) for the--supplemented group ( days) compared to the conventional group ( days). the incidence of most infectious complications was lower in the supplemented group, but this difference reached significance only for urinary tract infections (p=o.o ). the supplemented group had a significantly shorter los from onset of infectious complication until discharge for patients with pneumonia ( vs. days) and skin/soft tissue infection ( vs. days). conclusions. administration of the supplemented formula was safe and well tolerated. when fed > days, it reduced the incidence of most infectious complications, and significantly reduced los. materials and methods: twenty-seven patients were randomised into groups ( n= each) to receive either a standard enteral formula, the same formula enriched with arginine, rna and omega fatty acids (enriched group) or isonitrogen, isocaloric parenteral nutrition. early enteral nutrition was started within hours following surgery ( ml/hour). it was progressively increased reaching a full regimen on day . on hospital admission and on post-operative day and , the following parameters were assessed: serum level of transferrin , albumin , prealbumin, retiool binding protein (rbp), cholinesterase. delayed hypersensitivity response, igg, igm, iga, lymphocyte subsets and monocyte phagocytosis ability were evaluated on admission and on post-operative day , , . the three groups were comparable for sex, age, cancer stage, type and duration of surgery, intra-operative blood loss and amount of blood transfused . in all groups a significant drop in all the nutritional and immunological parameters was observed on postoperative day . comparing post-operative day versus day a significant increase of prealbumin (p< . ) and rbp (p< . ) was found only in the enriched group. with respect to immunological variables an increased phagocytosis ability (p< . ) and a significant recovery in delayed hypersensitivity response (p< . ) was observed only in the enriched group. conclusions : these data are suggestive for a more effective post-operative recovery of both. nutritional and immunological status in cancer patients fed with enriched enteral formula. gastrointestinal intolerance was equivalent ( % in each group) and laboratory screening confirmed that both diets were safe. when analyzing clinical outcome for all patients, there were no significant differences in septic complications (immun-aid = % vs vivonex ten = %), mean mof score (immun-aid = l.b vs vivonex ten = . ), or mortality (immun-aid % vs vivonex ten = %) . kowever, when analyzing the subgroup of patients with severe injury (iss or ati _> ), patients receiving immun-aid appeared to have fewer septic complications ( % vs %) and their mean mof was significantly lower ( . _+ . vs . + . , p = . , student's t-test) . these preliminary data indicate that immun-aid is tolerated well when aggressively delivered immediately postinjury. the ultimate affect on clinical outcome appears ~avorable for immun-aid, but needs to be confirmed in larger patient groups. kemp?n, m., neumann, h.a., he i[michh b: as both increased, normal and reduced phagocytic capabilities of polymorphonuclear leukocytes (pmn) and monocytes in acute batterial infections have been reported, the role of phagocytes in patients with severe sepsis is less clear.we examined pmn and monocytes from patients in septic shock and heailhy votunteers for phagocytic function. phagocytosis was determined by flow cytometry (facscan) and was measured by the ability of pmn and monocytes to phagocytose e.coli marked with fluorescent antibodies. a septic shock was defined by the presence of a ~ource of i, nfoctiqn with a known bacteriology, distinct signs of a systemic response and defined minimum scores in icu scoring systems indicating the presence of a multiple organ failure. additionally we examined how phagocytosis is influenced when a new enteral diet formulation containing substrates suggested to improve immune function or arginine, one of its major compononts, is added in vitro in defined concentrations and incubated for minutes. pmn (p{o, ) and monocytes (p<o, ) of the septic patients showed a significantly enhanced phagocytosis compared tolhe phagocytes of the healthy group. the incubation with the enteral diet in vitro was followed by a higher dose-related rate of phagocytosis, especially in the healthy group, that was not statistically significant. after addition of l-argintne we atso observed an iqcrease in phagocytosis, that was lower than in the group with the complete diet. using a modern immunefluorescence-cytometric essay we founfl an improved phagocytic function in septic shosk. there are signs for an influence of nutrient substrates on phagocytosis which seems to be complex and should be further investigated. arg and gln were lower in the %-bcaa vs %-bcaa group; arg was related directly to arg dose and inversely to bcaa dose (p<o.o for all). clearances of bcaa increased with increasing bcaa dose (p<o.o ); arg and gln clearances were directly related to the bcaa clearances (rz=o. , p<o.o i). relationships between arg, gln and other aa seem to be ruled by patterns involving specific intracellular aa transport systems. regulation of arg and gln clearances through bcaa administration may be related to an increased flux of aa into synthetic processes. intestinal segments from rats immunized by infection with the nematode trichinella spiruus undergo intestinal anaphylaxis or type i hypersensitivity when challenged in vitro with parasite antigen. immunized rats exposed to t-radiation ( gy) and sustained on rat chow,fail to fully express type i hypersensitivity up to days post irradiation (dpi). we hypothesized that enteral nutritional support immediately following irradiation may be effective in preserving mucosal immune responsiveness or in reducing the recovery time after radiation-induced injury. rats were infected with x t.spiralis larvae. thirty to fifty days later rats received gy t-radiation from a co source as total abdominal irradiation (tai). immediately following tai, rats were fed an elemental amino acid diet (eaad) and at various dpi sacrificed and tested in ussing chambers for local anaphylaxis, expressed as antigen-induced ci secretion. the normal ci secretory response to antigenic challenge which is suppressed after irradiation,was restored by dpi when rats were placed on the eaad. antigen-induced c[ secretion is dependent on the interaction o~ antigen with specific ige antibodies on the surface o mucosal mast cells and their subsequent degranulation. mast cell-derived -ht,histamine and pg, together effect ci secretion.in irradiated rats on rat chow,the failure to respond to antigenic challenge appears to be associated with the destruction of mast cells. they are undetectable with standard staining procedures and mucosal histamine levels are drastically reduced. also,el secretion can be induced by direct stimulation of epithelium with cr secrctagogues and circulating ige levels are normal. despite a more rapid recovery of immune responsiveness in irradiated rats receiving eaad,mast cells were not restored. we conclude that the eaad contributes to an adaptation that supports the expression of local anaphylaxis in the absence of mast cells. total parenteral nutrition (pn) and bowel rest may influence the host response to infection. this study examined the different host response to infection in parenterally and enterally fed animals. forty-three rats were divided into pn group and total enteral nutrition (en) group. they received identically constituted isocaloric isonitxogenous diets for seven days. animals were then challenged intraperitoneauy with xl(y escherichia coli and survival were observed. in other experiments, they were sacrificed before and two hours after bacterial challenge. peritoneal cavity was lavaged with ml saline and peritoneal exudative cells (pec) were harvested and cultured in vitro for hours with and without lipopolysaccharide (lps). colony f(m, ning units of bacteria (cfu-b) in the peritoncal lavaged fluid (plf) were determined and tnf in the plf, serum and pec culture supernal,ants were measured by l bioassay. twenty-fonr hour survival rate in en group was significantly greater than that in pn group ( % vs %). the data suggest that local immune responses of pn-treated animals may be depressed with consequent disturbance in the clearance of bacteria. this may lead to a greater systemic cytokine response and resulting in a poor survival after bacterial challenge in pn group. the effects of intragastfic tube feeding of diets enriched with m- polyunsaturated fatty acids (pufa) from safflower oil (so) or (o- pufa from menhaden oil (mo) on eicosanoid production, and onthe membrane phospholipid fatty acid composition were investigated in a severe acute septic shock model. the percent calories from fat maintained at % in the diets was adjusted to provide % each of saturated, monounsaturated, and pufa using olive oil and palm oil as filler fats. after feeding for days, lipopolysaccharide (lps, mg/ g) was injected through the tail vein. the percent of animals surviving in the mo group was % ( / ), and did not differ significantly compared to % ( / ) in the so group. the plasma concentrations of tnf ct for the groups of animals fed so ( . + . ng/ml) and those fed mo ( . + . ) did not differ significantly. the levels of prostaglandin(pg)e , -keto-pgflc~ and tumor necrosis factor-ct (tnf-c were determined min after lps injection. the fatty composition (relative mole%) of the liver was determined before (lps-) and h after the lps administration (lps+). the data (mean_+sd; n= ) are as follows. group these data indicate that a marked reduction in the plasma levels of poe and -keto-pgflct for rats fed mo diet was associated with a reduction in aa which was displaced by epa in the membrane phospholipids. further, in these rats, we observed that there was a . % reduction in the percent of epa following lps challenge compared to the basal levels. however, for the group of rats maintained on so diet, the liver membrane phospholipid fatty acid composition before and after lps administration was unaltered. these finding suggest that although a reduction in aa was associated with a decrease in the production of pro inflammatory eicosanoids after days of continuous mo feeding, there was no marked effect on the survival following lps challenge. animal models have been used to examine the effects of various nutrients and nutrient combinations upon the immune system. we studied the effects of standard and specialized enteral formulations on the response of mice to infectious challenge with listeria monocytogenes, influenza a or candida albicans in order to test the efficacy of specialized ingredients. cf- outhred female mice ( - g) were fed purina # chow, commercially available osmolite hn ®, perative ® or impact*. mortality and tissue burden of pathogen were examined during the d period following induced infection. the results indicate that there were no differences between the groups fed the liquid formulas with regards to mean survival time or % survivors in these models of infection. examination of spleens in the groups challenged with l. monocytogenes and kidneys in the groups challenged with c. albicans revealed no differences in tissue burden of pathogenic organisms. alterations in the length of pre-feeding from to days prior to infection did not affect these results. these data demonstrate that, contrary to previous reports, the use of specialized nutrients did not improve resistance to disease in mice challenged with l. monocytogenese, influenza a or c. albicans as compared with mice fed osmolite hn. animals fed standard chow tended to be more resistant to infectious disease than those fed the liquid formulas perhaps due to the form of diet or complexity of ingredients. the results indicate that these animal models of infectious challenge may be of limited use to distinguish effects of modified nutrient composition of enteral formulas. laboratories the beneficial effects of sesame oil (ses) have been attributed to the presence ofsesamin, a non-fat constituent which is claimed to iultibit a- desaturase activity. we investigated the effects of ad libidum feeding of ses enriched diet on fatty acid composition of phospholipids from plasma, liver, on eicosanoid production, and on the protective effects in mice after cecal ligation and puncture (clp) and compared with safflower oil (so) diets. olive and palm otis were added as filler fats to the so diet to maintain the ratios of saturated, and unsaturated fatty acids similar to ses diet. thus, while the total fat remained at wt%, the only difference between the two diets is the presence ofsesamin in ses diet. the animals were fed for weeks. the incorporation of dihomo-y-linolealc acid (dgla: : o)- ) in the phospholipids from plasma and from the liver for the group of mice fed so diet ranged between - % compared to the undetectable levels for those fed so diet. there were no significant differences in the incorporation of other fatty acids either in plasma or in the cell membranes between the two groups. following an intraperitoneal administration oflps ( p.g/kg body wt), the plasma levels of both pge , and txb , were significantly decreased (p< . ) by nearly % for the group of animals maintained on ses diet compared to those maintained on so diet. these findings suggest that sesamin inhibited the release of arachidonic acid (aa) which upon accumulation is retroconverted to dgla which could reflect a modest increase in the content of dgla. failure to decrease the formation of aa could mean that the effects of sesamin on chain elongation process may be after aa is formed, and that sesamin may not inhibit a- desaturase activity. on the other hand, our data suggest that sesamin present in sesame oil inhibited the activity of cyclooxygenase which converts aa to its metabolites), or alternatively could block the activity of phosphalipase a (pla ) (which releases aa from membrane phospholipids) as is evident from a marked decrease in eicosanoid production. the percentage of animals surviving after cecal ligation and puncture in rite group of mice fed ses diet was % ( / ) which was markedly higher (p< . ) compared to only % ( / ) for the so group. increase in survival in the group of mice fed ses diet was associated with nearly % reduction in the production of tnf in response to lps i.p. challenge, for ses group compared to so fed animals. our data suggest that sesamin, present in sesame oil, decreased the production tnf~, inhibited the activity ofpla and consequently offered a significant protection against clp. thus sesamin or sesame oil appear to be novel antiinflammatory agents which are present naturally in many edible products. [dept. surgery, ~e. deasoness hosp.,harvard medical school, boston, usa] stress causes alterations in the homeostasis of an organism with major changes in various organs, lifespans of cells, protein turnovers, metabolic pathways of activation or stimulation, energy mobilization, etc. punctual changes have been described in several organs and various cell types of the nervous, endocrine and immune systems. many stored or newly synthesized proteins are released to the bloodstream to be transported to target organs or to be disposed of. as stress alters protein synthesis and requirements in the targets, the bloodstream is a useful system for monitoring the relevant changes. we present here the pattern of newly synthesized or released serum proteins in c bl/ mice that have been stressed by immobilization. the proteins have been labelled with ssmethionine in vivo and the study was performed by two dimensional gel electrophoresis based on the method originally described by o'farrel. the electrophoretic run was carried out in an isodalt apparatus. a molecular dynamics laser scanner and the kepler image analysis system (lsb, rockville, usa) were used for modelling the radiofluorographic images. the radiofluorographic images of the gels from serum samples obtained from mice injected with i mci of ss-methionine reveal about protein spots, from which a small fraction -about are altered in both qualitative and quantitative manner. the major changes are in the range of to . d. the analysis displays a highly reproducible pattern, where clear differences between stressed and non-stressed conditions are shown. differences between patterns attributed to chronic vs. acute stress will be presented. patients with severe trauma or major surgery are known to acquire alterations in neutrophil functions which contribute to their enhanced susceptibility towards microbial infections. we analyzed neutrophil functions from fourty patients admitted for major surgery days and days preoperatively and on the ist and th postoperative days (study-days i, , , and ) in a randomized placebo-controlled double-blind study. patients were divided into two groups, one ~eceived days preoperatively an enteral nutrition enriched with omega- fatty acids, arginiee, and rna (impact), the other an isocaloric, not enriched control nutrition (placebo). meutrophils were isolated from the peripheral blood and stimulated with the ca-ionophor a ( . pm). the capacity of the respective neutrophils to generate leukotrienes was analyzed by rp-hplc. neutrophils from impact group generated significantly higher amounts of ltb (mean values . ng/l x i~ cells) compared to the placebo group ( . ng) at study-day [p, . ). in contrast, the capacity of neutrophils to produce ltb was not significantly different in both patients populations at study-days and . the omega-oxidation of ltb to its biologically less active metabolites oh-ltb and cooh-ltb was not significantly different in both groups. however, neutrophils from group f patients generate more ltc at study-day (p( / ). the capacity of the patients'neutrophils to generate reactive oxygen radicals upon stimulation with fmlp, pma or the caionopbore a exhibited patient dependent differences but no correlations to the repective nutritional supplementation as was measured by luminol dependent ohemiluminescense= these data indicate that an enteral nutrition enriched in omega- fatty acids lead to alterations in distinct parameters of neutrophil functions. clinical patient characteristics and mean caloric intake were similar between the two groups. both formula were tolerated well and the incidence of diarrhea was low. the number of infectious and wound complications as well as the apache ii score was evaluated for the two study groups. although the number of complications in the group supplemented with arginine, rna and omega- fatty acids was lower no significant difference in the occurance of infectious and wound complications has been observed between the two groups. however, the apache ii score indicated a significantly improved clinical outcome in patients with supplemented diet. in conclusion, early enteral nutrition with an arginine, omega- fatty acids and rna supplemented diet helps to recover more rapidly after surgical total parenteral nutrition (tpn} is associated with intestinal atrophy and dysfunction attributed to the absence of the non-essential amino acid glutamine in current parenteral nutrition solutions. in this animal study with male wistar-rats we tested the hypothesis that glutamine-dipeptide supplementation during tpn for days would restore small bowel atrophy and tpn induced dysfunction. a conventional tpn solution ( kcai/kg bw) was compared to an isocaloric and isonitrogenous tpn ( , g n/animal/d) supplemented with alanin-glutamin (ala-gin) dipeptide ( , g n derived from ala-gin = % gin-n). an enteral fed cqntrol group was included. mucosal thickness, villous height and architecture, absorption of water and glucose as well as dissacharidase activity of maltase and alkaline phosphatase were evaluated. total parenteral nutrition in rats causes villous atrophy, a significantly reduced absorption rate and a decreased activity of villous enzymes compared to an enteral fed control (p<o, ). addition of ala-gin to parenteral nutrition solutions prevents intestinal atrophy and restores functional alterations with a significantly increased rate of water and glucose absorption as well as a higher dissacharidase activity compared to the standard tpn group (p< , ). there was no significant difference found between the enteral fed control and the dipeptide supplemented animals concerning intestinal structure and absorption, the enzyme activity was significantly decreased in the ala-gin supplemented group compared to the enteral fed control (p< , ). in this rat model supplementation of parentera] nutrition solutions with ala-gin dipeptide restores tpn induced intestinal atrophy and dysfunction. boston. ~ usa injury, infection and major o ~'ations s~nulate a variety of factors whi~ initiate the body's response to th~ st~..sses. 'i"hese reactions are m~liated by a cbmage ia the neta'al hormonal, eac.ranmemt, by the elaboration of eytokines and tl~ougb the stimu/ation of other inflammatory mediators. this eatabolio setting zesulis in body protein loss, which g-taduai y erodes both fimetianal and stm~ tissue. wiu _b the normally nom'ished individual can withslzod "d~ response for a brief period of time, ircolonged eatabollsm l~ associated with ~,nmunosuppmssion, poor wound healing, and proioagcd convalescence. surgeons have rej ed on intraveaous or eater~ feedings to ~everse this process. a va~ety of data now indicates that it is extremely di~edt to replete protein-containing tissue d~g the eataholie state of illness; the umutt response to hypercaloise feedings in this setting is the incxeased accretion of body fat md water. administration of gxow~ ho~moae ~cesults i.a n shift of the body's oxidative machinery to fat rather than eazbohydmte utiq~afic~; ¢oncomitaatiy, protein synthesis is stimulated. this metabolic state may have clinical utility in p~e.n.ts who need to heal large wotmds, in those who need to gain strength in order to be w~ed ore veatilatory support, or those patients who ~ve mulfiorgan failure and nee~ to ealaaace protein syatsesis to in.suze recovery. als are now in progress to dcterm~e the benefit of growth hormone in these and other disease state.s, rn the fature, the increased use of growth hormone, will occur;, this and other growth factors will serve to su~ po~ the host and shorten convalesceace following catabolic diseases. our objective was to study effects of pre-trauma growth hormone (gh) treatment on liver and skeletal muscle metabolism in a trauma model in piglets. twenty-four piglets were randomized to three treatment groups; one group was pretreated with gh iu daily three days before the experiment (gh- ), another group treated with gh ie at the start of the surgical procedure (gh- ) and one group served as untreated controls (con). they underwent a standardized surgical procedure to place sampling cathethers in the portal, hepatic and femoral veins and doppler flow probes around the portal vein, the hepatic and the femoral arteries. all pigs recieved a primed constant infusion of u- c-glutamine. substrate fluxes were measured one (lh) and five ( b) hours after termination of the surgery. nitrogen excretion was significantly decreased in the gh treated animals (gh- : . + . mg/kg, gh-i: . +_. . mg/kg, con: . +- . mg/kg, p= . ). in the hindieg, there was reduced net glutamine efflux due to decreased absolute glutamine release (gh- : . + . gmol/min at lh and - . + . in.tool/rain at h, gh-i: - . + . i.tmol/min at lh and - . + . pmol/min at h, con: - . +_ . g mol/min at lh and - . + . /amol/min at h, p= . , p= . ), whereas the absolute uptake of glutamine in hindleg was unchanged (p= . ). glucose uptake in the hindleg was decreased (p= . ). net glutamine uptake in liver was attenuated (p= . at h), whereas net glutamate release from liver was increased (p= . ). thus, pre-trauma treatment with gh improved nitrogen economy, attenuated net glutamine loss from hindieg due to decreased absolute release, and attenuated hindleg glucose uptake. liver net glutanaine uptake was decerased and net glutamate release increased. patients with major abdominal surgery exhibit a considerable catabolic response with negative nitrogen balance and protein breakdown, which may have detrimental effects on outcome. we investigated the effects recombinant human growth hormone on substrate metabolism in parenterally fed patients. metabolic healthy patients were randomized to receive either placebo or hgh in a dosage of , ; , or , i.u. per kg bw. substrate oxidation rate, energy expenditure as well as short life proteins were measured daily. six patients were excluded from analysis as drop outs, due to surgical complications. we could find a dose-dependend effect of growth hormone on resting energy expenditure, carbohydrate oxidation, fat and proteine oxidation. with increasing growth hormone resting energy expenditure increased from . calories per kg body weight to . calories. this was mainly due to an increased carbohydrate and fat oxidation, while proteine oxidation decreased. this was in accordance with a decreased urea.production rate and an improvement in cumulative nitrogene balance, which increased from minus . to plus . g n / days. in consequence short life proteins were also increased. the only negative side effect was an increased blood glucose concentration in some of the patients, making insuline administration mandatory in patients. our results are in accordance with other studies showing improvement of nitrogen balance, maintainance of lean body mass and muscular strength. if growth hormone administration may have any impact on morbidity, mortality and length of hospital stay in these patients it should be evaluated in a larger number of patients. in patient after liver transplantation (oltx) the effect of recombinant human growth hormone (rhgh) on protein metabolism and hormonal changes was studied. patients and methods: the underlying disease in all patients was end stage liver cirrhosis, non of the patients included in the study was suffering from malignancies. the patients were randomly allocated to receive either u of rhgh bid (sc) or no alternative medication. the study period lasted days. from daily hrs udne collection urinary nitrogen loss and daily loss of urea were determined. body compostion analysis (bca, bioimpedance, akern-ltaly) was performed preoperativly and at the postoperative days and to evaluate changes in body water and body cell mass (bcm). the effect on resting energy expenditure (ree) was analysed using indirekt calorimetry wrhin the same intervalls (metabolic monitor, datex). blood levels of gh, igf and igf , igfbp were measured daily during the study period, on day a hour profile of gh was.performed. samples were collected each minutes. results: cumulative udnary nitrogen and urea loss were not signifcantly different for the whole study period but for the first study days. bia indicated for the rhgh-group a loss of bcm to a lesser extent than for the controls (n.s.), changes in bodywater where similar for both groups. ree changes (kcal/kg bcm) were not significantly different for the two groups. blood levels of gh and igf differed significantly between the groups for the whole study period, but not igf and igfbp- . the circadian rhythm of endogenous gh-excretion had not been altered by gh, but absolute levels of gh were increased. conclusion: during the first days after oltx we could proof the protein sparing effect of gh treatment. although the differences between the two groups were not significantly different for the whole study period the results showed on all days a less catabolic situation for the rhgh treated patients. to possibly improve protein balance after major abdominal surgery we studied the effects of gh on protein metabolism after ltx. excluding malignant diseases, candidates for ltx were randomized to either postoperatively receive the usual treatment (co=control group, n= , age range - yr, bmi . + . kg/m ) or for days additional gh ( x i.u.s.c.) (gh group, n= , - yr, . + . kg/m ). metabolic studies (calorimetry and lsc-leucine infusion) were performed (test a) and days (test b) after surgery. tracer analysis was done by gas chromatography-mass spectrometry. during the -week study clinical parameters did not differ significantly between groups; however, there was a tendency for increased glucose levels, insulin need, and energy expenditure at the time of test b in the gh group. leucine oxidation (x+se) during test a;b was + ; + (co) and + ; ± (gh) pmol/kg ffm/h (n.s.). protein breakdown was ± ; + (co) and + ; + (gh) pmol/kg ffm/h (n.s.). nonoxidative-leuine disposal was ± ; + (co) and ± ; + (gh) pmol/kg ffm/h (p< . for the rise in the gh group). tracer data were supported by cumulative urea nitrogen excretion (days - : gh + vs co ± g; p< . ). we conclude that after major abdominal surgery gh lowers nitrogen excretion by increasing total body protein synthesis. it is not known which organs contribute to this effect. in several investigations it has been shown that the protein saving effect of recombinant human growth hormone (rhgh) in the postoperative state is accompanied by raised igf- levels in plasma. it was concluded that the anabolic effects of rhgh were probably, at least in part, mediated by igf- . this study was aimed at detecting the efficacy of igf-i on modulation of the protein metabolism in the catabolic state. patients and methodes: patients (both sexes, age: - years, bmi - kg/m ) with major upper gastrointestinal surgery (gastrectomy or partial gastrectomy) received ug rhlgf- /kg body weight/twice daily or placebo during treatment days beginning on the first postoperative day in a double-blind, randomized study. all patients received hypocaloric and hyponitrogenous total parenteral nutrition ( g chng, o. g aa/kg) troughout the whole study period. cumulated nitrogen balance, -methyl-histidin exretion in urine as well as serum-igf- levels have been determined. the two tailed wilcoxon test was used for statistical analysis results: first results will be presented previous studies have suggested that growth hormone (gh) potentiates various activities of leukecytes. however, it is not clear whether gh can improve survival of animals with gram-negative sepsis. we investigated the effects of gh on host response to infection in septic mice model. methods balb]c mice were randomized to groups (n= /gronp): gh-high ( + mg/kg/day), gh-iow ( a mg/kg/day) or control (saline). following subcutaneous treatment (every hours for days) with gh or saline, mice were challenged i.p. with e.coli (lxl /body). survival rate was recorded every hours. in the next experiment, gh-high and control animals were sacrificed hours after bacterial challenge. peritoneal cavity was lavaged with ml saline and the peritoneal exudative cells (pec) were harvested and counted. colony forming units (cfu) of bacteria in the peritoneal lavaged fluid (plf), liver, lung and blood were determined. pec were cultured in vitro for hours with lipopolymccharide ( p.g/ml in normotensive adults growth hormone (gh) rises when clonidine challenge is performed. recently evidence was shown for gh to accelerate wound healing. while gh secretion patterns are inconstant the gh-dependant insulin like growth factor (igf- ) and the insulin like growth factor binding protein (igfbp- ) reflect the integrated gh secretion over days. since we administer clonidine to patients with acute alcohol abuse we determined plasma levels of igf- and igfbp- . materials and methods: patients sheduled for esophagus resection were investigated once they had given written informed consent. patients showed acute alcohol abuse and were treated with clonidine postoperatively• patients with no history of acute alcohol abuse served as controls. besides liver enzymes igf- and igfbp- were determined. results: both groups had a comparable hepatic capacity of synthesis with decreased cholinesterase levels as to be expected after a major operation. regression analysis of igf- and igfbp- levels showed no differences between the groups. discussion: igf- and igfbp- plasma levels are not increased in normotensive patients who are treated with clonidine for prevention of postoperative alcohol withdrawl syndrom. further studies are required to discriminate whether our results are due to impaired postoperative liver function or if clonidine has not any impact on the gh-igf-axis in patients with alcohol abuse. recent studies have revealed that igf-i has several immanoregulatory roles. however, little is known about its effects on septic animals. we tested whether igf-i could increase the survival o f mice challenged intraperitoneally (i.p.) with e. coli. m~thqd$ balb/c mice received either high dose igf-i (n= , mg/kg/day), low dose igf-i (n= , . mg/kg/day) or saline ( = ) every eight hours subcutaneously for six days. animals were then challenged i.p. with lx e. coli. survival was observed every two hours. in the other experiment, mice that received high dose igf-i or saline were sacrificed four hours after bacterial challenge. peritoneal cavity was lavaged with ml saline and the peritoneal exudative ceils (pec) were harvested and counted. colony forming units (cfu) of bacteria in the peritoneal lavaged fluid (plf), liver, lung and blood were determined. in addition, pec were cultured/n vitro for hours with lipopolysaccharide ( ).tg/ml). tumor necrosis factor (tnf) in the supernatants of pec culture, plf and serum were measured by l bioassay. results igf-i improved the survival rate at a dose of mg/kg/day. severe chronic neutropenia (scn) is a disorder characterized by severe neutropenia secondary to either a maturational arrest of myelopoiesis at the level of promyelocytes (kostmann-syndrome; scn) or regular cyclic fluctuations in the number of blood neutrophils with a median absolute neutrophil count (anc) of less than /~tl (cyclic neutropenia). patients suffering from scn have an impaired acute inflammatory response to injury and an increased susceptibility to infections, i.e. bacterial or fungal infections, resulting in chronic oral inflammation, severe pneumonia, abscess formation and bacteraemia. we have treated patients ( scn, cyclic neutropenia) with r-methug-csf (filgrastim). thirty of patients with scn and all cyclic neutropenia patients responded to this treatment with an increase of the median anc to greater than /~tl. the dose of r-methug-csf needed to achieve and maintain the response varied between . and ~tg/kg/d. long-term treatment did not exhaust myelopoiesis: the anc remained stable after up to years of treatment and antibodies to r-methug-csf were not detected. the increase of anc was associated with dramatic clinical responses: significant reduction of severe bacterial infections, reduction of intravenous antibiotic treatment, and reduction of hospitalizations. no severe bacterial infections occurred in any of the r-rnethug-csf responders during longterm treatment. severe adverse events, most likely due to the underlying disease, included the development of mds/leukemia in two patients, and osteopenia/osteoporosis in patients. these results demonstrate the beneficial effects of r-methug-csf treatment in severe chronic neutropenia patients. the newborn is predisposed to mortality during infections due in large part to developmentally immature host defenses. recently cytokines have been identified that regulate the development of these defenses. one such cytokine is specific for neutrophils and is termed granulocyte colony stimulating factor (g-csf). in the studies to be discussed, we have attempted to impact hematopoiesis in the fetus using exogenous rhg-csf delivered through the pregnant dam. our rationale was that an enhanced myeloid system may result from such in utero treatment leading to, perhaps, enhanced protection to microbial insult. rhg-csf crossed the placenta and reached peak fetal serum concentrations hours after administration. these levels were -fold lower than the levels detected in the adult dams serum. white blood cell counts were elevated approximately - -fold over control newborn blood. this increase was due to circulating numbers of neutrophils. the marrows from these pups were hyperplastic consisting of predominately immature and mature neutrophilic cells. no changes were seen in the thymus or livers. pups born to mothers treated with rhg-csf since day of gestation (parturition in rodents occurs on approximately day ) survived a lethal challenge of group b- hemolytic streptococcus. in contrast their untreated yet infected counterparts did not survive. recent clinical developments have led to trials of rhg-csf in certain neutropenic states including cyclic and chronic neutropenia. we have identified several of these patients who were pregnant during treatment with rhg-csf. biologically and anfigenically identifiable rhg-csf was detected at increased levels in the cord serum of these neonates. we will discuss our findings with these patients in light of our animal model of neonatal myeloid development. we have previously demonstrated decreased g-csf production and g-csf mrna expression from activated mononuclear cells from newboms compared to adults (cairo, pediatr res : , ) . we have also recently observed that administration of a single dose of rhg-cse to one-day-old newborn rats induced significant neatrophilia, while administration for days induced neulrophilia and increased the bone marrow (bm) neutrophil storage and progenitor pools (cairo, blood : , cairo, pediatr res : , ) . we embarked on a phase i trial exploring the safety, pharmacokinetics, and biological efficacy of g-csf in newborns with presumed sepsis. infants < hrs old with a diagnosis of presumed sepsis were stratified into three groups: very preterm ( - wk), preterm ( - wk), and term (> wk) and randomized to receive either a placebo or , , and gg/kg/qd or and p.g/kg/bid of rhg-csf infused by pump over hour for consecutive days. cbcs were obtained at , , , , and hrs. tibial bone marrow aspirations were performed hrs after study entry and differential counts and cfu-gm pools were determined. c bi expression was determined at and hrs after rhg-csf, and g-csf pharmacokinetics were performed after the first dose of rhg-csf utilizing a sandwich elisa. a significant increase in the anc was observed at , and hrs following administration of both and ~tg/kg/d of rhg-csf. the maximum increase in the anc occurred hrs after and ~tg/kg/d ( - %) (p< . ) and ( % -+ %) (p< . ), respectively. there was a significant dose-dapendeat increase in the bm neutrophil storage pool ( _+ % vs. + %) (p< . ) (placebo vs. ~tg/kg/d). there was no significant difference in the nantrophil proliferative pool. an increase in cfu-gm and cfu-gemm was seen at all doses tested, compared to placebo ( . _+ . vs. -+ ) (colonies/l(p cells/plate). c bi expression was significantly increased hrs after bg/kg/d of rhg-csf ( + % vs. +- %) (p< . ). peak serum g-csf levels occurred at hrs and were dosedependent. the half-life of rhg-cse was . + . hrs. most importantly, there was no observed toxicity from g-csf in all patients studied. of patients were on ventilators prior to administration of rhg-csf and there was no increase in pulmonary toxicity. these preliminary data suggest that rhg-csf is well tolerated at all gestational ages in newborns with presumed sepsis. a multi-center phase ii/iii randomized double-blindad placebo controlled trial is required to determine the efficacy of rhg-csf in this clinical setting. we investigated the effects of recombinant canine granulocyte-colony stimulating factor (g-csf) on survival, cardiopulmonary function, serum endotoxin levels and tumor necrosis factor (tnf) levels in a canine model of lethal bacterial septic shock (clinical research. : , ) . methods: awake ylo beagles had serial cardiopulmonary and laboratory studies before and for up to days after intraperitoneal placement of an e. celi infected clot. nine days before and daily until days after clot placement, animals received high (n= ) or low dose (n= ) g-csf or protein control (n= ) subcutaneously. results: survival in high dose g-csf animals ( / ) was significantly improved compared to low dose ( ) and controls ( ) (p< . wilcoxon). high dose g-csf also improved cardiovascular function evidenced by a higher mean left ventricular ejection fraction (day after clot, p< . ) and mean arterial pressure (day , p< , ) compared to low dose and controls. high dose rcg-csf increased (p< . ) peripheral neutrophil numbers both before and after clot implantation ( hours to days) compared to low dose and controls. in addition, high dose rcg-csf produced a more rapid (p< . ) rise (day ) and fall (day ) in alveolar neutrophils determined by bronchoalveolar lavage compared to low dose and controls. lastly, high dose rcg-csf decreased serum endotoxin ( to h, p< . ) and tumor necrosis factor (tnf, h, p< . ) levels compared to low dose and controls. discussion: these data suggest that therapy with g-csf sufficient to increase peripheral neutrophil numbers during peritonitis and septic shock may augment host defense and endotoxin clearance, reduce cytokine levels (tnf) and improve cardiovascular function and survival. the use of g-csf in sepsis prophylaxis in neutropenic patients is well established and has been ascribed to accelerated recovery in granulccyte counts. here, an additional sepsis-prophylactic property could be demonstrated in healthy volunteers: eleven volunteers were employed in a sinqle-btind, controlled study and were given uq g-csf or saline placebo via subcutaneous injection. blood was withdrawn immediately before and or hours later. lps-inducible tnf, il- , stnf-r p and il-lra were assessed in the supernatant of whole blood incubations stimulated with ug/ml lps from salmonella abortus equi. similarly to previous animal studies, lps-inducible tnf was attenuated by about % hrs. after treatment. the same was true of il-lb. in contrast, lps-inducible stnf-r p which was indetectable in blood incubations from untreated donors increased dramatically hrs. after g-csf treatment. il-lra found after lps challenge was increased tenfold by g-csf treatment. it is concluded that g-csf treatment switches peripheral leukocytes to an antiinflammatery state characterized by an attenuation of il-i and tnf releasing capacity and an augmentation of the release of cytokine antagonists. this findinq minht offer a novel concept in septic shock prophylaxis. objective.the aim of the study was to investigate the effect of recombinant human g-csf (rhg-csf) on survival, bone marrow neutrophil myelopoiesis, neutrophil counts, levels of bacteria and some important sepsis mediators in a model of rat abdominal sepsis. lethal peritonitis was induced with a mm coecal perforation (cp) in male wistar rats. rhg-csf was administered as /.tg/kg iv every h, first dose at sepsis induction. bone marrow neutrophi] progenitors were determined as blast colonies, cfu-gm and cfu-g. neutrophils and bacteria were determined in peripheral blood and peritoneal fluid. lps, tnf, endothelin and lactate were measured in blood from femoral vein. mortality rates were registered with g-csf treatment starting either or days before or hours after cp. results. mortality was reduced from % to about % with rhg-csf intervention and there was no difference between the pretreatment and treatment groups. bone marrow blast colonies were not influenced while neutrophil myelopoiesis was augmented at the stages of cfu-gm and cfu-g. neutrophils in blood and peritoneal cavity were enhanced and numbers of bacteria in the same compartments were substantially reduced. circulating lps, tnf, endothelin and lactate were attenuated the first hours after cp. neutrophil myelopoiesis is augmented with increased number of neutrophils in blood and peritoneal cavity, resulting in enhanced clearance of pathogens. lps, tnf, endothelin and lactate are suppressed the first hours during sepsis course. a. wendel, j. barsig, g. tiegs gm-csf stimulates the proliferation and differentiation of granulocytic and monocytic progenitor cells. in addition the hemopoietic cytokine activates the inflammatory response in mature leukocytes. the priming effect of gm-csf towards lipopolysaccharide (lps)-induced cytokine production in vitro has been described, but little is known about proinflammatory gm-csf effects in vivo. we detected gm-csf in plasma of lps-challenged mice with kinetics similar to tnf, reaching peak levels h after lps administration. gm-csf pretreatment ( ~tg/kg i.v.) enhanced mortality in mice challenged by a sublethal dose of lps. plasma levels of tumor necrosis factor (tnf) and interleukin- (il- ) were significantly enhanced. a monoclonal antibody, which neutralizes gm-csf bioactivity, rendered mice less sensitive towards lethal lps-challenge. tnf-and il- -tevels were reduced in these mice compared to control animals without antibody treatment. in addition, severalfold potentiation of lps-induced cytokine release by gm-csf was observed in vitro in murine bone marrow cell cultures. these data demonstrate the proinflammatory capacity of gm-csf and suggest that the hemopoietic cytokine plays also a role as an endogenous modulator of lps toxicity. immune dysfunction, developing in the wake of multiple trauma, overwhelming infection and other forms of critical surgical illnes% is associated with increased infections, morbidity and mortality. the mechanisms responsible for alterations in immune regulation are incompletely understood but monocyte appear to play a central role. polymorphonuclear leukocytes (pmn) are known to play a central role in the inflammatory response of the host toward invading microrganisms. reports of defects in all the aspeots of pmn function have been accumulated in recent years. the possible role of gm-csf in modifing the state of immuno suppression detected in severe intraabdominal infected pt~. inspite of surgical appropriate procedures and in reducing the expected mortality is investigated. the safety of rh-gm-csf administration in sepsis is also evaluated. a double blind randomized study is proposed. this study include icu patients who do not exhibit signs of shock and/or ards, with clinical signs and symptoms of abdominal infection. immunodepressed patients-aids, chronic chemotherapy or chronic steroid administration do not partecipate to the study. patients will receive rgm-csf (l~g/kg/day) or placebo in hs. continuous infusion for days. safetyandefyieacy will be assessed till to day . the apache ii score is adopted for risk stratification of patients because it is reliable and validated, objective and composed of information that is indipendent of diagnostic criteria. patient's entry criteria is apache ii > (score corresponds to expected mortality rate of %).in this protocol the surgeons report the judgement of the efficacy of surgical procedure to remove or not the focus of infection. objectives: infections and subsequent septic responses remain the leading cause of death among surgical intensive care (sicu) patients despite tmprovetaunts in supportive care and brond-epectrum antibiotics. usually invading bacteria are efficiently cleared by neutrophil granulocytes. however, during sepsis various neatrophil dysfunctions have been demonstrated, leading to impaired host defense. granulocyte colony-stimulating factor (g-csf) induces a sustained increase in circulating neutrophils and enhances various noutrophil functions. it was the purpose of the present study, to evaluate the safety and efficacy of g-csf (filgrastim) in sicu patients at risk of sepsis. materiel a.d methods: the study was designed as an open-label phase-ll study of filgrastim. ten consecutive slcu patients, with a therapeutic interveotion score greater than , were included in the study. filgrastim was given by daily continuous intravenous infusion for days or discharge from the sicu. apache ll-score, multiple-organ-failure (mof) score, definitions of infections, sepsis, systemic inflammatory response syndrome (sirs), and acute respiratory failure were applied daily. a response to filgrastinl th_erapy was defined as an improvement in disease severity quantified by a decrease of > apache i score points on day after onset of treatment. results: none of the patients developed a sepsis or mof later on and no patient died during hospitalization. specific postoperative complications occured in one patient ~jth a leekage of the oesophagou-gastric anastomosis after oesophageus resection. at study entry the leucocytes amounted to . + . /~tl (mean + sem) and reached a level of . +_ . /tal at day after onset offilgrastim therapy. the apache ii score initally was + . (mean + sem) and as an indicator of filgrastim response a decrease of points ~dthin days oceured in out ot patients. filgrastim was well tolerated, side effects were not noted. growth of solid tumors might be modulated by the activity of inflammatory and/or immune effector cells of undefined specificity. in this study patients undergoing surgical treatment for gastric (n= ) or colorectal (n= ) cancers were evaluated for endogenous serum levels of granulocyte colony-stimulatingfactor (g-csf) during a pre-and postoperative time period. from the same blood specimens mononuelcar cells (mnc) were prepared. the release of ifn-%, and il- , which are secreted by thl cells, were stimulated in vitro by pha during a cell culture period up to hours. the patients were further classified for their immunreactivity by responses in dth skin testing to seven different antigens (e.g. tetanus toxoid, ppd, diphtheria toxin, trichophyton, streptococcus, candida and proteus antigens). dth testing has been repeated in each patient two remarkable results were obtained. the serum levels of endogenous g-cse showed a biphasic increase with maximum values of pg/ml (preoperative < pg/ml) on day and day to after surgical treatment. similar patterns of g-csf production were found in both groups of patients with gastric or colorectal cancers. high serum levels of g-csf were significantly (p < , ) correlated with infectious complications in patients whh gastric cancer (n= / ). secondly patients could be arranged into two groups according to an anergic (n= ) or normergi¢ (n = ) responsiveness in dth testing. the frequency of anergi¢ responsiveness was similar in both patients with gastric (n= / ) or colorectal (n= / ) cancers. interestingly we found a significant correlation (p < , ) between low serum levels of g-csf and anergy during the postoperative period in both groups. stimulation of mncs from anergic patients (n= ) within the pre-and postoperative period resulted in reduced mean values (about %) for ifn-ff release (preoperative means llo pg/nfl), if compared to patients with normergic dth (n= , preoperative means pg/ml). similar, but less significant results were obtained for il- secretion. our results confirm a correlation between infectious complications and g-csf in the postoperative period, however elevated levels were also found in some patients without any signs of infections. more interestingly there might be an association between cytokine (c~csf, ifn-% and il- ) release and dth, which is known to be mediated by activated thl calls. to recognize anergic dth as a possible higher risk in the postoperative outcome of cancer patients extended periods of observation are needed. objectives of the study effects of recombinant huraan granulocyte colony-stimulating factor(rhc-csf)a galnst severe septic infections were investigated by its single use or by its corn b{nation with cephera antibiotlcs.we examined its effects on the mortality,and circulating blood neutrophyis counts and functlons,such as phagocytic activity and h production using the rat severe septic model. rats were subcutaneously administsrd rhc~csf(s orl o ~ g/k~ body wt)after on set of peritonitis brought about by cecal ]igation and one puncture withe -gaug e needle once a day for three days.in addjtlon,cefmetazol na(cmz)( m$/k bo dy wt)was injected intrarnustularly to the rats tv~ce a day for three days. cirehlatlng blood neutrophyls counts were determoned electronically with a hem ocytometer,and blood smears stained with may~runwaldm.qlemsa~taln. neutrophyls functions in vltro,such as phagocytic activity and h producti on using the rat severe septic model was analyzvd by automated flow cytometri c single cell-analysis methods. the reortallty rate after weeks was significantly decreased by administratlon of rh~-csf(p< , ).ln addjtion,a combination therapy of rhg-csf wlte cephern ant~biotics(cmz)showed a significantly survive] advantage and the rate had b een reached . %. nextly,treatn%ent wlth rhg-csf(s ~ $/k body wt)increased the nuzaber of the peripheral blood neutrophjls slgn[fieantly(p< . ). iv~oreover,functions of neutrophlis which were phagocytic activity and h p roduction were remarkably enhanced by admlnlstratlon of rhg-cs~( ~ /ks b ody wt) (p< .( ). these findings suggest that combination therapy of rhcrcsf with cephern antib iotlcs(cmz)is an efficient regime against severe infectlons.and the increased ne utrophils counts and enhanced neutrophiis functions were played a important ro le about the survival advantage. granulocyte macrophage colony-stimulating factor (gm-csf) is a haematopoietic growth factor active on neutrophils and macrophages. leukopenia often occurs following renal transplantation and can be associated with infection and/or the myelosuppressive effect of azathioprine. aim: we report the use of gm-csf in renal allograft recipients with leukopenia. nonglycosylated recombinant gm-csf was obtained from e. coli transvected by human gm-csf gene. m~terial ~,nd methods : written informed consent was obtained from all patients. patients were suffering from toxic neutropenia (neutrophils < /mm ) with medullar hypocellularity on bone marrow aspiration, or leukopenia (neutrophils < /ram ) with cytomegalovirus infection requiring ganciclovir administtation. gm-csf was given subcutaneously at a dally dose of to mcg/kg/day, according to renal function. results : in all cases, neutrophil counts returned to normal levels within to days. in most of them, spectacular correction was observed within hours, with a single injection. adverse events due to gm-csf at this dose were mild and easily managed ( cases of bone pain treated with paracetamol). one acute rejection episode was observed after correction of leukopenia. conclusion : on the basis of this study, it appears that gm-csf at a dose below mcg/kg/day is an effective treatment for renal transplant recipients with leukopenia associated with cmv infection or toxic neutropenia. department of nephrology, , rue de s~vres, hopital necker, paris, france. changes in serum g-csf and il- after surgical intervention hitoshi toda , atsuo murata , hidewaki nakagawa , takesada mori , nariaki matsuura osaka university medical school, osaka, wakayama medical school, wakayama, japan we measured serum immunoreactive interleukin (il- ) and granulocyte colony-stimulating factor (g-csf) levels of the patients undergoing major thoraco-abdominal surgery for esophageal cancer. serum samples were collected from eight patients on the day before surgery, at the time of operation, and thereafter at suitable intervals for one week. il- and g-csf were measured by means of enzyme linked immunoassay. the normal range of serum ]l- was less than pg/ml and g-csf less than pg/ml. values between groups were compared with linear regression analysis. both serum g-csf and il- levels reached their maximal levels at the first postoperative day and decreased thereafter. the correlation between g-csf (y) and il- (x) was y= . x+ . (r= . , n= , p< . ), showing a significant correlation. in the case who suffered from aspiration pneumonia and ards at the second postoperative day, the peak level of il- was pg/ml and g-csf pg/ml respectively. the estimated value of g-csf was pg/mi by the regression equation. this means the real g-cse level was less than half of the estimated value. it suggests that low responsiveness of g-csf is one of the reason of immunodeficient state after the major surgery, neutrophils from injured patients ingest and kill bacteria less efficiently as compared to those of healthy individuals, probably reflecting the suppression in respiratoly burst which occurs after severe trauma. one of the main mechanisms of killing bacteria by neutrophil granulocytes is production of oxygen radicals (respiratory burst). granulocyte colony-stimulating factor (g-csf), a kilodalton cytokine, leads to a sustained, dose-dependent increase in circulating neutrophils. thus, it was investigated whether filgrastim (recombinant human granulocyte colony-stimulating factor, rhg-csf) therapy fits for prophylaxis of sepsis in postoperative/posttraumatic patients, and whether, besides an expected increase in neutrophil count, filgrastim would also augment neutrophil function. material and methods: this study was designed as an open label, prospective phase ii study of filgrastim and performed in a surgical intensive care unit (sicu) (university hospital). postoperative/post-traumatic patients with a therapeutic intervention scoring system (tiss) score greater than were treated with filgrastim ( . - l.tg/kg/day) for prophylaxis of sepsis on days or until discharge from the sicu. production of oxygen radicals can be quantified by analysis of fmlp-and zymosan-induced chemiluminescence. neutrophil oxygen radical production was tested by fmlp-and zymosan-induced chemiluminescence by the polymorphonuclear cells (pmn) of these patients in multiple blood samples over a period of up to days. results: none of the patients treated with filgrastim for prophylaxis of sepsis developed sepsis. in vitro fmlp-induced ( - reel/l) neutrophil oxygen radical production was significantly increased under therapy with filgrastim by a maximum of % +- % ( % - %) compared to pretreatment values of %. tapering of filgrastim resulted in a reduction of fmlp-induced neutrophil oxygen radical production within hours. in contrast, zymosan-induced neutrophil oxygen radical production was not affected by filgrastim treatment. conclusions: besides its quantitative effect on neutrophil counts enhanced neutrophil function, documented here as increased fmlp-induced oxygen radical production, may account for the beneficial effect of filgrastim for prophylaxis of sepsis in posttraumatic/post-operative patients. granulocyte colony stimulating factor (g-csf) and granulocytemacrophage colony stimulating factor (gm-csf) have been recently introduced in the treatment of chemotherapy-induced neutropenia. effects of these csfs on cellular immune system were evaluated in neutropenic gynecological cancer patients during chemotherapy. g-csf and gm-csf were equally able to induce a rapid recovery of white cell count within one or two days. g-csf treatment resulted in a significantly higher concentration of leukocytes measured in the peripheral blood although by gm-csf a sufficient effect was achieved (p< . ). before initiation of csf treatment urinary neopterin was similar in both groups of patients ( +/- and +/- lamol/mol creatinine for gm-csf and g-csf respectively expressed as mean +/-one sd). in g-csf treated patient only a marginal induction of neopterin was observed. on day the mean value was about % above the basal level (p< . ). on the other hand gm-csf treated patients were characterized by a pronounced increase in urinary neopterin levels. in comparison with the basal level a more than fold induction was noted and the difference between g-csf and gm-csf was highly significant (p< . ). this effect was confirmed in vitro by investigating the effects of these csfs on interferon-gamma mediated pathways in thp- human myelomonocytic cells. results suggest activation of immune effector cells by gm-csf which may help the organism to overcome infections. however, activated macrophages produce several growth factors which may increase malignant proliferation, and augmented neopterin production as sign of macrophage activation has also been associated with poor prognosis m several malignancies. more data are therefore necessary to clarify whether csf mediated immune activation is beneficial or deleterious for cancer patients but considering our results caution in applying csfs in oncology seems advised. from a historical perspective, the development of humoral immunity to bacterial endotoxin has assumed a prominent position in the spectrum of therapeutic approaches which have been explored for the treatment of gram negative septic shock. predicated upon the fact that rough strains of bacteria manifest lps containing exclusively conserved structural features common to lps from all gram negatives, specific antibodies were elicited which conveyed cross protective immunity in experimental models of bacteremia and endotoxemia. such studies culminated in a well-conducted, randomized, double-blind placebo-controlled clinical trial using passively administered human polyclonal antiserum to treat patients with suspected gram negative sepsis. the efficacy of treatment established in that trial spurred efforts to develop monoclonai reagents which, to date, have not been uniformly successful in reproducing those earlier studies with polyclonai antibodies. nevertheless, the numerous successes which have been documented in experimental models of endotoxemia continue to foster promise for this immunotherapeutie approach. several recent studies with human polyclonalimrnunoglobulin preparations containing antibodies reactive with lps and lipid a have yielded promising results in treatment of patients with sepsis. in addition, the recent development of an antiidiotypic monoclonal antibody which reflects an internal image of a kdo specific monoclonal antibody has provided an alternative experimental approach to generate anti-lps antibody. immunization of mice with the antiidiotype provides significant protection against subsequent lps lethality consistent with the development of circulating immunoglobulin specific for lps. thus, the use of polyclonal immunoglobulins contrives to provide an alternative and potentially cost effective method for the treatment of endotoxin shock. supported by r a and pot ca . john holaday, anne fortier, shawn green, glenn swartz, john madsen, carol naey, and jan dijkstra entremed, inc.. rockville, md, . at the time of diagnosis, the signs and symptoms of septic shock are an indication that the systemic inflammatory response is well underway; thus, it has been argued that the endotoxin "cat is out of the bag", and that subsequent passive immunization may be too late to achieve therapeutic benefit. our approach has been to evaluate active immunization as a prophylax~s against sepsis. mice were inoculated twice (two weeks apart) with liposomes containing dmpc[i. ], dmpg[ . ], cholesterol [ . ] , and monophosphoryl lipid a [ - gg/txmole phospholipid] by several routes (i.p., i.m.), and serum was collected - days after each inoculation. after a single injection, highest tilers of ab were produced in mice inoculated i.p., but mice inoculated by all routes produced anti-lipid a ab. following the second injection. ab levels were roughly equivalent in mice inoculated by all routes, regardless of lipid a concentration. mice vaccinated i.p. with liposomes containing , or gg lipid a were treated with cyclophosphamide to produce neutroperda and then challenged with e. cole in an infection model of gram negative sepsis. the lds for control (liposomes with no lipid a) mice was x bacteria; ld for mice vaccinated with p.g was x ( -fold increase in resistance) and with ~tg was x bacteria ( -laid increase in resistance). mice vaccinated as before were also treated with actinomyein d to increase sensitivity to lps (salmonella minnesota) challenge in an endotoxemia model of grain negative sepsis. the ld for control (liposomes with no lipid a) mice was ng lps; the ld for gg lipid a was rig lps ( -fold increase in resistance) and for xg was ng lps ( -fold increase in resistance). mice were similarly vaccinated and challenged with an aggressive gram negative pathogen, francfsella tularensis. the ld of franciseua in normal mice or mice inoculated with liposomes without lipid a was - bacteria. in contrast, mice vaccinated with liposomal lipid a ( ggl survived challenges as high as , bacteria, ( logs of protection). the impressive protective capacity of this vaccine did not correlate with ab liter in any of the sepsis models, nor did it correlate with classic nonspeeific events, such as macrophage activation. maerophages harvested from the peritoneum of mice vaccinated and protected against sequelae of gram negative infections did not spontaneously kill the bacteria in vitro, but could be activated by ifn-y for antimicrobial activity equivalent to that of macrophages from unt#eated mice. research is underway to defme the protective mechanism(s) activated by this liposomal-lipid a vaccine. intervention by monophosphoryl lipid a in septic shock jon a. rudbach, ribi immunochem research, inc., hamilton, montana, usa monophosphoryl lipid a (mla), the clinical form of which is called mpl®-immunostimulant, has been tested extensively as an intervenient material in septic shock. mla is protective when given to experimental animals prior to a live microbial challenge or challenge with lethal doses of microbial products or certain cytokines. this is shown with gram negative and gram positive bacteria, gram negative bacterial endotoxins, and gram positive bacterial exotoxins. furthermore, animals treated with a regimen of mla which results in a refractory state to a lethal dose of gram negative bacterial endotoxin concomitantly display increased resistance to a live bacterial challenge. thus, both endotoxin tolerance and nonspeciflc resistance to infection can be manifested simultaneously. also, prophylactic doses of mla do not interfere with other therapies given subsequently; an additive or a synergistic protective effect can be demonstrated with certain combinatorial treatment regimens, such as mla followed by antiendotoxin monoclonal antibodies. the preclinical studies were extended to human trials wherein the safety of agonistic doses of mla was verified. furthermore, when mla was administered to human volunteers hr before challenge with a pharmacologically active dose of reference endotoxin, febrile, cardiac, tnf, il- , and il- responses were all decreased significantly as compared with the responses of subjects pretreated with a control solution and challenged with endotoxin. human trials with mla are being extended into patient cohorts which have high probabilities of developing septic shock; this will expand the safety base and establish clinical efficacy for mpl®-immunostimulant. a considerable body of in vitro evidence supports the concept that the effects of lps on cells of the immune/inflammatory systems are controlled by interactions of lps with cd . to evaluate if blocking lps-cd interactions has potential as a therapeutic in septic shock we have evaluated the effect of anti-cdi monoclonal antibody (mab) on lps-induced cytokine production and physiologic changes in an experimental model of endotoxin shock performed in cynomolgus monkeys. a novel model has been established where animals were treated with interferongamma for three days prior to infusion of highly purified lps over an eight hour period. in this model lps challenge resulted in marked release of eytokines in the blood, substantial hemodynamic changes, release of liver enzymes and alteration in lung permeability observed over a hour period. to evaluate the effect of treatment with anti-cd mab, animals were given either nothing, an isotype control or anti-cd mab ( mg/kg) rains, prior to the beginning of the lps infusion. evaluation of physiologic changes including mean arterial blood pressure and cardiac output, quantitative analysis of eytoldne levels including tnfct, il- , i,- , il- and il- , and liver enzymes during a hour period revealed that treatment with anti-cd mab markedly attenuated all parameters of injury including decreased mean arterial blood pressure, increased cytnkine levels and the release of liver enzymes observed in animals given the isotype control mab or those not treated. administration of anti-cd mab to interferon-gamma treated animals not challenged with lps did not induce any detectable physiologic changes or increases in cytoldnes. these studies suggest that strategies to block lps-cd interactions will have utility in diseases such as septic shock or ards where lps plays a central role in initiating injury. preclinical studies with recombinant bactericidal/permeability increasing proteins (rbpi and rbpi ). p.w. "frown, dept. of preclinical science, xoma corporation, berkeley, california, usa. bactericidal/permeability increasing protein (bpi), from neutrophils, binds to and neutralizes lipopolysaccharide (lps); it also specifically kills gram-negative bacteria (gnb). these properties, which reside in the n-terminal half of the molecule, indicate potential therapeutic application in the treatment of gram-negative sepsis. the gene for human bpi has been cloned and recombinant holoprotein (rbpi) and a kd n-terminal fragment (rbpi; ) have been produced in sufficient quantities for preclinical studies. both rbpi and rbpi bind to lipid a and neutralize the biological activities of lps derived from a variety of organisms, rbpi has equivalent antibacterial activity to bpi against rough gnb but is up to x more potent than bpi vs. serum-resistant and smooth gnb. rbpi and rbpi compete with lps-binding protein (lbp) for binding to lps under physiological conditions. consequently, both rbpi and rbpi block the cd -dependent lpsinduced synthesis of the cytokines tnf, il- , el- and il- in vitro. rbpi has also been shown to inhibit the lps-induced synthesis of reactive metabolites, endothelial adhesion molecules and the procoagulant molecule tissue factor. in animals, rbpi has been reported to increase survival of endotoxin-challenged rats and mice, to inhibit the dermal schwartzman reaction in rabbits and to increase survival of neutropenic rats with pseudomonas bacteremia, rbpi increases survival and decreases cytokine production in endotoxin challenged mice and rats. it normalizes lps-induced changes in hemodynamic, pulmonary and/or metabolic parameters in lps-induced rats, rabbits and pigs. treatment with rbpi also increases survival and decreases cytokine production in bacterial challenge models in rats and mice. rbpi was not toxic to rats after daily consecutive i.v. doses of mg/kg. this combination of properties indicate that recombinant bpi may be useful in the treatment of sepsis. phase i/ii clinical trials of rbpi have begun. the discovery of lps binding protein (lbp) and subsequent identification of cd as a receptor for lps or lps-lbp complexes has resulted in a new understanding o£ how lps responsive ceils are stimulated. cd is found either as a glycosylphosphatidyl-inositol (gpi)-anehored membrane glycoprotein (mcd ) of myeloid cells or as a soluble serum protein (scd ) lacking the gpi-anchor. binding of lps to mcd triggers cell activation while binding of lps-scd complexes to cells such as endothelial or epithelial cells that normally do not express mcd activates these cells. these pathways are shown in schematic form below. ~di mcd plays a crucial role in presentation of lps to additional membrane components that make up a functional lps receptor. an immediate consequence of engagement of this functional receptor is protein tyrosine phosphorylation. the molecular mechanisms leading to these events will be discussed. understanding of these pathways will lead to the development of new therapeutic approaches to controlling host responses to lps. pretreatmen t posttreatment (before or after tnf peak) d) with different antibody dosages: mg/kg --- . mg/kg pretreatment with anti-tnfab prevented death in most model situations (except peritonitis), but also posttreatment up to h after sepsis induction was successful in the few studies performed. there is additional evidence that low-dose tnfab is partially effective. especially baboon anti-tnfab studies provided many insights into the pathophysiological sequences of sepsis induction, due to crossreactivity with human reagents. those events include the cytokine sequence with tnf-dependent il-i, il- , or il- , but also il-lra or stnf receptor release. granulocyte as well as endothelial cell activation were shown to be partly tnf related, and the procoagulatory response was influenced by anti-tnf treatment. from many animal studies the concept that tnf plays a pivotal role in sepsis is clearly evident and therefore anti-tnf therapy is a major candidate tbr clinical studies. the beneficial or harmful effects of tnf-mediated inflammatory responses depend on the clinical context. decreasing exaggerated tnf-mediated inflammatory responses may be useful in some patients with organ failure. tnfr:fc (immunex, seattle, wa) is a recombinant human protein composed of two identical extracellular p tnf receptors linked by the fc region of iggl. it neutralizes tnf with an affinity for tnf<z of - m and has a t / of • h in normal humans. methods: normal volunteers were randomized to receive either tnfr:fc vehicle (n= ), or low dose (ld) tnfr:fc ( mg/m iv, n= ), or high dose (hd) tnfr:fc ( mg/m iv, n= ) infused over rain prior to endotoxin (e) (escherichia coil : ; ng/kg iv) administration. plasma cytokines were measured using elisa and tnf bioactiv'dy. systemic hemodynamics were evaluated with indwelling arterial and pulmonary artery catheters and radionuclide heart scans and compared before and after fluid loading in subjects given vehicle with hd tnfr:fc. results: endotoxin-related symptoms were unchanged after ld or hd. peak temperature occurred at a later time point ( - h) in subjects given tnfr:fc compared to vehicle ( h) (p=. ). at h, h (post fluid load ), and h, subjects given vehicle developed increased cardiac index and heart rate and decreased systemic vascular resistance index (all p=. ). hd tnfr:fc did not alter this hyperdynamic cardiovascular response. ld and hd inhibited the e-induced teukopenta at i h post endotoxin (p<. ) and later leukocytosis (p< . ). peak tnf bioactivity in subjects given vehicle was + pg/ml and < pg/ml in the ld or hd tnfr:fc groups (p<. ). two immunoassays for tnf were performed because the detection of receptor bound tnf varies with elisa. tnf (biosource) was decreased in ld vs vehicle or hd (p=. ) whereas tnf (r&d systems) was increased after hd or ld vs vehicle (p<. ). decreased levels of il- (p=. t), granulocyte colony stimulating factor (p=. ), and il- receptor antagonist (p=. ) were found after ld or hd vs vehicle. il- levels were lower after ld vs vehicle or hd (p=. ). il- levels were similar among subjects given vehicle, ld, and hd tnfr:fc. conclusions: ld and hd tnfr:fc delayed the febrile response to e but did not alter the early hyperdynamic cardiac response. this suggests that mediators other than tnf play an important role in the initial cardiovascular response to e in humans. tnfr:fc attenuated the release of some e and tnf-induced cytokines. ti~e antiinflammatory responses of tnfr:fc may be useful in some patients with disease processes resulting from excessive tnf-mediated inflammatory responses. the biosynthesis of tnf within macrophages is regulated both at the transcriptional and the translational levels. the ' flanking region of the tnf gene contains several transcriptional control elements, including two kb enhancers similar to those of immunoglobulin genes and a "y box" similar to that of the mhc class ii promoter. these elements are critical for the enhancement of transcription noted after stimulation of macrophages with lps. despite these and other elements, transcriptional regulation alone accounts neither for the absence of tnf protein during normal homeostasis nor the profound increasein tnf production following stimulation with lps or other secretagogues. the translation of tnf mrna into protein is also tightly regulated via mechanisms involving the octameric "ttatttat" motif present in the 'untranslated region of tnf, human inducible no synthase, and several other cytokine genes. this region not only destabilizes mrna, but also confers a translational blockade so that tnf protein is not normally synthesized despite leaky basal transcription. lps stimulation releases translational blockade and, together with enhanced trancriptional rate, accounts for significantly increased tnf secretion. opportunities for inhibition of tnf production are available at each of these two levels. agents which increase intracellular camp (pentoxif¥ ine, amrinone) inhibit accumulation of tnf mrna; in contrast, corticosteroids act primarily at the level of translation, inhibiting lps induced translational activation. understanding the regulation of tnf biosynthesis may assist in clinical strategies designed to regulate tnf secretion. the serine protease thrombin is formed by enzymatic conversion from its proenzyme form after coagulation activation and may enhance the inflammatory response in various ways. in the last step of the coagulation cascade, thrombin cleaves its substrate fibrinogen, thus forming fibrin. the fibrin clot may prevent phagocytosis of bacteria and promote local bacterial growth. thrombin can also stimulate a specific th.rombin receptor that exists on a variety of cells. for example, minute amounts of thrombin ma), stimulate platelets to develop tissue factor and boost the activation of more thrombin, thus initiating a positive feedback loop. other cellular effects of thrombin receptor stimulation include increase in intracellular calcium of platelets and monocytes, contraction of smooth muscle cells, increase in endothelial permeability, thromboxane generation by neutrophils and lymphocytes, pulmonary vasoconstriction, and enhanced cytokine production. animal experiments have been conducted with a variety of thrombin inhibitors including heparin, antithrombin ili, hiradin, and hirudin-like peptides. an alternative approach is the inhibition of the coagulation cascade at an earlier point in the cascades, or administration of the anticoagulant enzyme protein c work from our own group in a porcine model of lipopolysaccharide-(lps)-induced shock with disseminated intravascular coagulation has shown that prelreatment with recombinant desulfatohirudin (r-h) or with a preformed complex of human donor antithrombin iii with heparin or post treatment with r-h are able to block the degradation of fibrinogen and the formation of fibrin monomer. in addition, after pretreatment with r-h it was found that lps-induced lung injury was reduced. since both natural hirudin as well as r-h were well tolerated by healthy volunteers, adminislration of r-h may be a promising therapeutic approach in patients with sepsis and sirs. corticosteroids have been used in the management of various shock syndroms including sepsis. the data concerning the effects of this therapy is, however, conflicting and in large prospective studies, the use of early administration of high doses of corticosteroids have been found to give no beneficial effects in patients with sepsis. we have particularly been engaged in studies on possible effects of corticosteroids on the plasma cascade systems and on the mediator release from leukocytes. in in vitro studies, high doses of methylprednisolone were found to facilitate endotoxin induced generation of plasma kallikrein. furthermore, plasma prekallikrein and kallikrein inhibitor values decreased together with formation of kallikrein-c inhibitor complexes ( ). in this in vitro plasma model we also found that methylpredoisolone alone in doses of mg/ml induced contact activation with the formation of kallikrein-c inhibitor complexes. methylprednisolone was also found to have an additive effect on endotoxine induced decreases in kallikrein inhibitor functions. in the same experimental model on endotoxemia methylprednisoione was found to give an additive effect on activation of the initial part of the complement cascade ( ) . activation of the terminal part of complement, however, was inhibited by the same dose of methylprednisolone. addition of methylprednisolone alone to plasma was also found to activate the initial part of complement. using a full blood model, we studied the effect of methylpredoisolone in modulating the endotoxin induced cytokine response. when ng/l e. coli endotoxin was added to citrated blood from healthy human donors preinkubation with gg/ml methylprednisolone significantly reduced the release of tumor necrosis factor et ( %) and interleukin- ( % ) at two hours after exposure to endotoxin. in conclusion, these studies show that corticosteroids might facilitate contact activation of plasma and reduce the function of major protease inhibitors. furthermore, we also observed that this drag in in vitro conditions facilitated activation of complement. on the other hand, corticosteroids were found to reduce endotoxin induced cytokine release from leukocytes in whole blood. these studies also showed a dose dependence of the effects of corticosteroids on endotoxin induced cellular and cascade system activation. different predisposing conditions like extensive trauma, infection or pancreatitis result in a remarkably similar inflammatory response. although thls inflammatory response primarily aims at the removal of devitalized tissues, destruction of bacteria and reestablishment of the integrity of host tissues, it may potentially become unregulated and generalized and thereby producing deleterious effects to vital organs or the body" as a whole. cytokines play an important role in the development of the systemic inflammatory response. most of their biological effects, however, are not directly mediated but exerted through other mediator systems. when the inflammatory response results in the formation of capillary leak syndrome and refractory hypotension, the unregulated activation of complement and contact systems appears to be the cause. both systems are almost exclusively regulated by c - nhibitor. am unbalanced degradation of the inhibitor protein was found to be associated with the onset of capillary leakage in various conditions such as bone marrow transplantation, severe burns, and septic shock. these observations suggest a relative deficiency of biologically active c - nhibitor in these septic shock like syndromes. therapeutic intervention studies were initiated using high doses of c - nhibitor concentrate. first results are promising, as in most patients the administration of the drug was followed by a quick and marked improvement of the patient's hemodynamics. whether the administration of c - nhibitor alone or in combination with other drugs is also sufficient to improve long-time survival has to be investigated in double-blind, placebocontrolled studies. salutary effect of human soluble complement receptor type- in models of adult respiratory distress syndrome g. feuerstein, m. dimartino, and *r. rabinovici, smithkline beecham pharmaceuticals, king of prussia, pa, usa, and *jefferson medical college, philadelphia, pa, usa adult respiratory distress syndrome (ards) is a severe pulmonary insufficiency syndrome associated with diverse diseases and injuries. ards is believed to be the consequence of a massive acute inflammatory reaction consisting of activated neutrophils infiltration into the lung. neutrophil activation is likely the result of multiple factors of which complement is believed to play a major role. a potent complement regulatory system in the form of the complement receptor type- (cr- ) exists on many cells where protection against complement injury is provided by inhibition of both the alternative and classical pathways for c /c convertase formation. we have recently purified the human recombinant cr- in a truncated form (brl , tp-io, scr- ) and tested this soluble protein for protective effects in several models of ards. specifically, we have used the following rat models: ) endotoxin-induced ards in paf primed animals; ) .- induced ards; ) thermal injury ( % body surface)-induced ards; ) acid aspiration-induced ards. ards-like features included edema (increase in lung wet weight and water content), neutrophil accumulation (histological inspection and myeloperoxidase assay) and increase in cells and protein in the bronchoalveolar lavage (bad. scr- , - mg/kg, i,v., given as prophylactic (and in some cases, therapeutic) treatment significantly inhibited edema formation and leukocyte infiltration and, in some cases (e.g., endotoxin/paf or il- ), virtually completely. these comprehensive studies strongly support the therapeutic potential of scr- in ards due to diverse injuries. the xanthine derivative pentoxifylline (ptx) and several analogs of ptx have been evaluated for their protective effect in various animal models of septic shock. data from these in vivo studies demonstrate that ( ) ptx suppresses lps-induced tnf release from activated macrophages; ( ) ptx prevents tnf-induced pmn activation; ( ) ptx attenuates lps-or tnfinduced acute lung injury as evidenced by prevention of increased pulmonary vascular permeability and detoriation of gas exchange; ( ) ptx exerts its .protective effects even when administered following initiation of sepsis. the sum of these actions suggest that administration of ptx in sepsis may have therapeutic potential. hans hoffmann md, dept. of surgery, klinikum grosshadern, ludwig-maximilians-universit~.t, marchioninjstrasse , d- m nchen, germany. pentoxifylline [pof] and related xanthins are drugs of known haemorrheologieal activity and widely used clinically. recently, new pharmacological aspects of these established drugs could be demonstrated. it was found that pof selectively inhibits the formation of tnf but not il- most likely by causing accumulation of intraceliular camp via inhibiting phosphodiestersse activity, and, secondly, by inducing prostacyclin in different cell types. furthermore, pof is able to counteract tnf-mediated adherence of neutrophils to vascular endothelium and to inhibit fmlp-indueed respiratory burst in neutrophils. we and others have, therefore, studied its effect in different animal models. it was found that pof protected from increased pulmonary vascular permeability and sequestration of neutrophils into the lung in different animal models of acute lung injury. moreover, in pigs with induced faecal peritonitis the drug improved haemodyrmmle variables as well as pulmonary compliance and reduced the number of pulmonary neutrophila and lymphocytes. consequently, as a general outcome, pof could be found to improve survival in different models of haemorrhagie and endotoxie shock. the protective effect of pof was dose-dependent and observed even when pof was given up to hours after endotoxin. in order to evaluate these pharmacological effects of pof in humans, we studied pof under controlled conditions of endotoxlnemia in volunteers. we found that pof selectively inhibits the lps-indueed endogenous formation of tnf without affecting il- and il- . moreover, pof counteracts the lps-indueed initial leukocytopenia by interfering with the adherence of neutrophils in the microvasculature. meanwhile the inhibition of endogenous formation of tnf by pof could be demonstrated under different clinical conditions of acute and chronic cytokine release syndromes, {okt first-dose reaction, cancer-or tuberculosis-induced cachexla}. it appears worthwile and promising to investigate wether pof exhibits beneficial effects also in septic patients. objectives: to determine the specific role of paf in both lethal primate bacteremia and nonlethal human endotoxemia. materials and methods: two double-blinded placebo controlled studies were performed. first, ten baboons ( . +. kg), were randomized to a control group receiving ° cfu/kg of intravenously administered e. co/i (n= ) and a treatment group (n = ), pretreated with . mg/kg of paf receptor antagonist ro - two hours prior to e. co/i infusion. in a second study, ten healthy male volunteers were randomized to a control group receiving ng/kg of intravenously administered endotoxin (lps) (n= ) and a treatment group (n= ) pretreated with mg of ro - eighteen hours prior to lps administration. physiologic parameters and cytokine levels were measured continuously in both studies for hours. results: baboons pretreated with the paf antagonist had improved oxygenation ( + mm hg v -+ in controls, p < . ) and creatinine clearance hours post e.coli ( . + . ml/min v . _+ . in controls, p < . ). similarly, volunteers pretreated with the paf antagonist experienced fewer symptoms, including rigors and myalgias at hour post lps. this was in concert with a diminished peak cortisol ( +_ mmot/l v +- mmol/l in controls, p < . ), epinephrine secretion ( + nmol/l v + nmol/l in controls, p < . ). hemodynamics and circulating tnfa levels (data not shown) were unaffected in either study by prior paf antagonism. concluslons: paf influences some components of the multi-organ failure syndrome in lethal gram negative sepsis and the counter-regulatory hormonal system in human endotoxemia through tnf-independent mechanisms. paf antagonists may serve as adjuncts to cytokine blockade in the treatment of gram negative sepsis. the mediator role of platelet-activating factor in gramnegative septic shock pierre g. braquet, david hosford and matyas koltai institut henri beaufour, le plessis robinson, france considerable evidence has been accumulated to support the concept that a paf/cytokine autogenerated feedback network is responsible for priming and amplification of inflammatory mediator release in septic shock. cytokines, such as tnf~x, il- and other interleukins interact with paf which then amplifies cytokine production, therefore, paf may be the principle mediator in endotoxin shock. a single factor identified as tnf is suggested to play a pivotal role in the fatal phase of septic shock. presumably excess tnf release is the result of amplification process primarily triggered by paf. one may assume that the high tnf concentration in the blood of 'non survivors' is the consequence rather than the cause of cell death. the dubious results of clinical trials with anti-tnf antibodies and il- ra, a naturally occurring il- antagonist protein, have risen debate around the exceptional role of cytokines in the pathomechanism of septic shock or systemic inflammatory response syndrome (sirs) induced by gramnegative microorganisms. there are similar problems with the interpretation of the results obtained in clinical trials of monoclonal igm antibodies against e. coli endotoxin, ha- a and e . future studies will answer the question as to the effectivity of inefficiency of this treatment. perhaps when the plasma concentrations of lps and cytokines exceed a critical level, treatment fails to save the patients life. with regard the causal role of lps in septic shock, the putative role of bacterial porins may have to be taken into consideration. the marked release of paf induced by endotoxin leading to excess txa production may be responsible for the microvascular failure and death in septic shock. antagonists of paf markedly protect against the release of txa , and may interrupt the vicious circle of amplification process. no produced by the inducible no synthase plays a pivotal role in causing vascular paralysis in lps-induced sirs. to explore the relationship of paf to no synthesis will provide better understanding of the pathomechanism of septic shock. several paf antagonists, including bn , have undergone phase ii and phase iii clinical trials. the strategy in the treatment of sirs, however, remains multifactorial, since little is known about the sirs caused by microorganisms other than gram-negative bacteria. evidence has begun to accumulate which suggests that in sepsis excess production of lps and cytokines can lead to uncontrolled production of inos and that this might in part explain the severe unresponsive hypotension seen in some septic patients. a number of strategies have been explored in an attempt to limit excess no production. a favourite target has been competitive inhibition of nos by arginine analogues such as l-nmma. in animals, some investigators have shown that the haemodynamic effects of lps challenge can be attenuated by l-nmma, but there is a narrow toxic-therapeutic ratio. in a model of live e. cell sepsis, we have been unable to reproduce these findings. localisation of no production by immunohistochemistry suggests that no production is compartmentalised, and more subtle methods of regulation may be required if this approach is to have clinical valuc. anti-adhesion molecule strategies ch wortel, repligen corporation, one kendall square, building , cambridge, ma , usa. the neutrophil has been implicated as a pivotal player in the pathogenesis of multiple organ dysfunction. an important first step in the process of neutrophilmediated organ injury involves the binding of neutrophils to endothelial ceils. this process is largely regulated by complementary adhesion molecules, some of which are present constitutively on the cell surface and others that can be upregulated in response to chemotactic and pro-inflammatory stimuli. several different adhesion molecules have been described. l-selec tin is expressed on the plasma membrane of neutrophils and is shed from the surface early in the inflammatory process. it is therefore thought to mediate the initial interactions with endothelial cells. e-selectin and p-selectin are endothelial adhesion molecules. e-selectin is not constitutively expressed but is upregulated by inflammatory mediators, particularly il- and tnf. p-selectin is present in the weibel-palade bodies within the endothelial cytoplasm and can be upregulated rapidly in response to thrombin, histamine, and oxidants. all selectins recognize oligosaccharides, particularly sialylated lewis x antigen. this carbohydrate moiety is expressed on many proteins, including the selectins themselves. the leukocyte integrins are glycoproteins expressed on the neutrophil surface and in the cytoplasmic granules. integrins consist of a common beta or cluster differentiation (cd)i chain covalently linked to one of three different alpha chains (cd a, cd lb, cd lc) and exist on the cell surface as three distinct heterodimers. cd l a/cdi is expressed on all leukocytes, whereas cd l b/ cd and cd lc/cd are restricted to cells of myeloid origin. cd i/cd interacts with intracellular adhesion molecule- (icam- ), its ligand on endothelial cells. icam- is a member of the immunoglobulin family of adhesion molecules. it is constitutively expressed on endothelial cells and can be upregulated by cytokines. the potential for monoclonal antibodies to adhesion proteins to reduce vascular and tissue damage has been studied in alarge number of experimental models. protective effects have been observed in a wide variety of inflammatory, immune, and ischemia-reperfusion injuries such as arthritis, bums, endotoxic shock, bacterial meningitis, autoimmune diabetes, nerve degeneration, allograft rejection, allergic asthma, acute lung inflammation, skin lesions, and ischemia-reperfusion models of the intestine, myocardium, lung, skeletal muscle, and central nervous system. protective effects have also been observed in animals resuscitated following hemorrhagic shock. since modulating the function of adhesion molecules may temporarily leave the host without effective defense machinery, safety evaluations are of utmost importance in evaluating this therapeutic approach. treatment of gram-negative septic shock with an immunoglobulin preparation: a prospective, randomized clinical trial ingolf schedel, ursula dreikhausen; birgit nentwig; marion hockenschnteder, dirk rauthmann, salim balikcioglu, rolf coldewey, helmuth deicher, md endotoxin may play a major role in the pathogenesls of muitiorgan failure in the context of the toxic process in septicemia induced by gram-negative pathogens. the hypothesis which has led to a prospective clinical study consisted in the idea of inhibiting the biological effects ofendotoxin during the early phase of septic process, and thereby attampting to attain a positive effect on the clinical course of the disease. -objecave: to evaluate the effectiveness ofa polyclonal immunoglobulln (ig) preparation containing igg, lgm, and iga as an adjunctive therapy for septic shock. -desigru prospective, randomized clinical trial. patients: fifty-five patients w~th septic shock were randomly allocated to two groups according to criteria of septic shock. -intervention: one group of patients (n = ) received a commercially available immunoglobulin preparation (containing high titers of antibodies specific for determinants to bacteria endotoxin) during the first days after inciosion in the study. the other randomized group (n = ) did not receive any immunogiobulin preparation. -measuremems and main resmts: during the period of < wks after the beginning of clinically apparent septic shock, death related to the septic process occurred in one ( %) of patients who received immunoglobulln. by comparison, nine ( %) of control group patients died during this period (p <. ). within the first hrs after onset of the clinically apparent septie process, significaptly increased activity of circulating endotoxin and simultaneously decreased specifie igg serum titers to lipid a were detected in the group of nonsurvivors. the rationale for the use of polyvalent intravenous immunogiobulins (ivig) to treat severe infections stems from in vitro and animal studies documenting that high-dose igg enhance opsonization and phagocytosis of pathogenic bacteria. moreover, recent clinical studies have shown that in septic patients the phagocytic function of circulating polymorphonuclear neutrophils (pmn) is defective; the degree of such impairment correlates to the severity of the septic state, the beneficial effect of administering high dose igo in septic patients can be two-fold: i) ivig provides large quantities of antibodies against invading pathogens; the igg bound to the pathogens can opsonize their phagocytosis; ) the opsonization of phagocytosis by exogenously administred polyvalent igo would be of special importance in those patients who present a significant defect of their phagocytic function, when they are challanged by a large bacterial invasion. a prospective, randomized, double-blind study was carried out comparing the administration of ivig (sandoglobulin@) vs, paeebo (human albumin) in severely septic surgical patients, only patients with gepis score >_ (meaning a mortality risk > %) were accepted into this protocol. patients were randomized to receive . g/kg of ivig or placebo on day (when they reached sepsis score> ), repeated on day + and + . at the beginning of icu treatment, the two groups of patients were similar for severity of sepsis, age, concomitant disease, type of surgical procedures, antra and perioperative procedures, antibiotic administration. the results of the study indicated a significantly reduced mortality in patients with severe surgical sepsis treated with ivig as compared to placebo control patients (mortality: % vs, % respectively; p< , ). in conclusion, the results of our study in patients with severe surgical sepsis were the following: ) ivig plus multimodal treatment of sepsis, including antibiotics, reduce mortality significantly', ) the reduction of mortality seems to be due to a decreased incidence of lethal septic shock. despite substantial clinical research, the avallable data regarding the effectiveness of supplemental immunoglobulin (ig) treatment in sepsis in adult patients do not yet allow definitive conclusions. in view of the persistently high sepsis mortality there is a need to continue clinical investxqations regarding supplemental sepsis treatmen~ in general, as well as concerning ig administration in particular. we present and discuss the protocol of the ongoing ,,score-based-immuneglobulin therapy of sepsis (sbits)" study. the protocol (theoret surg ( ) - ) of this multicenter, randomized, prospective and double-blind trfal relies on the results of an observational trial on i.v. igg treatment in patients with sepsis and septic shock (infection ~ ) - ), carried out as a prerequisite for the present trial. using microcomputer-based bedside routine score monitoring, we regard quantitative measures of severity of disease and sepsis: only patients with a certain degree of both severity of disease (apache ii score - ) and severity of sepsis (elebute sepsis score - ) will be included. by observing these previously validated inclusion criteria, this trial snould iqentify a priori and include patients with potentially optimal response to therapy, consisting o~ either placebo ( .i % albumin) or polyglobin n" - ml ( . g)/kg on day and ml ( . g)/kg on day i. with an anticipatedpopulation size of patients the study should comply with the statlstical requirements (estimated mortality: %, with a % reduction in -day mortality in the treatment groupl to prove or disprove the question of igg effectiveness in sepsis in terms of improved prognosis. up to november , more than patients had been included; patient enrollment will be finished in . previous studies have demonstrated rhll-i ra, a naturally occurring antagonist of il- , increases survival in animal models of andotoxemia and eschehchia coli bacteremia and attenuates the decrease in mean arterial pressure resulting from challenge with both gram-negative and gram-positive bacteria. previously, in patients, rhll-lra was demonstrated to increase survival in patients with sepsis syndrome and septic shock in a dose-dependent manner. methods: a randomized, double-blind, placebo-controlled, malticenter, clinical trial enrolled patients at academic medical centers in europe aad north america. eligible patients received either placebo (vehicle) or rhil-lra (anakinra) . or . mg/kg/hr by continuous intravenous infusion for hours. the presence of organ dysfunction (i.e., ards, dic, renal, and hepatic) at study entry was determined prospectively by a clinical evaluation committee using definitions which were developed a-priori. survival time was evaluated over days utilizing a linear dose-response model, assuming a log-normal distribution. results: patients had one or more sepsis-induced organ dysfunction(s) at study entry. a dose-related increase in survival time was observed with rhll-lra compared to placebo in patients with ards, dic, and renal dysfunction (p --< . endotoxin infusion releases platelet-activating factor (paf), a potent phospholipid mediator which leads to an autocatalytic amplification of cytokine release. bn (ginkgolide b), a natural paf receptor antagonist, has provided significant protection against sepsis in different animal models• a randomized, placebo-controlled, double blind, multicenter trial on efficacy (mortality at d ) and tolerance of bn ( iv infusion of mg x /day over days) in severe sepsis has enrolled pts. the day mortality rate was % for the placebo group and % for the bn group (p = . ). the efficacy of bn was greater in pts with gram-negative sepsis: the -day mortality rate was % for the placebo group and % for the bn group (p = . ). bn also reduced mortality among pts with gram-negative septic shock (mortality was % for placebo vs % for bn ; p = . ). using statistical adjusments for pronostic factors, the relative risk of death of the bn group was . ( . - . , % confidence interval; p = . ). this risk corresponds to an adjusted reduction in mortality of % for pts receiving bn . no differences in mortality rates were found between the placebo and the bn groups in the absence of gram-negative sepsis• there were no differences in adverse events between the placebo and the bn groups. bn is a safe and promising treatment for patients with severe gram-negative sepsis. a confirming study, focused on gram negative sepsis, is in progress. v~ lliam a. kanus m.d. and the rhll-lra it has been traditional within the field of infection and sepsis to think in terms of specific indications for drugs based on the type of infecting organisms, advances in antibiotic therapy now control or ltnflt the growth of bacteria. the majority of deaths are now caused by either an initial overwhelming response to infection or subsequent multiple organ system failure attributed, in part, to the effects of intrinsic biologic responses of the host. type of organism, therefore, may not be as critical as determining the exact severity of the host's severity or risk of death from infection. we also know that both the relative benefit of a new treatment across groups and its absolute benefit for an individual patient will vary with their risk in a predictable fashion. we recently iuve~iguted the relationship between one measure of host response, the acute risk of death as prospectively estimated by u comprehensive risk mode[ for -day mortality (jamb. ; : , - ) , by its retrospective application to the results from the phase in evaluation of recombinant human intcrlenkin- receptor antagonist (rhll. ira). we found that there was a significant interaction between the patient's predicted risk of mortality at the time of entry to the study and the ability of rhil-lra to prolong survival time (x = . , p [] . , log.normal) for all patients in the trial• survival benefit began st approximately % baseline risk of -day mortality. for the $ patients with a predicted risk > %, there was a % reduction (p= , $ log normal). when we examined the variation in patients above and below the % risk level with hazard functions, i.e., their daily risk of death during the study period, we found that placebo patients with < % risk had lltile acute daffy risk during the hlltial two days follawh~g study entry and this risk was little affected by rhil-lra, in contrast, patients with > % risk had high daily mortality risks during the tuttlal two days that high dose rhtl-lro substantially reduced. these results are compatible with our current understanding of outcome from sepsis and the proposed mechanism of action o£ immunotherapy, the earliest deaths from sop sis are secondary to an immediate inflammatory response followed closely by deaths secondary to multiple organ system failure, later deaths (after days) are not as closely related to the acute effeete of the inflammatory cascade. because of the timing and action of most proposed tmmunotherapy, they may be capable of preventing mortality primarily in these initial two phases. in this study, an independent predicted risk of mortality reflected this mortality pattern ned illustrated the potential benefit of immtmotherapy. use of a predicted risk of mortality in the design and analysis of clinical trials could improve our understanding of the clinical benefit of these new therapeutic approaches. the systemic inflammatory response syndrome (sirs) is a term recently proposed to describe patients with systemic inflammatory responses to insults such as infections (sepsis), trauma, burns, pancreatitis, and other initiating events. patients with sirs may have similar activation of inflammatory mediators and similar outcomes independent of the initiating event. these outcomes include organ dysfunction and failure, shock, and death. challenges to the successful conduct of clinical trials in sirs include the complexity of illness in these patients and the important--but limited--clinical benefits of novel compounds that may be limited to selected patient subsets. addressing these challenges will require new tools and approaches. these will include more sensitive and appropriate endpoints, and the use of methods such as baseline risk adjustment, to allow detection of drug risk interactions not captured adequately by categorical definitions, such as sepsis syndrome. on the basis of supportive preclinical and phase i safety studies, we have initiated phase ii clinical trials of a novel bradykinin antagonist, cp- , in four sirs subcategofies: sepsis, multiple trauma, burns, and pancreatitis. each of these studies is designed to measure the effect of cp- on mortality, organ dysfunction and failure, and activation of mediators. in addition to investigating rates of organ failure using standard definitions--a new endpoint--a continuous summary measure of organ dysfunction (the acute physiology score of apache tm iii) is being used to quantify the degree of organ dysfunction and the speed and pattern of recovery of physiologic stability. in the sepsis study, another new approach--a study specific risk model based on the apache ill database--has been developed which will be used to assign a pre-treatment baseline risk to each patient enrolled. the primary outcome variable will be risk adjusted survival time to days. this type of risk-adjusted analysis may allow for more efficient and powerful trials and more accurate and useful indications for use. study purpose: in post-cardiac surgical patients (pat.) at risk for sepsis, the efficacy of early i.v. immunoglobulin (ig) treatment was compared to a matching historical control (con.) population. postoperative risk assessment: using apache ii scores lap) (first postoperative [pop.] day) in a pilot study phase, we were able to differentiate between the large population ( . %) of pop. low-risk pat. (ap< ; mortality: %) and the small groups of pop. pat. at risk lap= - ) and high risk lap_ ) with a significantly higher mortality ( % and %, mainly due to sepsis). subsequently, among consecutive pop. pat. we prospectively identified and treated these pat. iq treatment reqimens: first study period (n = ): (gg (psomaglobin n a, tropon biologische pr~parate, cologne, frg, day : ml/kg, day : ml/kg). second study period (n= ): iggma (pentaglobin r, biotest, dreieich, frg, ml/kg on days to ). results: ig pat. and con. were comparable in demographic data, operation characteristics and baseline disease severity lap and elebute sepsis scores). in contrast to con. (risk: n= , high-risk: n- ), the ig pat. showed a marked improvement in disease severity (fall in ap), especially in the high-risk group (igg, n= : p<o. ; iggma, n= : p: . ). in this group, ig led to higher (p< . ) response rates, defined as an ap score decrease -> within four days (igg: %, iggma: %; con.: %), and reduction in mortality (igg: %, iggma: %; con.: %), statistically significant (p< . ) for ig treatment as a whole (igg and iggma). conclusion: given the good comparability of the study groups, our results indicate, despite the non-randomized design, that early supplemental ig treatment can improve disease severity and may improve prognosis in prospectively apache ii score-identified high-risk patients after cardiac surgery. objective. elevated plasma levels of endothelin (et) have been demonstrated in both experimental and human sepsis. et has been proposed as a sepsis mediator leading to vasoconstriction with tissue hypoperfusion and organ failure. the aim of the study was to determine the effects of sepsis treatment with volume resuscitation, antibiotics and the anti-lps monoclonal antibody es® on big et and active, aminoacids et (et ) in rat abdominal sepsis. methods. lethal peritonitis was induced with a mm coecal perforation (cp) in male wistar rats. plasma levels of big et and et were determined with amersham tm endothelin rias , and h after sepsis induction. experimental groups: . cp control, . volume replacement (vr); , % saline ml/kg/h continous iv infusion started after h, . antibiotic; imipenem mg/kg iv after h, . e ®; mg/kg iv after h, . vr + imipenem + es® after h. results. high concentrations of both big et and et could be demonstrated after h and lasting for h after cp. neither volume replacement nor imipenem did influence the elevated plasma et. e ® significantly reduced et both , and h after sepsis induction, but did not reduce big et. when es® was combined with vr and imipenem, reduction of et was the same as for e ® alone. these results strongly suggest that bacteria and hypovolemia per se are not decisive stimuli for et production during sepsis. e ® reduces circulating lps and tnf which is the probable mechanism of the suppressed et synthesis. the unaltered big et fraction after e ® treatment indicates conversion of big et to et as the site of action responsible for reduced et . conclusion. lethal peritonitis in the rat is followed by elevated plasma levels of big et and et . e ® anti-lps antibody significantly reduces plasma et while volume resuscitation and antibiotics failed to do the same. es® did not reduce plasma big et. pmx treatment on severe endotoxemia with multiple organ failure was safety and effect in prognosis, and sepsis related parameters. it was certified that reduction of plasma endotoxin was effective in severe endotoxemia. a. lechleuthner,s. aymaz, g. grass, c. stosch, s. dimmeler, m. nagelschmidt, e. neugebauer. ii. dept. surgery, university of cologne, germany. introduction: the cardiovascular therapy of hypodynarnic shock states is a challenging problem. in clinical as well as experimental studies beneficial functions of a new hg-agonist bu-e- in congestive heart failure has been demonstrated aumann, ). therefore, we investigated the effect of bu-e- in hypodynamic shock in pigs. materials and methods: pigs (deutsches hausschwein, pitrain, [ ] [ ] [ ] [ ] [ ] [ ] were anesthesized with fentanyl/dormicum, ventilated (n :o = : ) and cardiovascular parameters were monitored with a complete icu-eqnipment. the hypodynamic model was established in a pilot study ( animals) to evaluate the effective concentration of bue- in healthy and endotoxin (lps)-treated animals. endotoxic shock was induced by continous infusion of ~g lps/kgkg/h ( :b , fa. difco). the hypodynamic state was defined as a decrease of cardiac output by % of steady state levels. a wedge pressure of - mmhg was kept constant by volume resucitation during the experiment. in a subsequent randomized controlled trial (rtc) groups with animals per group were studied. the groups were treated as follows: group i, lps and , % nac ; group ii, lps and bu-e- ( #g/kgkg/h); group iii, famotidine (h -blocker) pretreatment ( mg/kgkg), lps and bu-e- . results: the pilot study in healthy pigs revealed, that bu-e- had positive inotropic effects. these effects were inhibited by the h antagonist famotidin. bu-e- however had no beneficial effects in the hypodynamic phase of endotoxic shock in the rct. cardiac index (ci) and the oxygen delivery (do ) were not significantly influenced by bu-e- application (group i versus group ii). bu-e- did not ameliorate the negative inotropic effect measuring left ventricular stroke work (lvsw) in hypodynamic shock phases. on the contrary, bu-e- led to a further significant decrease of lvsw (p < , ). famotidin pretreatment did not affect the response (group iii versus group ii). conclusion: in hypodynamic shock states the h -agonism seemed to have no beneficial effect under these experimental conditions. receptor down regulation or changes of signal transduction under septic conditions may be responsible. cellular studies may help to identify these mechanisms. objectives. antithrombin iii inactivation of proccagulant proteases is so far the only inhibitory therapeutic approach to disseminated intravascutar coagulation (dic). we therefore set out to investigate whether cll substitution reduces coagulation activation in an endotoxin induced rabbit dic model. materials and methods. male rabbits chbb:hm(spf) were randomty assigned to one of the following groups. group k : naci . % (control without endotoxin, n= ). group e : endotoxin tjg kg " bolus i.v. + naci . % (control with endotoxin, n= ). group c : endotoxin pg kg - bolus i.v. + cll u kg - bolus + u kg " h "~ i,v. (treatment group, n= ). all animals were anesthetized and mechanically ventilated. blood samples were drawn prior to endotoxin administration (m ) and after (m ) and rain. (m ). thereafter, lung and liver tissue samples were taken intravitatly in a standardized fashion for h&e microscopic fibrin quantification using a triple score (fibs). from all blood samples the prothrombin time (pt), activated partial thromboplastin time (aptt), fibrin monomers (fm), and d-dimers (dd) were measured. for statistical significance of differences between the groups anovas and the wilcoxon test (fibs) were performed. results. fibs for lung/liver were significantly different (p< . ) between group e (lung , liver ) and c (lung , liver ) (group k : lung , liver ). , a synthetic serine proteinase inhibitor, has an anticoagulant activity in the absence of" antithrobim iii. gabexate has been reported to be useful in the treatment of disseminated intravascular coaguiation due to neoplastic diseases. in this study, we investigated gabexate therapy for the treatment of dic due to sepsis in the postoperative critical patients. materials and methods: from july to june , patients in the surgical intensive care unit met the criteria of dic or pre-dic. eleven were male and four were female with the mean age of . years. all these patients suffered from some complication of operations which led to the development of sepsis. foy was administered at the rate of mg/kg/hr untii the coagulation profile retumed to normal or the patient died. the coagulation parameters were monitored before and on the st, rd, th and th day. results: fourteen of these fifteen patients died despite transient improvement of the coagulation parameters in five patients. these patients suffered from sepsis resulting from surgical complications which could not be well controlled. the only survival was a case of recurrent intrahepatic duct stone with biliary tract infection complicated with sepsis and dic. after choledocholithotomy and the use of foy, the patient recovered gradually. conclusion: dic is a late manifestation of sepsis in the critical surgical patients. the most important thing is to eradicate the cause of sepsis. if the underlying septic focus cannot be controlled, dic will persist despite the use of gabexate mesilate. emergency surgery, taipei veterans general hospital, taipei, taiwan. there are main types of bradykinin (bk) receptor, namely bk~ and bk z. the bk receptor is constitutive. the bk receptor is also constitutive but in the majority of cases is inducible and involved in chronic inflammatory syndromes such as sepsis, hyperalgesia and airways hyperreactivty in animals. the mechanism(s) involved in the upregulation of the bk receptor is unclear, however a variety of agents including lps, e coil and ill are particularly efficacious in vitro and in vivo. ill and bradykinin acting at their respective receptors are believed to be involved in sirs/sepsis. we have investigated the effect of antagonists at ill (antril), bk (bradycor [cp- ]),bk~ (cp- ) and bkz/bk (cp- ) receptors on the de novo generation of bk~ receptors (reflected by hypotensive responses to a bk agonist) in the lps-treated ( ug iv) rabbit. in lps treated rabbits hypotensive responses to bk~ but not bk agonists increased with time and at time min appeared maximally induced. constant iv infusions of cp- blocked bk but not bk~ and cp- bk~ but not bk responses. cp- ,cp- +cp- and antril+cp- blocked both bk and bk~ responses. antril alone had no effect on bk or bk~ responses. within - min after stopping the infusions of antagonists the responses to bk~ and bk z agonists were the same as those in nonantagonist infused rabbits. these results indicate, at least in the lps-treated rabbit, that neither bk ,bk ~ or ill receptors alone or in combination, are involved in the de novo generation of bk receptors. in vitro studies demonstrated that beth bradycor and cp- (but not antril) were antagonists at both bk z and bk~ receptors. if both bk z and bk receptors are significantly involved in chronic inflammatory situations in man such as sirs/sepsis then the rationale for the use of compounds such as bradycor or cp- is clear. infection is a major cause of or contributor for morbidity and mortality in liver transplant recipients. effectiveness of prophylactic and therapeutic protocols is important for the success of liver transplantation ( olt ). sdd is used as prophylaxis for reduction of infection caused by gram negative or fungal microorganisms. between september and july olt's in patients were performed at our department. the actuarial -year patient survival is %. infection prophylaxis is started with sdd and ciprofloxacin once the patient is accepted as an olt candidate. perioperatively metronidazol, tobramycin and cefotaxim, postoperatively cotrimoxazol are prescribed additionally. the table shows pneumonia, peritonitis, major wound and urinary tract infection are common nosocomial infections following severe injury. in a series of severely injured patients from the university of louisville hospital, pneumonia was the most common infection followed by peritonitis, intra-abdominal abscess formation and burn wound infection. pneumonia is actually the leading cause of death from nosocomial infection. these are defined as occurring from to hours after hospital admission. this definition has important implications for antibiotic therapy because the likely pathogens and their respective sensitivities are different for community acquired pneumonia. the diagnosis of nosocomial pneumonia is difficult following major injury as many patients will have pre-existing fever, leukocytosis, tachypnea, and chest x-ray changes. reliance on sputum gram stain and culture is important and best obtained by a bronchoalveolar lavage or protected specimen brush during bronchoscopy. predisposing risk factors include severe head injury, emergent intubation and shock, and such patients have been shown to benefit by early tracheostomy. staph aureus has been the most common pathogen isolated from the sputum and the remainder gram-negative organisms with pseudomonas aeruginosa, and klebsiella pneumonia predominating. bacteria recovered by site as well as by intensive care unit is published in the six month antibiogram which also includes recent antibiotic sensitivities. this aids in empiric antibiotic selection against such nosocomial organisms. in a series of severely injured patients (iss - ), mean temp. was . f, leukocytosis was k, pan was , fin was . , and peep was . at the time of diagnosis (ards excluded). there was marked reduction in class ii histocompatibility antigen (hla-dr) density on peripheral and bal monocyte/macrophages which recovered over time with resolution of pneumonia. immune suppression occurred prior to development of pneumonia, was especially localized to the infected tissue, but recovered with clinical improvement. specific immune modulation targeted to pulmonary white cells may hasten clinical recovery and minimize pulmonary dysfunction. -clinical experience j. tnllemar amphntericin b remains the drug of choice for many systemic fungal infections. its advantages include a broad spectrum of activity and intravenous administration. the major disadvantages of amphoterlcin b is its severe side-effects, especially the nephrotoxicity. to decrease the toxic side..cffccts various liposomal amphoteficin b formulations have been produced. it was found that these liposemal formulations were as effective as amphotericin b but in contrast had a low incidence of toxicity. at present there are three ~different variations of lipid formulations under assessment: amphotericin b lipid complex (ablc), amphotericin b coloidal dispersion (abcd) or true liposomes. the ablc has a ribbon like structure. it has been shown to have a reduced toxicity and an efficacy ranging from being as effective to four times less effective that conventional amphotericin b. regarding abcd the particles have a disk-like structure with a diameter of around t am and a thickness of nm. the ami-fungal efficacy is - times less than that of conventional amphotedcin b. both ablc and abcd are presently investigated in phase ii/iii studies in the us. ambiseme is currently the only commefieally available true lipesome. ambiseme is a spherical small unilamellar lipesome with a diameter less than nm with a mutina ld of > mg/kg. it has been used in dosages up to mg/kg/day in compassionate based studies with good tolerability. the mycological efficacy range from a % response rate for invasive candida infections to % response rate for aspergillosis. ambisomc have been evaluated as anti-fungal prophylaxis in randomized trials in bone marrow (bmt) and liver transplant (ltx) recipients. it was well tolerated. in bmt recipients the incidence of proven fungal infections was % among placebo treated patients compared to % for the ambisome treated patients (ns). in ltx recipients ambisome prophylaxis was effective, significantly reducing the incidence of deep fungal infections from % to % ill placebo and ambisome treated patients respectively (p< . ). prospective randomized trials comparing these various amphotericin b preparations with conventional amphotericin b is needed to determine their future place in the therapeutical arsenal. two patlentgroups ere particularly at risk to develop serious cmv disease: cmv seronegative transplant recipients of seroposltlva donors and those patlants treated for rejection with anti t-ceil preparations, we have evaluated the value of prophylactic anti-cmv immunoglobulin (cytotect", biotest pbarma gmbh, dreieich, frg) administration in high risk heart and kidney transplant recipients, in a double blind placebo controlled study kidney transplant recipients, treated for biopsy proved re)action with rabbit atg, received globullntplacebo infusions. the preparatlons were given i,v, in a dose of mg/kg at day , , , , and after the initiation of anti = rejection therapy, passive immunization completely prevented cmv related death, although it did not reduce th~ incidence of cmv isolation, viraemia or disease, this effect was mainly observed in cmv saronegativa recipients of a serop sitive donorktdney. seroposltive recipients did not benefit from treatment and seronegatlve recipients of a seronegetlye donor were not et risk for cmv infection at e!l. in a open study the incidence of cmv infection and disease was evaluated in consecutive i~eart sllograft recipients. sixty-five patients were cmv seronagatlve and they all received passive immunlzation according to the dosage schedule used in the kidney patients, but starting on the day of transplantation, this scheme resulted in median snti-cmv igg titers of elisa units during months. cmv infection occurred in / ~eronegetlve and in / seropositive recipients (n,s,), in ssronegetive donor-recipients pairs the incidence was significantly lower ( / ] , the passively immunized seronegstive recipients of e seroposltlve donorheart showed comparable incidence of cmv infection f t ) vs the seropositive recipients. primary infection more often resulted in disease than secondary infection ( v / ), but no difference in incidence of disease ( vs / ) or severity in symptoms was noted between the immunoglobulln treated serone(]ative patients and the seropositiva recipients. apparently passive immunization induces anti-cmv immunity which crossly resembles naturally acquired resistance. abdulkadirov k.,chebotkevich v., moiseev s. the incidence of infection is still high in patients underwent bmt. this complication is the major cause of mortality if it is not recognized and treated promptly and properly. our data showed that from patients with different types of leucemia after autologous and allogenzc bmt had the episodes of fever. in the ma i ority of these episodes the bacterial etiolog$ gram negative bacflli and gram positive cocci) can be proved. on the other hand, in % of the fever cases we detected also viral respiratory (corona-, adeno-, rs-and other) infection. our previous investigations showed that even in healthy persons the viral infection has influence on antibacterial immunity, in the cases of model experimental reaction in volunteers we found the decrease of delayed hypersensitivity - days after intranasal inoculation of influenza virus a (h n - ) to bacterial (staphylococcal, streptococcal and pneumococcal) and ~iycoplasma pneumoniae antigens in the leucocyte migration inhibition test. these results showed that respiratory viruses may be the important pathogenic factor in the development of bacterial infection in posttransplanted period. we consider the constant control of latent and visual respiratory viral infection in bmt patients to be very important. ficcb the ~ter£~li of the nation~l institute of trad/~atoloqy in budapest . consecutive cases of revision hip grafting were carried out arthroplasties wlth hemoloquous bone between the years and . in the same period of time pri~ total hlp replacen~nts were performed under i entieal technical conditions. the average septic rate for the 'total hip althroplasties was less than %. in the selected i cases the septic rate was % indicating the role of bone grafting° homografts were prepared by deep freezing~ it .is recognized that the cells of the hl~grafts become destroyed by the ium~unological, response of the host~ and the patients develop ~ti-hl~, ar~tib'o~ies. the dead ~trix, however, has a bone-inducing capacity that stimulates host osteoblasts to recolonize the *i~/trix which serves as scaffolding. the sequence of events favours the infections. for this reason, beside preventive perioperative systemic ant/biotic treatment, local ~ntibioties were also applied in the form of antibiotic-//npregnated cement. the role of age and the .immune status of the patients .is discussed.. the purpose of this study is to evaluate the rate of toxemia in patients with acute panereatitis and to find this coudition to the activation of cascade systems that are encountered in the subsequent complications of the disease. we studied a series of patients with acute pancreatitis, the severeness of which was evaluated by the ranson's criteria and the apach-ii scoring system. all of them were considered to have severe acute puncreatitis. the determination of toxemia was made using the limulus test (lal test). we also determined the levels of the third (c ) and fourth (c ) complement components as weu as the coagulation factors, iibrinolysis faeters and kimns by serial measurements. the severity of the disease was serially determined by the apach-ii scoring system. it was found that complement activation ( which was also assessed using a graphically illustrated method by a aggregometer ) was followed by an increase of morbitity and mortality .we also detected that toxemia (positive lal-test) was closely correlated with complement activation and more of the ranson's criteria. a clear relation existed between the number of ranson's signs and the enmplieations' rate ( "= - . , p < . ). the documentation of toxemia and the complement activation cannot predict the kind and the severity of complications. the study of coagulation, fibrinolysis and kinms systems didn't reveal any results with statistical significance. necrotizing pancreatitis still represents a life-threatenthg disease. infectious complications dominate among the causes of death. differences in the individual immune response could possibly explain different clinical courses even in patients with comparable pancreatic morphology. to explore the inflammatory response in acute pancreatitis, the following investigation was performed. methods: peripheral-venous blood was withdrawn on admission and furthermore twice weekly in as yet patients with acute pancreatitis and tested for the parameters mentioned below. in parallel, polymorphounciear granaiocytes were isolated using density gradient centrifugation and assessed for superoxide anion and hydroxyl radical producing capacity using electron spin resonance techniques. results: total leukocyte cotmt and total lymphocyte count did neither reflect the clinical course nor predict complications. this comes tree also for serum igg, igm, iga, c , c , crp, alpha-l-antitrypsin and neopterth as well as for plasma il-la, il-ib, il- ra, il- , il- r, il- r, tnf-ct, tnf-~r (p ) and icam- . in contrast, pmn-elastase, il- and il- closely correlated to the clinical course. isolated pmn's in vitro capacity to produce oxygen radicals depended on the respective radical species and was slightly elevated (superoxide anions) or decreased (hydroxyl radicals), respectively. patients with a cd +/cd + ratio below i were seen at risk of developing septic complications. in contrast, a percentage of monocytes of % or more among total mononuclear cells indicated an uncomplicated course, in general. conclusions: the immune status of the individual patient may significantly influence the course of acute pancreatitis. the cytokine pattern in peripheral blood is very complex and most parameters are of little use for the clinician. the pmn-elastase, il- and il- , however, closely correlate to the clinical course and may prove valuable for follow-up. the cd +/cd + ratio was found the best predictor of septic complications, but it failed in non-septic patients. a percentage of % or more of monocytes among total mononuclear ceils indicated a rather mild course. the reduced ability of the pmns to produce hydroxyl radicals may help to explain the frequent development of septic complications in severe necmtizing pancreatitis. peroxidation of membrane lipids contributes to ceil injury in pancreatitis. overwhelming release of toxic metabolites by infiltrating neutrophils is regarded a major pathogenetic factor, too. as yet little is known about the mechanisms by which oxidative stress and leukocytes damage pancreatic cells. the present study examines (i) the susceptibility of pancreatic acinar cells to attacks by oxidants and leukocytes and ( ) the potential of antioxidants to prevent such damage in order to better understand the cellular mechanisms of pancreatic injury in inflammatory states. methods: freshly isolated rat pancreatic acinar ceils were exposed to a model system of oxidative stress consisting of mu/ml xanthine oxidase (xod), mm hypoxanthine (hx), mm fec and mm edta. in a second set of experiments, acinar cells were exposed to excess autologous neutrophils or neutrophils obtained from patients with acute pancreatitis. neutrophils were stimulated by zymosan a, pma, and il- . cell viability was assessed by both cellular uptake of trypan blue (tb) and by release of ldh. results: the xod/hx system caused a time-dependent acinar cell injury. this injury was effectively prevented by catalase (cat) and gfutathione peroxidase (gpx). in comrast, superoxide dismutase (sod) enhanced cell injury. addition of both sod and cat abolished the damage seen with sod alone. the non-enzymatic scavengers mannitol, dmso, dmtu and the iron chelator deferoxamine were not protective and at a higher concentration even accelerated cell decline. the newly developed antioxidants of the lazaroid type effectively prevented oxidative acinar cell damage. stimulated neutrophils, both autologous and heterologous, did not damage healthy acinar cells but had even protective effects. conclusion: pancreatic acinar ceils are very susceptible to oxidative injury. a combination of catalase and sod prevented cell damage effectively. sod when given alone may rather damage than protect aelnar cells when h is generated in concentrations overwhelming the capacity of endogenous catalase. therapeutic approaches to pancreatic disease using antioxidants should, therefore, include combinations of protective substances. the lazaroids seem to be candidates for clinical use as antioxidants in pancreatitis. the results argue against direct toxic effects of stimulated neutrophils to pancreatic acinar cells. are ch~act~z~ by the presence of a polymicrobial flora, the pmtotyi~ cffthese inf~ons is secend~,y bacterial pedtonitlw, whereby a pathololoeal process in the ~trointesfimd tract r~ful~ in tim disrup~on ofi~ inteffrlty and ¢ollseqtlent sptl]nge of inte~.i,o~.l gontents into the peritoneal c~iry. the ensuing infection invariably contains a mixtm~ of gt~m negative enteric bacilli, gram positive b~eria and anaerobe& experimental and clinical =t~ies have de~ed the eantrlbution of each of th¢~ components to ti~ ovemu virulence of these in~ons, gram negative enteri~ such as f.veher~chla coil ere endowed with a virulent l~l~x~lyse~haride ptill~ly t~sponsible for lethality, by contrast, bacteroldes sl~cles, which rarely c~se death, prornot~ abscess fonllation, a uniqm~ capsul~ polyseccluu'ide, particularly on b.j~ogiljs slrai~, oontributes to tjtis erect, several mecltanims have bccn pml~ed whereby or~ microorganism mi~t interact with its microbial ~net to augment the overall virulence of a r~xed im~edan. these include: l) provision of nutrients by one apexes which stimulates the growth of its ~opathoge& ) inhibition of host deletes by one of the migroorganisms so that the other microbes might persist and exert their virulence, ) the trant~ of vim.©n~e traits between ~renr~a.,dsms and ) the ~.mizatian d the mi~oe~vironmental con~tion$ by one d the baetez'isl pa#, so that the other might persist. exampl~ for each of these m~banisms imv~ been provided by experimental ttudies i~stigating e.co!l-b.p~flls synergistic in~ra~ons. byproducts ofg.coli metabolim l~¢ovide essential short ebath fatty acids £~ optimal b,frosili~ ga'owth. fm-ther, oxygen ¢ons~tmption by kcelt lowers oxygen tension end redox potantial to levels eomlucive to b#a#lts gro~h. coawr~ely, b,~agtlis rolea~s proteases and fatty acids wl~¢h impair pl'tsgocy~¢ ~lt rmctlon tnd permit f-..¢oli proliferation and expression of its intrinsic virulent. in summaxy, interactions among the separate microbial cemponents of mixed infections heighten the overall virttienee of these lafectiot~, this knowledge provides ~r rationale for targetting of antibiotic therapy against the knowa eantributors of these synergistic pro~¢sses, intraabdominal abscess formation and the macrophage william g. cheadle, m.d., department of surgery, university of louisville school of medicine, louisville, ky inflammation of the peritoneal cavity following bacterial contamination has been classified into primary, secondary and tertiary, the last two relating to bacteria originating from the gastrointestinal lumen. the natural history of such infection is either resolution without clinical sequelae, which is uncommon, abscess formation, or generalized peritonitis, which occurs as a result of failure of peritoneal host defenses. early clearance of microorganisms by peritoneal fluid circulation and filtration througti subdiaphragmatic lymphatics into the thoracic duct and systemic circulation occurs as well. simultaneously peritoneal macrophages and the omentum approach the area of inflammation and lead to neutrophil influx and abscess formation adjacent to the affected viscus. we have found a shift in peritoneal macrophage function from antigen presentation to proinflarnmatory cytokine production that occurs early after experimental peritonitis produced by cecal ligation and puncture. this is also reflected by reduced class ii histocompatibility antigen expression on peripheral blood mononuclear cells and peritoneal macrophages. this is accempauied by an influx of both neutrophils and macrophages into the peritoneum and subsequent abscess formation. interestingly, there is little serum endotoxin or tnf seen in this model despite tnf mrna expression in peritoneal macrophages. we believe this model is more clinically relevant than other models of endotoxemia or bacteremia in which different patterns of cytokine expression are seen. newer agents aimed at reduction of systemic manifestations of sepsis originating from intra-abdominal infection such as monoclonal antibodies against cytokines or il- receptor antagonists may need to be directed against remote organ macrophage populations while preserving peritoneal macrophage function. inflammation is a complex process involving microcirculatory changes, extravasation of fluid and a cellular influx in the affected body area. in our communication, we will only consider the regulation of the cellular infiltrate which plays a major role in the defense of the peritoneum against microbial invasion. until recently, it was thought that the influx of leukocytes in the abdomen was induced by bacterial products, local humeral factors and secretions of resident macrophages. there is now increasing evidence that this view is too simplistic. many other cell types present in the abdominal cavity or composing the peritoneal membrane (mast-cells, mesothelial cells, fibroblasts) are able to release or secrete vasoactive or chemotactic substances such as histamine, prostagtandines, or cytokines. they are most likely to play a role in the regulation of intraperitoneal inflammatory reactions. the emigration of leukocytes towards the abdominal cavity is also modulated by a previous contact with gram negative bacteria. in the rat, this intriguing phenomenon is long lasting, cannot be transferred by serum and seems independent from t lymphocytes. the clinical relevance of these various regulating mechanisms has still to be determined. kinnaert paul, h pital erasme, route de lennik , bruxelles belgium generalized response in secondary peritonitis the clinical course of an intraabdominal infection may depend on a variety of variables including the capacity of host defense mechanisms and the degree of the inflammatory response. if local defense mechanisms fail to restrict the inflammation to the abdominal cavity a generalized inflammatory reponse will result. in a first stage generalized signs of a local inflammation become detectable whereas the second stage comprises the overwhelming systemic inflammatory response. the extent of this systemic response determines the outcome. sometimes it may appear to be unrelated to the severity of the intraperitoneal findings. the activation of plasma systems and cellular elements leads to a fast release of cytokines, inflammatory mediators and other substances. these parameters precisely reflect the degree of the generalized response. inflammation of the peritoneum causes significant morbidity. objektives: to test the hypothesis that peritoneal mesothelial cells play a role in regulating inflammatory responses within the peritoneal cavity, we examined neutrophil-chemotactic activity (interleukin ) and monocyte-chemotactic cytokine (mcp) release by sytokine-etimulated mesothelial cells. confluent human peritoneal mesothelial cells were exposed to varying concentrations of phorbolmyristate-acetate (pma) and the cytokines tumorneerosis factor a (tnf a) and interleukin i~ (il-i~). the supernatant was examined for il- by elisa and for mcp by investigating the ehemotactic activity for isolated human monocytes. mesothelial cells express low levels of il and monocyte chemotactic activity when cultured. these activies were significantly increased ( -fold) after stimulation with either tnf a or il-i~. additionally macrophage inflammatory protein was detected. these observations provide a probably important mechanism whereby peritoneal mesothelial cells respond to imflammatory stimuli released during peritonitis and how leucocyte recruitment by liberation of chemotactic cytokines is regulated. the perioperative course of lps, tnfa and il- in patients with bacteriologic proven abdominal infection (intraabdominal abscess , diffuse peritonitis , pancreatic necrosis , pancreatic abscess ) was followed prospectively and evaluated for possible correlation with septic state and organ function. methods: patients were studied in a to hours period during their first surgical intervention because of intraabdominal infection. all were monitored for their cardiovascular, respiratory, hepatic and renal function. plasma samples for lps. tnfa and il- determination were drawn preoperatively, intraoperatively, and until h postoperatively in regular intervals (min /pat), results: preoperative apache ii was in median (rain , max ). patients fulfilled the criteria of sirs. of them were in septic shock.there was a significant correlation between preoperative tnfa and apache ii (p= , i, spearman coefficient). preoperative cardiovascular (systol. rr< mmhg) and respiratory (pao < mm hg) dysfunction were associated with significantly elevated tnfa (cardial: p= , i, wilcoxon; pulmonal: p= , ) and il- (cardial: p= , ; pulmonal: p= . ) overall, lps, tnfa and il- values varied considerably during the observation period. however, tnfa was markedly higher in patients with sirs and septic shock (group a: n= i , mean pg/ml) than in those who did not fulfill these criteria (group b; n= , mean pg/ml; p= , i, wilcoxon). il- was significantly higher in group a (mean pg/ml) than in group b (mean pg/ml; p= , o i wilcoxon). conclusion: perioperative tnfa and il- were shown to correlate significantly with preoperative organ function, apache ii and the severity of sepsis. these results could help to define patients that might benefit from further therapeutic strategies, e.g. antibody administration. department of surgery, university vienna, akh wien, wahringer gurtel - , wien. aim of the study: the purpose of this pilot study was to establish and to prove a standardized reproducible animal model of intraperitoneal sepsis induced by e.coli-endotoxinaemia in lew.lw-rats in order to investigate early immunoserological responses to find a mediator based evaluating system of peritonitis sepsis. materials and methods: in lew. lw-rats, diffuse peritonitis was induced by intraperitoneal injection of a mixture of e.coli (khu +) and autogenous haemoglobin solution. in the control animal group (n= ) an intraperitoneally injection of physiological saline solution was done. blood samples were obtained by heart puncture after hours. stastistieal calculations were performed on a personal computer with the spss programm vers. . (correlation with pearson's r, mann-whitney-u-test, descriptives statistics, discriminant analysis). results: in contrast to the sham treated rats, the peritonitis animals showed significant differences in the concentrations of endotoxin, interferon-gamma (wn-y), the pteridin derivate biopterin and serum pla -activities [endotoxin range from . eu/i, sd= . to . eu/ , sd- . (p < ), ifn-¥ levels, range from . pg/ml, sd- . , to pg/ml, sd= (p < . ), circulating pla -activities range from . , sd= . to . u/ , sd= . (p < . ) and biopterin range from . nmol/l sd= . to . nmol/l, sd= . (p < . )]. for the peritonitis group we found strong correlations between the degree of endotoxinaemia to elevated levels of ifn-'~ (rp = . , p < . ) and bioptefin synthesis (rv= . , p < . ). the increase of ifn-t levels was correlated to the regulatory synthesis of biopterin (r = p < . .. p • , . . ) and to the pla -actwtues (rp = . , p < . ). the biopterin synthes~s correlates slightly with the pla -actn,ities (rp= : . ; p < . ). using the para, meters of endotoxin, ifn-y levels, biopterin and the pla~ -activities only, the statistical procedure of the linear discriminant analysis makes it possible, to distinguish between non-septic animals and septic animals correctly at a rate of %. anaerobes were found in . %, anaerobes were isolated in . %. there were aerobic and anaerobic associations in . % and microflora was not found in . % of the cases. express method of anaerobes discovering let to receive information on - days early than in generally accepted nethods. intraaotal transfusion of oxygenate blood and laser irradiation of blood reduces the duration of anaerobic sow, disminishes intoxication and accelerate the patients recovery. patients with abdominal sepsis are subject to long periods of hospitalization and high associated morbidity and mortality rates. this category of patients is thus consuming extensive facilities and costs. as the age-related outcome of abdominal sepsis is not fully known, the aim of the present study was to investigate abdominal sepsis in the elderly. out of patients with abdominal sepsis treated at the surgical intensive care unit during a -year period, ( %) had an age of years or more. were women and were men, a sex distribution not differing with patients younger than years. the patients were scored according to apache ii and septic severity score (sss) upon arrival to the intensive care unit. bacterial cultures, the occurrence of organ failure, hospitalization and outcome was noted. in median two operations were performed for both "younger and elderly" patients. the median time of hospitalization in the elderly was (- ) days including in median days in the icu. figures in patients less than years of age were comparable ( (- ) days out of which in median days in the icu). apache ii and sss-scores did not significantly differ ( . vs and . vs . , respectively), between the groups. neither did the incidence of organ failure differ ( / vs / ). however, the incidence of multiple organ failure was significantly lower in elderly patients ( / vs / (p < . )). the mortality rate, however, did not differ between the groups ( / vs / ). in conclusion, severe abdominal sepsis in the elderly was not associated with an increase in mortality, incidence of organ failure or hospital stay. with the help of light transmissional scanning electron microscopy morphology of erythrosytes of peripheric blood was studied in patients with different stages of diffuse peritonitis before and after intravascu!ar irradiation of blood with heliun-neon laser. peritoneal morphology was investigated in patients who died from peritonitis, it was established that in all phases of peritonitis occured stomatocytoric and echinocytoric transformation of erythrocytes which progressed simultaneously with increase of intoxication. it combined with strongly pronounced vessels variability of microcirculatory peritoneal bed which displaied by erythrocytes aggregation, stasis and microtrombogenesis. in intravascular laser irradiation of blood number of erythrocytes which underwent to stomatocytoric and echinooytorie transformation was lower than in patients without laser irradiation. it indicated that the intravascular irradiation of blood with helium-neon laser can prevent development of severe alterations of rheological property of blood and consequently variability of microcirlatory peritoneal bed in patients with diffuse peritonitis. abdominal sepsis is still associated with high morbidity and mortality rates, frequenfly caused by multiple organ failure. it has been reported that changes in capillary permeability play a role in the pathogenesis of multiple organ failure. the present study aimed at evaluating the influence of intraabdominal sepsis induced by cekal ligation and puncture on capillary permeability in multiple organs and tissues. adult male sprague-dawley rats were subjected to laparotomy with separation of the cekum (sham operation) or induction of intraabdominal sepsis by cekal ligation and puneatre (n-- in each group). at , , , , and hours (n= /timepoint), the animals were evaluated concerning mortality and capillary permeability as determined by the passage of : i-labelled albumin from capillaries to the peritoneum, the proximal and distal small intestine, cekum, colon, spleen, kidneys, lungs. the mortality rate in rats with intraabdominal sepsis was % both at and hours. capillary permeability in the peritoneum, cekum, colon and kidneys significantly increased from hours and on in rats with intraabdominal sepsis. in septic animals, capillary permeability in the lungs and spleen increased from hours and on and in the proximal and distal small intestine from hours and on. different types of alterations in capillary permeability seem to appear: ) a temporary short increase e.g. in the proximal small intestine and spleen; ) a temporary longer increase e.g. in the colon and kidneys; ) a persisting increase e.g. in the peritoneum, cekum, distal small intestine and lungs. we conclude that experimentally induced intraabdominal sepsis induces early alterations in capillary permeability in multiple organs and tissues. such changes may contribute to explain the development of sepsis-induced multiple organ failure. despite a number of significant advances in the care of burn and non-burn traumatic injury, infection and sepsis remain major causes of morbidity and mortality. the severe immunosuppresslon often seen in patients with severe trauma or large burns may predispose these patients to life threatening infections. included among the many immune alterations are changes in the functional capabilities of neutrophlls (pmns). we have examined the expression of the p integrins (cd l a, b,c/cd ), and the fc'?r (cd , cd , and cd ), as well as several functional parameters, on pmns from thermal and non-thermal traumatic injury, pmns were obtained from patients sustaining severe trauma (initial apache ii score > ) or thermal injury (> ~ total body surface area, % full thickness), and healthy controls. the expression of cd b and c and to a lesser degree cdi a was significantly reduced on pmns. the expression of cd and cd but not cd was also significantly reduced. pmns displaying this reduction in receptor expression have a significantly reduced ability to phagocytose bacteria and undergo the oxidative metabolic burst response. thermal and traumatic injury result in global reduction in the expression of integrins and for which may lead to decreased functional capabilities, these abnormalities may in turn account at least in part for the increased rate of infection in these patlems, institute, dept. of surgery, ~ ethesda ave, cincinnalt, oh, usa, - s b, antibiotic-phagocytic cell interactions: their effect on endotoxin release. c g c-emmet , dep[baeteriolog.z, univer_sitv of glasgow, scotlan~_d increasingly it is recognised that pathogenic bacteria are capable of surviving intracellularly within phagocytic cells in addition to their capacity to produce disease whilst in the extracellular milieu. as well as providing protection from certain antibiotics which fail to penetrate the phagocyte, such intraceltular bacteria may be transported from the initial site of infection to a distant more vulnerable body site wherein they may proliferate. it is also known that some antibiotics are capable of becoming concentrated within phagocytic cells mid displaying bioactivity therein. such bioactivity might be responsible for the release of endotoxia #orn gram-negative bacteria which when liberated from the celt could ~gger the cytokine cascade. anfib,.'otic-induced damage to the ultrastructure of bacteria can also occur when the target bacteria are exposed to low (sub-mic) concentrations of certain drugs. such bacteria may present quite altered surface components m host-defense cells as well as releasing biologically active ceil wall components such as endotoxin. the nature of these interactions at the cellular level as well as the consequences for the host will be discussed. new jersey medical school: umd, newark, nj a technique of physiologic state classification has been developed based on the m~itlvariable analysis of patient derived data sets of seventeen physiologic variables. these multivariable data sets obtained from critically ill patients requiring intensive care, were aormallsed by the mean and the standard deviation of recoverin~ trauma patients who were not critically ill, the resulting normalized seventeen variable sets were then clustered. seven independent data groupings were developed. the normal stress response hyperdynamic state seen post-trauma and in compensated sepsis (a stets)/ metabolic insufficiency seen in septic decompsnsation (b stste}; early (c,) and late (e ) respiratory insufficiency associated with ards; cardlogenlc dscompensation (n state); post-trauma hyvolemla without shock (r stats). the stats closest to a new patient's values allows patient classifi atlon with regard to his previous physiologic state. classifying observations f~om patients who lived or died who fell into these physiologic states enables a probability of death (p death) to be obtalned. utilizing this criteria for the staging of severity in recent trauma patients the physiologic states accurately and significantly predicted the likelihood that the patient had an increased circulating level of the eytoklnes tnf and il- . the probability of death (p death) as well as the cytoklne levels appear to be a function of the physiologic b state with the highest levels being seen in the b state of metabolic insufficiency and the c~ state of oombined respiratory and metabolic insqffioienoy characteristic of septlc ards. the increase in the magnltude of metabolic abnormalities associated with the transition from non-sepsls to septic a, septic b, or septic c z states was associated with an increasing probability of death (p denth)(mean a state =. , mean b state = . , mean ~ state = . ). the accuraay of this estimate was prospectively analyzed in this group of m~itlple patients of whom % had sepsis and % had ssptlo ards. the survivors had a mean p death of . and the deaths had a mean p death of . . the severity of post-trauma sepsis can be quantified by probability analysis and stra~ifie~ by physiologic state. serologic tests have not been extensively tes'~ed in surgical patients but seem to be of limited value. we use nystatin as the main form of chemoprophyhxis. patients "~'ith signs of infection who do not rapidly improve with antibacterial therapy are candidates for anti-funsal therapy, amphoteradn b remains the first llne of therapy although combination therapy '~'ith flueonazole is use;l with increasing freque~;c)', the recovery of c~dida from an antra-abdominal site represents a challenging problem, anti~ngal therapy in such patients depends on the underlying disease, the nature of the infected material and overall patient risk. role of neural stimuli and pain principles and practice of anesthesiology effect of combined prednisolone, epidural analgesia and indomethacin on the systemic response after colonic surgery arginine: biochemistry, physiology and therapeutic irnplications immunosfimulatory effects of arginine in normal and injured rats arginine stimulates lymphocyte immune response in heahhy humans rote of arginine in trauma, sepsis and immunity arginine enhances wound healing in humans if labrecque t, gv campion t, and the rhll-lra phase i//sepsis syndrome study group the cleveland clinic foundation a murine-anti-human tnf-monoclonal antibody known as cb was the first anti-tnf mab which was studied in a phase ii multinational trial in the treatment of patients with severe sepsis.this was an open-label, dose-escalation trial consisting of patients who were enrolled into one of four treatment groups: ( ) . mg/kg of anti-tnf mab, ( ) . mg/kg, ( ) mg/kg or ( ) . mg/kg at study entry and the second dose hours later. the small sample size in each group (n= ) precludes detailed statistical inference in this study. nonetheless, a considerable amount of useful information was obtained from this investigation. irst, this study demonstrated the clinical feasibility of specific anticytoldne therapy in septic patients. second, the measurement systemic levels of tnf proved to be an elusive target; interleukin- may prove to be a more useful indicator of cytokine activation. third, immunologic reactions including tnf: anti-tnf mab immune complexes and human anti-routine antibodies were frequently found in these patients. despite their apparent lack of overt toxicity in this study, these immunologic reactions may complicate this form of anticytokine therapy. additionally, the potential benefits of anti-tnf mab therapy occur within the first hours of therapeutic administration in these septic patients. infecting organisms differ in their potential to induce tnf in vitro and these differences correlate with circulating tnf levels observed in septic patients. rapid methods to define those patients most likely to respond to anticytokine therapy are needed to determine the ultimate therapeutic potential of these agents in clinical medicine. wherry, j., abraham e., wunderink r., silverman h., perl t., nasraway s., levy h., bone r., wenzel r., balk r., allred r., pennington j. and the tnfa mab sepsis study group.tnfa mab (bay x ) is a murine monoclonal antibody raised against human tumor necrosis factor. tnf~ mab has been shown to reduce morbidity and mortality in animal models of septic shock and has been safely administered to septic and non septic patients.to evaluate the efficacy and safety of tnf~ mab in patients with sepsis syndrome, a prospective, multicentered, double-blind, placebo-controlled trial was conducted in hospitals in north america. patients were prospectively stratified into shock or nonshock groups and then randomized to receive a single intravenous infusion either of mg/kg tnf~ mab, . mg/kg tnf~ mab or placebo ( . % human albumin).patients received standard aggressive medical/surgical care during the day post dosing period.the three treatment arms were well balanced with respect to demographics, apache ii score and other parameters. for all infused sepsis syndrome patients, those who received tnf~ mab had slightly reduced day all cause mortality compared to placebo. among shock patients there was a more pronounced trend towards efficacy at day post dosing with lower mortality rates in both active treatment arms. among nonshock patients tn~ mab did not appear beneficial. the initial clinical experience with a chimeric anti-tnf monoclonal antibody, ca , was undertaken in septic patients. the objectives of the study were to determine the safety, pharmacokinetics and effects on cytokine levels of ca . as a single infusion or in combination with ha- a in septic patients. the study was conducted with the intent to progress to an efficacy trial based on the information collected.the trial was conducted in three stages. stage was an open label trial in which groups of patients each with the clinical diagnosis of sepsis received ascending doses of ca ( . , , , mg/kg). stage was a randomized, double blind study in which patients received a single dose of ha- a ( mg) and placebo or one of doses of ca ( , , mg/kg). stage was a randomized, double blind study in which patients received a single dose of placebo or one of doses of ca ( . , , mg/kg). in addition to usual laboratory tests, the following assays were performed: chimeric anti-tnf concentration, anti-chimeric antibody, endotoxin, tnf, il- , and il- levels.a total of patients were enrolled from clinical sites ( in stage , in stage and in stage ). primary analyses were performed on patients in stage and . there were patients who received ca exclusively and patients received placebo. administration of ca was well tolerated at doses up to mg/kg. no patient discontinued treatment due to adverse events. human anti-chimeric antibody responses were positive in % ( / ) of evaluated patients. mean cma × and auc increased proportionally with increasing doses of ca . the mean half-life was - hrs ( - hrs). a dose related decrease in tnf concentration was observed hr post infusion of ca . tnf is considered to be one of the central endogenous mediators for the inili'ation of the pathophysiological changes in patients with sepsis and septic shock. high tnf levels were demonstrated to correlate with patient outcome. blocking or neutralising tnf with specific antibodies was effective in preventing death in some animal modets of sepsis. in a placebo controlled prospective randomized study we tested the mur~ne derived antibody mak f. it is a f(ab') fragment. the fragment rather the complete antibody was selected in order to reduce the potential immunogenicity and to facilitate tissue penetration. patients with severe sepsis or septic shdck were enrolied in the study, three different doses of mak f or placebo were administered ( , ; , and i mg/kg) over a perid of hours in random order. the patients were evaluated for side effects, hemodynamics, organ dysfunction, cytokines (il , il and tnf), and outcome. at this time only an interim analysis of patients is available i indicating that mak f in all dosage groups resulted in a decrease in il . this contrasted to a further in crease of il in the placebo patients. no serious side effects have been reported so far. a more detailed analysis on all patients in the study will be presented and discussed.$ s staubach,k.h., otto, v., kooistra,a,, rosenfeid,j.a., bruch, h.p., univ. lfibeek, germany once endotoxinemia occurs in sepsis a vieieus cycle with translocation of et can be established. increasing the clearance capacity for et would therapeutically be the ulimate aim. we developed a new et on-line adsorption (ad) system in whole blood by means of polymyxin b (pb) coupled eovalently to a matrix (acrylic particles) via a atom-chain spacer. the detoxification capacity was ug[et/ml column material. the biocompatbility resulted in ~ platelet recovery. the column contained ml of admaterial and was sterilized by high steam autoclave, anticoagulation was achieved by heparine . iu/h in the inflowline after bolus injection of . iu. hp was performed on pigs at a rate of ml/min by means of a roller-pump until the animals succumbed (h). animals served as controls (c). serum et levels rose from . pg/ml to , pg/ml after hours in the c and from . pg/ml only to pg/ml in the h group after hours whieh was highly significant. survival time could be extrended from to min. results are listed in the following l. blinzler, p. zaar, m. leier, r. b( rger, d. heuser clinic of anaesthesiology , city hospital nuremberg, germany sepsis and multiple organ failure (mof) are still related with poor prognosis inspire of pharmacological and technical progress. impressed by revealing reports about blood purification the continuous veno-venous hemofiltration (cvvh) was used as supporting treatment beside the critical cam basic therapy of mof. from to consecutive patients were treated by cwh. mof was caused by hemolrhagic-traumatic noxa in °, and by septic-toxic event in %. all patients required mechanical ventilation (fio > , ) . ° showed hyperdynamic shock. % had renal and % hepatic failure. medium appache ii score amounted to , points. cvvh was performed in postdilution mode with a polyamide membrane (fh ) and high volume exchange ( l/die). anticoagulation was done with heparin. hemofiltration in mof was installed, when critical cam basic therapy including adequate respiratory and hemodynamic management, pamnteral nutrition, antibiotic treatment, etc., failed to stabilize organ functions. during consequent application of cvvh most of these patients showed improvement of their clinical course. pulmonary stabilization was seen in %, hemodynamic in % and renal in % of the cases. % of the patients survived and were discharged from hospital. of non-survivors ( %) died because of fatal mof within h after admission to icu. patients with early application of cvvh in mof showed a better survival rate.mediators of mof, i.e. products of the complement cascade measured in blood and nitrafiltrate by elisa, were partially removed by cvvh. the testing ultrafiltrate by hplc demonstrated decreasing spikes ofpolypeptides during hemofiltration. mof seems to be generated by cascade-activation of immune competent cells and plasmatic mediators (e.g. bmdykinin, eicosanoides, cytokines, anaphylatoxins, etc.). therapeutic approaches aim to inactivate or eliminate single substances. cwh with high-flux membranes in combination with high-volume exchange allows elimination of many mediators with different molecular weight and therefore may contribute to improve the prognosis of mof. other significant advantages of this teqalnique like adequate nutrition, optimized fluid balance and control of body temperature should not be negicctod. introductioni pseudomonas (p) aeruginosa has to be considered an important pathogen of nosocomial pneumonia and septic organ failure. the lung seems to be the predominant target organ for the pore-forming p. aeruginosa cytotoxin, thus inducing microvascular injury. with respect to therapeutical consequences, the potential protective effects of paf-antagonist (web ), cyelooxygenase inhibitor (diclofenac) and specific and unspecific antibodies on cytotoxin-induced pulmonary vascular reaction and mediator release were studied in the isolated perfused rabbit lung. methods: cytotoxin ( p_g/ml) was administered into the perfusion fluid in all groups, either in the absence of inhibitors (n= ), or after pretreatment with web ( xl -gm, n= ), or diclofenac ( #g/ml, n- ). furthermore, the application of specific antitoxin (mg/ml, n= ) was tested in comparison with the unspecific immunoglobulins (venimmun®, behring, . mg/ml) (n= ) and the combination of immunogiobulins, web and diclofenac (n= ). six experiments without toxin served as controls. the arterial pressure mad the weight gain as an indicator of edema formation were continuously monitored during the three hour peffusion phase. arachidonic-ucid metabolites, as well as lactate dehydrogenase (ldh) and k + concentrations were determined at rain intervals. results: cytotoxin caused a gradual increase in pulmonary arterial pressure, reaching a maximum value of . times higher than the control, starting after min and a delayed onset of edema formation resulting in a mean weight gain of g after min. this was paralleled by a significant increase in prostacyclin generation and a continuous release of k + and ldh. thromboxane synthesis exceeded about times that of controls in the toxin treated lungs. pretreatment with web or diclofenac significantly attenuated the pressure response and edema formation evoked by cytotoxin. the addition of the unspecific immunognbulin preparation alone induced a transient pressure increase within the first minutes, but mean values remained below those of the cytotoxin group in the continuing observation period. mmost complete inhibition of the pressure reaction, the edema formation and the metabolic alterations was achieved mainly by the combination of immunoglobulin, web and diclofenac and to lesser extend by the specific toxin antibody. conclusion: the current results point towards the crucial role of paf and aa-metabolites as mediators of cytotoxin induced microvascular injury. the systemic or local application of cytotoxin antibodies or even unspecific immunoglobolins in combination with paf-antagonist and diclofenac appears to be a promising therapeutic approach in the case of infection with cytotoxin-preducing strains. cytokines have long been shown to be of particular importance in the metabolic derangements occurring in lps-induced shock. recent studies strongly imply the involvement of platelet aggregating factor (paf) in the pathogenesis of gram-negative bacterial sepsis. an autocatalytic feedback network has been postulated to exist between paf and tumor necrosis factor (tnf), a key cytokine involved in septic metabolic cascade, leading to an uncontrolled amplification of inflammatory mediator release. we have previously shown that st ( -n,n,n trimethylammonium-(r)- -isovaleroyloxy-butanoic acid z- -( -chlorphtalidiliden) ethyl ester bromide) was quite effective in inhibiting the "in vitro" binding of h-paf (ki= . x - m) to rabbit platelets. the present study shows that pretreatment of c bl/ mice with st , administered by different routes, dose-dependently and significantly reduces the lethality induced by endotoxin (e.coli :b injected at mg/kg intraperitoneally). very interestingly, st administered at the same doses as above (i.e. . , . , and mg/kg body weight) results to be significantly effective in reducing the endotoxin-induced release of serum tnf. the reported dual activity of st (i.e. paf antagonism and decreased circulating tnf levels) may turn out to be greatly beneficial, in combination with current therapies, in the treatment of diseases that involve overproduction of tnf and paf such as septic shock. introduction: recently, we reported that prophylactic whole body hyperthermia ( . °c) induces heat shock protein ('asp) and increases smvival - fold in a mouse endotoxin model (am. j. physiol. in press). other investigators reported that prophylactic pharmacologic induction of hsp- by sodium arsenite improves survival in a rat sepsis model (abstract a am. rev. resp. dis. vol. , ) . the effects of heat are complex and in addition to formation of lisp- include release of cytokines, changes in cellular ph etc. thus, the protective mechanisms of heat may differ from those due to pharmacologically induced . the purpose of this study was to compare the protection of heat vs the protection of pharmacologically induced hsp- in a mouse endotoxin model to determine if different protective mechanisms were likely to be involved.. i%'lethods: both sodium arsenite ( mg/kg) and ethanol ( ~ of % ethanol) caused marked induction of hsp- in lung, gut, kidney, and liver, which was comparable to heat-induced hsp- . female nd mice weighing - gms were pretreated with arsenite or alcohol hours prior to challenge with escherichia coli endotoxin (-ld ) and survival was compared to control mice. results: survival at hrs. for arsenite treated and alcohol treated mice was % and % respectively and was statistically different from the % survival for control mice. (p< . ) (n= mice per group). however, at days post endotoxin, there were no differences in survival in the groups, i.e., ~ % survival for all groups. in contrast, the protective effect of hyperthermia remains present at days, i.e., ~ % survival vs % survival control. conclusion: the protective effect of heat is probably due to other factors such as the effect of hyperthermia to release il-lc~ and is not due solely to hsp- formation. it was the aim of the study to examine whether bacteria play a causative role in the pathogenesis of anastomotic insufficiency following gastrectomy in man.the study was carried out in form of a prospective, randemised, double-blind, multicenter trial. primary endpoints were the rate of anastomotic insufficiencies, infectious-and uncomplicated postoperative courses. all pat. received a periop, i.v. prophylaxis with cefotaxim. identical numbered vial either contained placebo or polymyxin b, tobramycin, vancomycin and amphotericin b . the vials were administered x per day from the day be ~ fore the operation until the th postop, day. insufficiencies were detected by gastrographin swallow and recorded by x-ray on day postop.. evaluation was carried out on an "intention to treat'basis. statistical analysis was done with the pearson's chi square and fisher's exact tests~ results: interim analysis was carried out in / after pat. had been recruited. along with a significant reduction of s.aureus and enterobacteria there was a reduction in the rate of anastomotic insufficiency of the esophago-jejunostomy from . % in the placebo-group to . % in the treatment group. the difference was not yet significant. the rate of nosocomial infections (e.g. respiratory tract infection and uti) were significantly reduced from . % in the placebo-group to . % in the treatment-group (p ~ . ;fisher's exact test). in march final results with more than patients will be presented for the first time. (= po < mm hg, b s-creatinin > mg%). respiratory insufficiency was the most frequent systemic complication followed by sepsis and respiratory insufficiency. etiology of pancreatitis and initial serum increase of pancreatic enzymes predicted neither complications nor outcome. only of deaths occurred during the st week, all other deaths occurred late (after - weeks), generally as the consequence of septic complications and multi-organ failure. high levels of crp were correlated with a compliacted course and a fatal outcome. although same cytokines (e.g. -- ) were found increased in severe disease, the predictive value of these markers was not better than the combination of ctinical scores (ranson, imrie, apache ii) with gt or crp. conclusions: intensive care medicine can often control the inital shock situation in severe pancreatitis. thus. only % of deaths today occur eady in the course of the disease, whereas this percentage varied between - % just years ago. nowadays, most deaths are caused by late septic complications and multi-organ failure. ranson-and ct-scores as well as serum crp predict a course with systemic complications; they are less helpful for prediction of sepsis and late mortality. it is doubtful whether measurements of cytokines will help to better predict the late outcome. as yet, only careful and continuous monitoring of patients (e.g. by apache scores) may help to early identify those who develop septic complications and multi-organ failure. the classic description of severe acute pancreatitis has hinged upon the release of large volumes of activated enzymes into the peritoneal cavity and thertce the lymphatics and blood stream. these activated enzymes escape from the pancreas due to disruption of cells with associated ischaemia and occasional infarction of tissue. for to years it has been postulated that the bocly's defence system to activated pancreatic enzymes required supplementation iu the form of anti-protease support either in the vascular space or in the peritoneal cavity. all controlled studies have shown that this is either impracftcal or unnecessary.hore recently release of a large number of cytokines from monocytes, macrophages and neutrophils have been considered to be harmful to the body and various agent~ which oppose the action of tnf alpha, paf and similar cytokines are being examined in experimental anim~is and certain clinical trials, it has clearly been shown that higher levels of cytokines are released in the patients with objectively graded severe acute pancreatitis than in those with milder disease. we now seem to be moving into an exciting phase of potentially beneficial therapy in acute pancreatitis which has had no specific effective therapy through studies utilising aprotinin, gabexate mesilate and fresh frozen plasma. inflammation cascades may play a role in the pathogenesis of acute pancreatitis. to evaluate the status of the cellular immune system we examined serum concentrations of immune activation markers in patients with acute pancreatitis ( males, females; median age: years, range: - years). concentrations of neopterin, serum soluble tumor necrosis factor receptor (stnf-r) and serum soluble intercellular adhesion molecule type (slcam- ) were determined using immunoassays (henning, bender, t cell sciences). / had increased concentrations of stnf-r compared to the th percentile obtained in healthy controls (> . ng/ml), and / patients had increased neopterin (> . nmol/i), / presented with elevated slcam- (> u/i). all patients with increased neopterin also had increased stnf-r, patients had concentrations of all three markers outside the normal range. there existed a significant correlation between neopterin and stnf-r (rs = . , p < . ). weak associations between age and stnf-r (rs= . , p=o. ) or neopterin (rs= . , p = . ) were also found. our results demonstrate activation of the cell-mediated immune system taking place in a sub-group of patients with acute pancreatitis. the finding of increased neopterin and stnf-r levels implies that activated monocytes/macrophages are involved in the pathogenesis of the disease. further data are necessary to evaluate potential associations between changes of marker concent-rations and the course of the disease. pancreatic injury after heart surgery was reported as soon as ( , ) and characterized by increased serum or urine amylase levels (in about % of patients) in the fi~t postoperafi.'ve days. this pancreatic injury, which sometimes led to acute pancreatitis, was atreaay at~buted to inappropriate perfusion of this organ. in the ffs, studies were published dealing with pancreatic suffering alter heart surgery, in large series of patients, concluding ~n~at panc~a~c injury (with a low incidence of pancreatifis) is more common than previously recognized and is a potential source of complication after camliac surgery ( , , ) . in a recent study ( ), evidence of pancreatic cellular injury was found in out of patients undergoing cardiac surgery, with out of these patients presenting abdominal signs or symptoms and developing severe pancreafitis. this injury was associated w~th preoperative renal insufficiency, valve surgery, ~..stoperalive hytxxension, calcium administered periopuratively and length of bypass. we studied patients submitted to cardiopulmunary bypass (cpb) for heart surgery and used the measurement of un:~sin, pancreatic iso-amylase and lipase in plasma for biochemical characterization of pancreatic cellular injury. blood samples were obtained before surgery, directly aller surgery (return to inte~ve care unit), hours alter surgery and in the folfowing days alter surgery (days , , , and ). computed tomography scan of pancreas was performed in patients presenting hi~ levels of amylase on day . we measured abnormal levels of trypsin and pancteatic iso-amylase in % of patients and observed simultaneous releases of these enzymes, the fi,'st one in the hours after surgery and the second more intense from day and pa~icularly on day after smgery. this second release was concomitant with abnormal levels of llpase. these biochemical observations were accompanied by radiological and clinical signs of pancreatic injury in about % of our patients : pancrealic abnormalities were revealed by scan in patients and acute pancreatitis in i patient. more pronounced pancreatic suffering was observed in patients undergoing valve replacement than in patients undergoing coronam-anrtic bypass grafm~g. analysis of trypsin and pare're, tic so-amylase are sw.cific of pancreatic cellular injury and their simultaneous ir~rease in plasma alter cpb in our padents confirms the presence of an exocrine pancreatic injury. the presence of a simultaneous peak of lipase mcaezse~ the specificity of overt pancreatic injtu diagnosis. the precise cause of th/s injury could he related to hypoperfnsion leading to ischemic injury of foe splancbnic area, pancreas being largely sensible to hypoperfnsion ( ). this hypoperfosion could he responsible for the ftmt release of pancrealac enzymes observed in our patients and would contribute to the deterioration of other organs leading to an inflammatory reaction developing in the following days and responsible for the second release of pancreatic enzymes observed in our patients. patients with necrotizing pancreatitis show a heigh rate of pulmonary, renal and septic complications, whereas the course in acute interstitial pancreatitis is generally very mild. we have prospectively analysed the value of endotoxin, interleukin- (il- ) and transferrin in compare with c-reactive protein(crp) for the early assessment of the severity of acute pancreatitis. patients aud methods: the values of endotoxin(measured by limulus-lysate-test), ii- (elisa), transferrin and crp (nephelometry) were analysed daily along the first i days of hospitalisation by patients with acute pancreatitis admitted to our hospital from / to / . it was judged whether the patients have either interstitial (aip) (n= ) or necrotizing (anp) (n=lg) pancreatitis. patients with anp have died during the course of pancreatitis (mortality= . %). results: -severity o~ pancreatitis: signifcant differences (p<o. , mann-whitney test) could be calculated between aip and anp for endotoxin, il- , transferrin and crp during the i days of monitoring. -mortality: except of il- on days , , and after ad-mission there were no significant differences between the values of analysed parameters in patients who survived and those values in patients who died. -organ failure: the patients with pulmonary, renal or multiorgan failure have significantly heigher values of endotoxin, il- and crp along the i days of monitoring in compare with those patients without an organ failure. conclusions: endotoxin, il- and transferrin, an important endotoxin carrier, are promising parameters to differentiate between the severe and mild form of pancreatitis comparable with crp. this parameters may be helpfull in the early clinical assessment of patients with acute panereatitis. the determination of cytokines may elucidate the pathophysiologic mechanisms that produce early systemic complications in acute interstitial (i) or necrotizing (n) pancreatitis (ap). the appearence of respiratory insufficiency (ri) is used to appraise the early systemic complications and is compared to the results of cytokine blood levels. in a prospective clinical trial from / - / , patients with ap were recruited and blood samples taken for cytokine determination with commercial elisa-kits. the differentiation between i (n= ) and n (n=l ) ap was made through ct-scan in all and laparotomy for drainage and necrosectomy in patients. the etiology of ap was gallstones in , alcohol abuse in , hyperlipidemia in and other or unknown causes in patients.five of patients with nap died early (n=l) or of late septic complications. none died of iap.the peak of cytnkine level in the first three days of hospitalisation was used for calculation. ri was diagnosed in the first week of hospitalisation, if oxygenmask or iutubation for at least days was nescessary to treat arterial hypoxemia. for statistical analysis u-test of wilcoxon, mann and whitney was applicated.the il- concentration in blood reached up to pg/ml in the first days depending on the severity of ap and dropped to almost zero in the next days, independently of the clinical course. the differentiation of i-versus nap, using a cutoff-line of pg/ml was correct in patients ( %, sensitivity (se): %= specificity (sp): %, (z: , ). high levels of il- over pg/ml correlated well with the prognosis ifri in the first week (accuracy: %, se: %, sp: %, c~: , ). the blood levels of il- reached a maximum of pg/ml in the first days, depending on the severity of ap, and showed a correlation to the clinical course in the following days. the peak of l,- blood levels indicated correctly the severity of ap in out of patients using a cut offtevel of pglml (accuracy: %, se: %, sp: %, ~: , ). there was no correlation between cytokine blood levels and mortality, also there seemed to be no correlation between the levels of il- and il- . in the bloodsamples of five patients with i-or nap no c~-tnf was detectable.the blood levels of il- , and to a lesser extent of [l- , can predict the severity and early systemic complications of ap in men. the excessive rise of cytokines can be explained by the stimulation of immunological cells ( macrophages, lymphocytes and endothelial cells) in the course of ap. objectives: in an opossum model, ligation of the sphincter of oddi or separate ligation of the bile and the pancreatic duct together leads to severe haemorrhagic pancreatffis while single ligation of the pancreatic duct causes only an exocdne atrophy. since bo has been discussed to be a contdbutor t¢, res dysfunction, this may depdve the organism of a potent defensive mechanism thus promoting the course of pancreatitis. the present study wa,,; carded out tc develop a new method for measuring dynamic liver res func.. tion and to test the hypothesis that bo causes a res dysfunction. material & methods: opossums were randomly placed in three groups. all received a central venous line. after midline laparotomy, a specially designe tourniquet was placed around the common hepatic duct above its junction with the pancreatic duct (group a, n= ), around the pancreatic duct (group b, n= ) or around both ducts (group c, n= ). after one week, the tourniquets were closed. using a scintillation camera, the liver uptake of nanocoll, a mtcalbumin colloid with a diameter of nm, was measured before, , and days after the obstruction. the curves were analysed by a computer and two parameters (r, s) were calculated using natural logarithmic regression. as a common measure for res function, the corrected granulopexic index (a) wa,,; determined, after day , the pancreas of each opossum was searched for necrosis by morphometdc methods. results: all animals survived till day . the opossums in groups a & had a macro-and microscopic normal pancreas, while those in group c showed a severe hemorrhagic pancreatitis. the granuinpexic index showed a significan~ change to the worse starting at day in group a & b (p<o, ) and at day it~ group c (p< ,ol). at day , res function in group c was significantly worse than that in group a & b (p< , ). the regression parameter r showed no significant change in groups a & b, but a highly significant decrease in group c starting at day (p< . ), thus showing a dysfunction of the hepatic res. conclusions: obstruction of the hepatic or pancreatic duct alone does no{ result in immediate dysfunction of the hepatic res, while obstruction of beth ducts does. because only ligation of both ducts is followed by a severe hereof.. rhagic pancreatitis, res dysfunction could be an important factor in the pathogenesis of pancreatitis and resulting organ failure.logarithmic regressinrl has proven to be a valuable tool to analyse dynamic hepatic res function. (b ) in lewis rats weighing - g. there were five groups: group a (n= ) were untreated controls; group b (n= ) were given isotonic saline intraperitoneally and observed for hours; group c (n= ) ml x e. coli intraperitoneally and observed for hours; group d (n= ) were given ml x e. coli and observed for hours; group e (n= ) ml x i e. coli and observed for hours, the rats were than killed, the spleens were removed and heparinised blood taken for immunological tests. total t-ceils, helper t-ceils, suppressor t-cells, monocytes, and the interleukin receptor were determined by monoclonal antibodies, indirect immunfluorescence, and flow cytometry (facs analyser ). statistical analysis was by the t test on rank transformed data.in group b (isotonic saline) the total t-ceils increased in the blood (p= , ) and spleen (p= , )com pared with the untreated rats (group a), in the groups with peritonitis (c, d, and e) we found highly significant rises in suppressor t-cells in the blood and spleen (both p< , ) compared with the non-infected control groups a and b. this increase was significantly higher in group d than in groups c and e. as well as other alterations, we found a uniform increase in the number of t suppressor ceils in our model of acute peritonitis that was both time and dose dependent, department of surgery, university vienna, akh wien, w~hringer gurtel - , wien. d~'na~'aics of som~ l~mnunologic indices in children with abdo;~tinal shock v.z.i~ioskalenko, s.f.vesiol$,t.v.p~bina serum (iga,:~i,g, circulating imaune co!~plexes, co:apleaentary serum activity, antimesothelialvisceral and parietal antibodies) and cellular (i-l~q~hocytes, ~s/th,b-lyaphoeytes,i nlaunoleukosis to aesothelial allergens; spontaneous blast cell transformation to phytohemaaglutinin and .nesoth<-~lial ~,togen; phagooftic neutrophil activity) im:~une indices v.'ere studied in children operated v:ith symi~to'as of abdo~ainal shock. ,'~!-~ of them had appendicnlar( - ocalized jo-diffuse, -~eneralized) and -hemoperitoni-~is (dull abdominal trau;na with injayy of 'the spleen- , the spleen and liver-q), flo patients tjere operated on for co~iplete iieus (~-intussnsc.sption, -com:lissural ileus). he follo~'~ing serum factors: cireula:;ing im~aune complexes and ~).esothelial antibodies are the aost i~portant ~ar~ers of the abdominal shock course. :yith the progress of the process the indices increase irresponsive of t.l~e cha±.aeter of pathology. in case of ileus regress and hemoperitonotis an abrupt drop in ~he titer of anti~aesothelial antibodies is noted. in bacterial peritonitis a high ~iter of anti:aesothelial parietal antibodies in great dilutions ("+++","++++"-q ; ) persisted even in the period of clinical recovery. cellular factors cham'acterize dfnaaics of the abdominal shock coulees less specifically llast cell transfor~aation and phagocyue neut~ophil activit can inderectly characterize transition of shock f~orn reversible into irreversible phases. the past so years have brought a number of major advances in burn care. the initial advance was the discovery that burn victims required large volumes of resuscitation fluid in the initial hours to maintain hsmodynamic stability, this was followed hy the dsvelopmsnt of topical antimicrohlal agents to prevent end treat infections. next, was the reporting that early excision of burn wounds, with autografting of the excised wounds was possible.finally, was the identification of the importance of aggrsssive nutritional support for the hypermstabolic burn patient.these advances have markedly increaesd survival rates for given burn mimes, s~ch that burns which would previously have been considered to be aniformly fetal, are now readily survivable.thsre remain two unsolved problems in burn care, which are limiting survivability cf burn patients.the first ie ths treatment of inhalation injury. ths sscond is how to obtain coverage of ths maaaivsly burned patient, who has limited skin graft donor sites available.this ssssion will focus on the new treatments being developed to obtain permanent coverage of burn wounds.these include the use of various tcplcal growth £aotore which can speed the rate of reepithelialization of wounds, both the beneficial and dstrimental effects of using cultured karatinooyte preparations, to obtain in excess of one squats meter of a pseudoskin from a single fifteen square centimeter biopsy of unburned skin, will be discussed, finally, the used for artificlal dermal preparations will be discussed. integumentary wound healing consists of simultaneous epithelializalion and contraction. not long ago, it was thought that healing proceeds at an optimum fixed rate and could only be delayed. the recent explosion in molecular biology and recombinant gene techniques have produced information on the biological activity of compounds previously believed to be biologically inert. many current attempts to modulate the rate of wound healing center on the topical application of various growth factors produced by integumentary cells or agents designed to modulate growth factor expression or response. epidermal growth factor (egf), plateiet derived growth factor (pdgf), transforming growth factor (tgf) and fibroblast growth factor (fgf) have been demonstrated, both in vitro and in vivo, to stimulate the proliferation and diferentiation of their designated cells types. egf and pdgf have been clearly demonstraled to increase the rate of wound closure in partial and full thickness wounds. pdgf also has demonstrated efficacy in the closure of recalcitrant pressure sores, whereas tgf increases the tensile strength of incisiona[ wounds and fgf stimulates angiogenesis. it appears that epidermal keratinocyte migration during wound healing depends on integrin-mediated interactions with compounds and ceils extracellular matrix. additionally, the activities of extracellular glycoproteins such as fibronectin, fibrinogen, laminin and thrombospondin are coordinated by multiple integrins with specific distributions and binding affinities. currently, agents which incorporate specific protein sequences essential for the interaction of the glycoproteins with the cells of the extracellular matrix are being investigated. it is has been clearly established that the rate and nature of wound healing can be influenced by the application of various agents and that sufficient quantities of these agents can be manufactured. the future challenge is to develop techniques to now the objective evaluation of the clinical efficacy of these various agents and to employ the appropriate agents in a cost-effective manner. transplantation; and ) the immune status/manipulation of the host.multiple interactive variables will determine the effect of employing allogeneic cells and tissue in wound coverage design and a batter understanding of the dynamics of the wound-graft microenvironment will facilitate the dove opment of clinicauy beneficial graft composites. cadaver allograft skin (cas) is the "gold standard" for wound coverage, but has limitations including varied availability & quality, immunogenicity leading to rejection, & potential for disease transmission. our development of a temporary living skin replacement (tlsr) addresses these issues; the tlsr consists of highly screened human neonatal fibroblasts (hf) cultured in biobrane a, a bilayer dressing consisting of nylon mesh laminated to a thin silicone membrane which controls water-vapor transmission. studies in our lab indicated that "fresw ~ tlsr grafts reproducibly close full-thickness wounds in mice & perform better than bb controls. we studied wound adherence & structural/molecular properties of fresh & cryopreserved (cryo) tlsr. methods: tlsrs were prepared by seeding /co hf in bb nylon mesh in dmem. hf quickly attached to the nylon mesh & were allowed to proliferate - wks. fibroblast mitochondrial activity was assayed by mtt assay. matrix proteins were identified by immunostaining, mrnas for specific growth factors were identified by reverse-transcription polymerase chain reaction amplification, & quantitated by gel scans. bb structure was studied by scanning electron microscopy & stretching measurements pro/post cryo. grafts were cryo'd in % dmso, quick-thawed & sutured onto x cm excised full-thickness dorsal wounds on athymic mice. "fresh" grafts were similarly placed. controls grafts were cas and aeellular bb. adherence was quantitated by a device which peeled grafts from wounds at intervals following placement, using a serve motor and a strain gauge. results: postcryo, storage and subsequent thawing tile tlsrs maintained > % cell viability by the mtt assay, indicating continued mitochondrial activity, and bb structure & stretchability were maintained. multiple matrix proteins secreted and deposited in the bb nylon mesh (types l/iii collagen, decorin, fibroneetin) were identified by specific immunostaining. growth factor mrnas in the tlsrs (afgf, bfgf, kgf, tgf~,p~,) were present in - , x higher levels in fresh/cryo tlsrs than in adult hcs. grafts adhered to wounds on mice through days of followup. histologic exams on days - showed excellent vascular ingrowth and minimal inflammation. adherence of tlsrs to wounds was >cas adherence. burn wound coverage in the massively burned patient remains a difficult problem. although cultured keratinocytes have been utilized for burn wound coverage, their impact on the patient with burns greater than % total body surface area has not been spectacular, with poor graft take and unstable epithelium.current investigations have been directed toward dermal replacement beneath either very thin split-thickness autografts (stag) or utilizing cultured keratinocytes. current products include: collagen dermal replacement with thin stag (burke, et al). collagen dermal replacement with cultured keratinocytes and fibroblasts (boyce, et ai). allograft dermis with cultured keratinocytes (cnno, et al). allograft dermis with thin stag (life cell). polyglactin acid mesh and neonatal human fibroblasts with thin stag (hansbrnngh, et al).investigations regarding culture media, use of growth factors, topical nutrients and antibiotics, and melanocytes for pigmentation as well as safety and efficacy are needed before any of the current products become viable options for coverage of the massively burned patient. the~ is a growing world-wide problem with the ujc of cadaver tissues and ocgans bae, au~ of the tren~m~s~km of dilemma such a; cmutzfeldt.jukob disease and iiiv as we ] as ready availability of urdform lis~ue~. on dec~mt~r , , the fda assumed control of as tissue bar~s in the uldtod st=tea in an attempt to bflng ~s difficult problem of dise~s~ transmission under ¢onlrol. in europe, ~om¢ of the governments are consldofll~ a c~mplcte bat) on the use of cadaverlc fissu~s such as ddn, 'this |ncroam in regulation of cadavefle ~s,quct will incmar¢ the difficulty of obtain~g and dlslflbulmg them. however, thc nc~ for these tissues contlnue~ m incrcaso, we will discuss ~'l¢ solulion to this important pmbl~n: tissue engineering. tlssu~ engineering is an in~rdisdpllnary field that applies pdnclplc~ of angin~edng and die life sclcnce~ reward the development of ~olok~¢al sub~dtute,~ ih= mslom, maintain, or improve tissue function, " ssuc ongln~cdng can provide ~ho nccassary tlssuoa for wound repair ~d ibe assuranoe fl'~t the lissuos are d.ls¢~¢ free. in addition, a ds~uo-cng~ne~n~l wound covering will bo u~lvemally acceptable and evntlublc as "off g~o shell", consis~t products, them are several approaches to restating thls function in a large wound, 'l'nosc i~elud~ tmmcdiete long term coverage, short t=nn coverage, uandtl~el coverage and compost= dssu¢ coverage, "flssuo onglncrcd wound coverings that meet those vaflous ne,.cds will he r~vlowod.cllni~:sl and experimental d~la in venous ulcer, dlabctl¢ ulcers, prossur~ ulcers and bum wounds wgj be mvlcw~, a~ welt as new approacl~s u~ csrtilag¢, bone, liver and bone marrow it~suos. c oomplon, k nadirs, w press, g wetland, j fallen iv, shrtners burns institute and massachusetts general hospital, boston, ma~schusetts, usa the clinical "take" rate o? cultured epithelial autografts (cea) has been observed to increase with transplantation to allodermls, but the reasons for the improved clinical performance have not yet been defined. the aim of this study was to determine the biological impact of normal human dermis on cea differentiation and maturation, biopsies of cea transplanted to engrafted and de-opldermlzed human homograft dermis have been compared to nopsles of cea transplanted to granulation tissue in tullthickness burn wound beds on the same patient, each patient serving as hls or her own control. paired test and control biopstes from six patients have acquired from as early as one week postgrafting to as late as years postgrafting (one patient) and analyzed histopathologlcally, ultrastructurally and immunoh[stochemloally, results demonstrate more rapid normalization of differentiation markers (e,g., involucfln, fllaggrln, cytokeratln profiles) in the cea transplanted to allodermls compared to their corresponding controls by in all patients, the proliferation rate within the basal layer ot the epidermis as determined by ki- (proliferation-associated antigen) is seen to norh~altze more quickly in the cea transplanted to allodermls in every case, persistence of allodermal matrix can be dooumented in all patients by elastic tlssue-trichrome stain, allowing visualization of the dermal elastin network. the popu;atlon densities ot intraepldarmal langerhans cells are conslstently and signlflcantly higher in cea transplanted to ,allodermls, possibly reflectlng an immunologlcal reaction to the underlying allogenlc tissue. overall, these preliminary results indicate that transplantation to a normal human dermal matrix accelerates the maturation of cea-deflved epidermis, wound closure continues to be a major problem in patients who have sustained a major thermal injury, cultured epidermal autografts (cea) have been utilized extensively since when galllco et el reported theh'use in two brothers with greater than % total body surface area burn. unfortunately, cea take rate varies widely and the resultant skin coverage is often fragile and the cosmetic results are less than optimal however the overall take rate and durability of the coverase can be markedly improved by using nn allodermls base as the recipient bed. a review of cea applications performed by physicians using cultured outologens epithelium obtained from blusurfaoe teclmology, inc. shows a marked discrepancy in the results obtained utilizing different methods of wound bed preparation. tgf-b is an important modulator coordinating complex physiological events associated with growth and development. it is assumed that tgf-b is also involved in the well-coordinated process of cutaneous wound healing by regulating proliferation, differentiation, chemotaxis and matrix deposition. the purpose of our study was to analyze the spatial and temporal pattern of tgf-b expression during granulation tissue formation in patients with accidanutl surgical trauma (monotraumata mid polytraumata) and bum wounds. after debridement (day ), the full thickness wounds were covered with epigard, a synthetic dressing until day . after this time the granulated wounds were closed by transplantation of mesh graft. biopsies of the wound center were taken from patients at the beginning of surgical treatment (day ) and after , , and days. cryosections were stained with antibodies against tgf-fi s using the apaap technique and -for standard histology -with hematoxylin-eosin. for identification of the cell type expressing tgf- , double staining immunofluorescence experiments were conducted using antibodies specific for monocytes/macrophages, polymorphoanclear neutropkils and fibroblasts. the results showed a characteristic pattern of tgf-t~ distribution during wound development. tgf-fi appearence was mainly cell-associated znd the absolute and relative number of cells that were positive increased with lime. infiltrating cells and developing blood vessels were most prominently stained; epithelial and t-cells showed no immuno-reactivity. a delay of emergence for tgf-b during the time course could be seen in one patient group. this might reflect various regulation patterns depending on the type and severity of injury.( ) pharmatec gmbh, frankfurt ( ) institut fiir immonologie and serologic, heidelberg ( immune cells extravasating specifically in skin recognize and eliminate the invading antigens (bacteria, viruses, etc.) either in situ or transport them to regional lymph nodes. they also participate in the process of skin wound healing. cells which traffic through the skin can be harvested from efferent lymph drained from a given area of skin. the type of migrating cells changes after trauma, heating and infection. we have developed a method for collection of human afferent lymph in lower limbs. the method allows obtaining immune cells from normal and injured skin and their characterization. aim of the study was to characterize skin immune cells in situ and in skin lymph with use of immunohistological methods (staining, facs). results. group , cells migrating through skin: + % t lymphocytes (cd ), + % langerhans and dendritic cells (cdla, hla dr, s ), + % cd , + % cd , no b cells (cd , ), % cd r (memory cells), + % il r. approximately % cells possessed cdlla and antigens. cd lc was expressed only on large cells. the frequency of all phenotypes was different from the blood populations. group , cells in skin: langerhans cells were found only in epidermis, cd , and , cd r , rb, ila/ cells around venules, cd (macrophages) uniformly dispersed, no il r and b cells. hla dr positive were endothelial and some dispersed mononuclear cells. group , one, three and thirty days after surgical wound (simple varicous vein extirpation): high density of epidermal langerhans cells, hla dr positive keratinocytes and all endothelial ceils, few il r cells, perivenular infiltrates of cd , r but less cd cells, high density of cdlla/ cells. classic staining of isolated and in situ located ccl!s with mgg or he did not allow to follow kinetics of changes. conclusions. this study presents the first in the literature quantitative data of immune cell traffic through normal and injured human skin. in the controlled release of biological response modifiers for soft tissue regeneration. alan s. rudolph, helmut speilberg, mariam monshipouri, and florence rollwagen, and barry j. spargo. we have employed lipid microstructures as controlled release vehicles for the delivery of growth factors in wound repair. traditional liposomes as well as novel lipid based microcylinders have been examined for their in vitro kinetics of the release of transforming growth factor beta (tgf-b). in vitro reiease has been examined by setting up models with examine the physical release of iodinated tgf-b as well as a cell based bioassay (based on the ht bioassay). the hollow lipid microcylinders ( microns in length and i micron in diameter) show an initial burst ( - ng) followed be zero order kinetics which result in the release of approximately i ng tgf/day. this release behavior can be modified by temperature based on the phase behavior of the lipid bilayer which comprises the microcylinder.we have also examined the cellular response to lipid microcylinders applied in vivo. the lipid microcylinders are mixed in agarose and implanted as a composite hydrogel block under the flank of a mouse. the blocks are removed , , and days following implant and the cells analyzed by facs sorter analysis. the observed pattern of ceil recruitment to the blocks mimics that seen in a local inflammatory response. cell surface phenotype studies included the determination of cd and cd , mac-l, and ig bearing cells. we have also begun to examine the change in cell surface phenotype and kinetics of recruitment following the inclusion of tgf-beta in the lipid microcylinders.center for biomolecular science and engineering, code , naval research laboratory, washington, dc. - . expression pattern of heat shock proteins in acute, good healing and chronic human wound tissue. abstract: wound healing is a complex biologic process that is well characterized at the histological level, but its molecular regulation is poorly understood. after clot formation, inflammatory cells are rapidly drawn into the wound, followed by migration of fibroblasts and epithelial cells that divide and repopulate the wound area. during the last decade peptide growth factors and cytokine are thought to play a key role in initiating and sustaining the phase of tissue repair. these factors which are released from different cells appear to initiate the cascade of events that lead to healing. different studys described the rapid activation of a family of proteins,named heat shock proteins (hsp) in differnt tissue that were exposed to various forms of stress (heat, toxic agents, mechanical). in this context hsp's have the ability to regulate protein folding and assembly, to transport proteins across cytoplasm and membranes, to disrupt protein complexes, to stabilize, degrade and regulate the synthesis of proteins and to take part in dna replication and repair. we now attempted to find out if hsp-gene activation is also involved in injury and wound healing, which likewise resemble a stress situation for cells. therefore we collected tissue samples during operation and single biopsies from chronic wounds (decubitus for example) and granulation tissue. after rna preparation from these samples we used rna-pcr and nothern analysis to study the expression of objectives of the study chronic, non-healing cutaneous tflcers are a challenging clinical and socioeconomic problem. several animal studies have shown that cytukines (e.g. egf, pdgf, fgf, tgfb) accelerate the healing process and tissue repair in general. results from first clinical trials indicate a promising value of cytokines in the treatment of chronic non-healing diabetic and venous ulcers. recent reports in the literature indicate that the biological activity of the solution of platlet derived wound healing formula (pdwt~) released from c~-granules (mainly pdgf & tgfi~) is greater than the activity of the recombiant single factors like e.g. pdgf-bb (robson, lancet ) . the aim of our study was to determine whether a correlation exits between the concentration of tgfi~ & pdgf and the time course of wound healing. materials and methods pdwhf was prepared from ml of auto]ogous patient blood and diluted with a special buffer to a final concentration of ng/ml g-thromboglobulin. the concentrations of pdgf and tgfg were determined by elisa-tests developed in our laboratory. patients with chronic non-healing ulcers have been evaluated alter treatment by topical application of pdwhf. pdfg and tgff~ concentrations of the topical solution were measured and two patient groups formed for analysis the time course of wound healing was regularly and meticulously documented and evaluated by photography and casting. the time from initiation of treatment instil o wound volume reduction to go of the origional size (t %) was noted• results: healing of extensive burn wounds can be accelerated by grafting cultured autologous or allogeneic keratinocytes. the stimulation of granulation tissue formation and reepithelialization is presumably based on growth factors and cytokines released by keratinocytes. we wanted to prove this hypothesis by investigating the bfgf expression during wound development, bfgf is mainly described as an angiogenic protein with mitogenic activity on various mesodermal and ectodermal cell types pointing to its stimulating potential in wound heating. in the present study we compared the pattern of human bfgf m-rna expression and the localization of bfgf protein during the first days of wound healing. biopsies were taken from juvenile human bum patients, immediately after wound debridemerit mad on day after transplantation of cultured allografts. biopsies were snap frozen and cryosected. the pattern of bfgf expression was assessed by in situ hybridization of the bfgf m-rna with a digoxigenin-labelled antisense-rna and the parallel detection of the mature protein with an anfi-bfgf monoclonal antibody. our study revealed typical patterns of bfgf-m-rna-expression and intense bfgfprotein deposition during granulation tissue formation and reepithelialjzation of healing bum wounds. 'it, is known that major thermal injuries cause early impairment of wound healing followed by decreased influx of granuiocytes st. the site of injury. the role of granuiocytes in the process of wound healing is not ~"~ "" elucidated, it is now assumed that they are not merely phagocytic cells but active participants in ~n~*' ~.,.,a+~o~: processes secreting_ a number of various cvt-;kines, in order to investigate the effect of there is accumulating evidence that neuropeptides could be involved in the pathogenesis of several inflammatory reactions. vasocactive intestinal polypeptide (vip) and substance p (sp) have been detected by immunohistochemistry in normal as well as inflammed skin mostly in perivascular and periglandular location. both vip and sp are involved in vasodilatation, mast cell degranulation and irnmunomodulation.we determined the influence of sp and vip on the proliferation of lymphocytes in patients with psoriasis and healthy individuals. peripheral blood t-lymphocytes of psoriatics and healthy controls were isolated by density gradient centrifugation and passage over nylon wool. cell enrichment was controlled by facs analysis, lx t-lymphocytes were then incubated alone or in coculture with x irradiated autologous lymphocytes in culture medium containing - mol/i sp or vip. cell proliferation was measured semiquanfitatively by tdr uptake in a betacounter. significance was tested by the wilcoxon signed-rank test.our results show that sp and vip exert only an effect on unstirnulated t-cells. in healthy individuals but not in patients with psoriasis sp increases significantly proliferation of t-cells. vip, however stimulates significantly the blastogenesis of t-lymphocytes only in psoriatics.our results confirm the psychoneuroimmunologic component in inflammatory reactions and vip and sp could be partially implicated in their pathogenetic mechanisms. moreover psoriatic lymphocytes show an altered reaction to sp and vip. this might be due to a preexisting (genetic?) or more likely to an epiphenomenal receptor defect. the adhesive interactions between endothelial cells and circulating ~enkocytes in shock and innammatory vondltions is mediated by several distinct families of ce -surface determinants. of particular importance are the leukocyte integrins cdib / cdlla-c. in this study monoclonal antibodies to two of the u chains (cdlla & cdiib) and the common [~ chain (cdib) have been used to investigate leukocyte-dependent and leukocyte-independent plasma leakage in tee skin of rabbite. plasma leakage was measured as the local accumulation of t si-hsa over a rain period, the chemotac~c peptide imlp ( . . ng) and bradykinin were used to induce cell.dependent and cell- ndependent leakage respectively, the antibodies used were . e (cdis), nri (cdlla) and antibody (cdllb). ]ntradermal in~ections of bradyklnin and ~dlp both caused a dose dependent increase in plasma extravasatien ( .~. ffi . p.l to . z b.bttl and . ,- . ~ to . z . d respectively. . e ( . - . mf,/k~ iv) caused a dose dependent inhibition of imlp-induced but not bradyldnin.inducecl plasma exudation. at . mk/kg, the plasma leakage was completely inhibited, antibody nr produced similar results, treatment with antibody did not cause inhibition o£ plasma leakage due to either tnedi~tor. in vitro, the irmnune system ex~nination in persons with bone, chest and abdominal traumatic injury (i group . patients without infectious coz~lications and group - patients with wound infections development) was carried out. to restore found immunity disorders and host defense to infection patients of the group were treated with thymalin-the biologically active peptides prepared from bovine thymus. the examination on t~e i- days after injury revealed a considerable decrease of lymphocytes, ed ",$d ~ and cd cells amo~it in the blood, cd /cd ratio and indexes of let~ocyte migration inhibition test in both groups of patients. the imm~lity disorders recovered to norm on the - days in pateents of+the i group. but stable ~eple$ion of cd and cd cells amount, lower cd /cd ratio and indexes of leukocyte migration inhibition test in patients of the group were observed~ besides that, these persons showed higher cd cells amount and ig level in the blood. after thymalin therapy valid ii~rovement of inun~e status was discovered. also good clinical effect of immunotherapy and best wo~id healing observed in % of cases. these results allow us to propose that the thymus involution and the reduction of cell-mediated immunity responsiveness with disturbances of immu_uoregulatio~ on the level of restriction of activated cd tho cells play the most important role in the pathogenesis of wound infections development in persons with traumatic injury.dept. of immunology, military-nedical academy, lebedeva str. , , st.petersburg, russia a severe impairment of neutrophil (pmn) function often occurs following severe thermal or non-thermal traumatic injury. our laboratory has previously reported that following severe burn or non-burn traumatic injury the expression of the p integrlns (cd a,b,c/cd ) and the fw receptors (cd , and cd ) were significantly decreased on pmns, in this study, the effects of gm and g-csf on the expression of the f~ r and the ~ integrln family on pmns were examined, pmns were obtained from severe trauma (initial apache ii score ;z ) or thermal injury (> ~; total body surface area, > ~ full thickness) and incubated /n v/tro with gm or g-csf. the j integrins or fcyr were detected with monoclonal antibodies and flow cytometry. gm end g-csf induced a sllght increase in the percentage of pmns expressing cd lb, cd , and cd while gm bur not c-csf induced an increase in the percentage expressing cdi a, cd lc, and cd , gm-csf and to a lesser extent g-csf induced an increase in the density ( , fold) of the ~ integrlns on pmns from normal, burn, and trauma patients, these data suggest that cytoklne modulation with csfs could have a role clinically in certain situations. institute, dept. of surgery, bethesda ave, cincinnati, oh, usa, - . funl~al infections after solid organ transplantatlon(sot) lewis flint, md and ed,~-afd e. etheredge, me) dept. of surgery tullrte univ. school of medicine new orleans. louisiana infections contribute to increased gra loss and mortaliw following sot. pr~isposing facton include diabetes, hepatitis, leukopenia, cc.¢xistem infection, and intense, especially triple drug, immunosuppression. funga] infections occur ~s isolated conditions in % and in association with bacterial infection(l %), viral infection( */.), and combined infections(it%), candida sp. is the most common fungus recovered but aspecgillus, coccidiodies, cryptococcus, histoplasma, mueor~ ghizopus, tinea, and toruiop~is s?. also are pathogens. clinical syndromes vary among orga.aizms or may be variable with a single p~tthogen, for ~ample, with aggressive immunosuppression, candlda my be localized esophagitis or cystitis or systemically iavaslve with an associated high mortality. aspergilius presents ~ a diffuse pneumonia while cryptococcus causes pulmonary and centrad nervons sy'stem infection, clinical examination, ct scanning and aggressive sampling for c'ultures a.s wall as serologic tests contribute to diagnosis. empiric the~py is ind',cated where there is a high level of suspicion. preventlon of ca.adlda izfection is ~ci~itated by early remov-a. of central }ants, ca~hetess and stents as well as by the use of oral nystatin. amphotericin ]~ remains the drug of choice for treatment of in.save fungd infection, surgical resection of infectious loci in the lung and brain is indicated in selected patients. the main problems of diagnosis in lower respirator-), tract infection are the differentation of infection from colonization or contamination, and the isolation of a reliable and true pathogen. expectorated sputum may be unreliable in pneumonia, because of contamination by oropharyngeal flora. although blood cultures may be negative, they provide a precise diagnosis and should be obtained in all pneumonias. other more invasive procedures are transtracheal needle aspiration, fibrobronchoscopic techniques including protected specimen brush and bronchoalveolar lavage with quantitative culturing and cytological analysis, transthoracic needle aspiration, thoracoscopy -guided biopsy and open lung biopsy. recently m. e -ebiary, a. torres et al, reported quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia offering reliable results in these patients and should be further investigated. any invasive procedure in a severely ill patient should be carefully directed weighing the risks as well as the benefits, whilst taking the underlying diseases and expected survival into consideration. -current therapeutic approach is based mainly on monotherapy with broad spectrum antibiotics. combination therapy is apparently indicated only in p. aeruginosa infections and severe s. aureus pneumonia. graft infection can lead to fulminant graft failure or rapid progressive cirrhosis. for prevention of graft infection immunoprophylaxis, i,e. administration of human polyclonal anti hbs hypedmmunoglobutin (hig), starting in the anhepatic phase during operation, has proved to be at least partially succesful when performed on a long term basis.from a total of olt in adult patients olt were performed for hbsag positive liver disease (cirrhosis n= , fulminant liver failure n= , retransplantation n= ) in pat. all pat. received . u hig in the anhepatic phase and . u/per day for the first week. a small group of pat. received hig only for i week (short term immunoprophylaxis), in all other pat. hig is administered on a long term basis to keep anti hbs serum levels above uii or until graft infection occurs (long term immunoprophylaxis);one-year survival rates are % in pat. who were transplanted for fulminant hepatitis, % in pat. with cirrhosis and long term prophylaxis, and % ir~ pat. with short term prophylaxis. all fatalities were related to hbv graft infection. the total rate of graft infection was % under short term prophylaxis and was independent from preoperative hbv dna status, under long term prophylaxis graft infection occurad in % in pat, negative for hbv dna. in hbv dna positive pat. infection rate was %, the total rate of reinfection for all pat. with long term prophylaxis was %the results of liver transplantation in hbsag positive pat. are comparable to other indications, graft infection with hepatitis b virus ist the major risk factor for these patients. under long term therapy with hig the rate of graft infection can be significantly reduced. the crucial cellular element for mods-mof: monocyi'f_./m acrophaoe ronald v. meier, m,d., f.a,c,s. the severely :injured or crldcally ill surgical patient is at high risk for immune dysfunction. a major consequence of this immune dysfunction is multiple organ dysfunction and failure leading to death, the underlying etiology is now recognized to be an uncontrolled, unfocused, disseminated activation of the host normally protective inflammatory. ,, cascades.. the resultant "mahgnant' systemic" inflan'a'natlon produces d~ffuso multiple organ bystander injury !eading to progressive organ dysfunction and failure. systemic malignant inflammation involves diffuse actlvatton of all components of the humoral and cellular inflammatory host response. of these various components, the macropha~e is the crucial central cellular element. the tissue fixed macrophage is ideally located diffusely throughout the various organs injured to orchestrate the inflammatory process. the macrophage is long-lived and highly metabolic, the macrophage regulates both the extent and the dissemination of the inflammatory processes. the macrophage is an exu'emely active c¢ capable of producing and releasing not only directly eytotoxlc agents, s irnil~, to the neutrophil, including oxidants and numerous proteases out also the multitude of other cytokines and initiators of the interacting inflammatory cascades. the macrophage is the central source for ehemotactic agents (il- , ltb , c a) for neutrophils and other inflammatory cells, production of vasoaetive arachidonie acid metabolites (tx, pgi , poe, lt's), complement components (c a, csa), thrombotic agents (pca, tx), metabolic and physiologic modulators (il, , il- or tnf), and immunosuppressivc agents (poe , il- ). these products of the macrophage are highly effective in enhancing and augmenting the inflammatory response. disseminated activation otthe macrophage is critical to the induction of the long-term diffuse activation of inflammation necessary to induce multiple organ injury and failure. our ability to elucidate the molecular mechanisms that control the macrophage will lead to our ability to conu'ol the maerophage response and prevent mods-mof.flarborview medical center, - th ave za- , seattle, wa usa key: cord- -y sfr c authors: nan title: scientific programme date: - - journal: pediatr nephrol doi: . /s - - - sha: doc_id: cord_uid: y sfr c nan the kidney plays an important role in ion homeostasis in the human body. several hereditary disorders characterized by perturbations of renal magnesium reabsorption leading to hypomagnesemia were described over the past years. only recently, mutations in renal ion channels and transporters have been identified in several of these diseases, following positional cloning strategies in families with these disorders. muations in the slc a gene have been identified in patients with gitelman syndrome, an autosomal recessive disorders characterized by hypokalemia, hypomagnesemia and hypocalciuria. slc a encodes the thiazide-sensitive na + , cl-cotransporter (ncc) in the distal convoluted tubule (dct), the nephron site of active renal magnesium reabsorption. the hypomagnesemia in gitelman syndrome has been shown to be secondary to the primary defect in ncc. mutations in the fxyd gene have been found in patients with autosomal dominant renal hypomagnesemia associated with hypocalciuria (idh). fxyd encodes the gamma-subunit of the na + , k + -atpase, which is expressed primarily in the kidney with the highest expression levels in dct and tal. hypomagnesemia in patients with idh can be severe (< . mm) and cause generalized convulsions. the molecular mechanism for renal mg + loss in this autosomal dominant type of primary hypomagnesemia remains to be elucidated. in patients with autosomal recessive hypomagnesemia with hypercalciuria and nephrocalcinosis (fhhnc) mutations in the cldn gene, and very recently also in the cldn gene, have been identified. these genes encode claudin and claudin respectively, which are essential components of the paracellular pathway for magnesium at the level of the thick ascending limb of henle's loop. mutations in trpm , encoding the epithelial mg + channel trpm in the apical membrane of dct cells, have been identified in patients with mg + wasting and secondary hypocalcemia (hsh). this autosomal recessive disease is due to defective intestinal and renal mg + (re)absorption, and affected individuals show neurologic symptoms of hypomagnesemic hypocalcemia, including seizures and muscle spasms during infancy. in my lecture, i will give an update on the proteins involved in magnesium reabsorption and the emerging pathophysiological understanding of hereditary disorders in which renal handling of this divalent ion is disturbed. transcriptional control of genes that regulate tissue patterning and the cell cycle is fundamental to normal renal development. the mammalian kidney arises from reciprocal inductive tissue interactions between the ureteric bud and the metanephric mesenchyme. these interactions result in growth and branching of the ureteric bud and its daughter collecting ducts, a process termed, renal branching morphogenesis, and formation of nephrogenic progenitors and mature nephrons. expression and activity of transcription factors in ureteric and metanephric mesenchyme cells determines the patterning of ureteric bud and metanephric mesenchyme derived tissue elements. this lecture will highlight transcription factors critical to renal branching morphogenesis and nephrogenesis, with particular emphasis on those factors that are mutated in humans with renal malformation. the regulation of transcription factor activity will be discussed in the context of growth factor signaling pathways downstream of wnts, bone morphogenetic proteins and sonic hedgehog and pathways such as notch that control cell differentiation. the complexity of transcriptional signaling will be highlighted in the normal and malformed kidney at the level of transcriptional factor interactions and target gene promoters that can be targeted by mutiple signaling pathways. t. benzing diseases of the glomerular filter of the kidney are a leading cause of end-stage renal failure. recent studies have emphasized the critical role of the slit diaphragm of podocytes for the size-selective filtration barrier of the kidney and revealed novel aspects of the mechanisms leading to proteinuria, both in inherited and acquired diseases. several critical structural protein components of the slit diaphragm have been identified. recently, it has been shown that slit diaphragm proteins, in addition to their structural functions, participate in common signaling pathways. this talk will focus on what is known about the importance of the podocyte for the function of the glomerular filter of the kidney. it will provide a snapshot of our current understanding of the signaling properties of slit diaphragm proteins and project a framework for further studies necessary to delineate the function and dynamics of the slit diaphragm protein complex and the pathogenesis of nephrotic syndrome. long-term survival of children with end-stage renal disease (esrd) has increased in the last years but the mortality rate remains high. cardiovascular disease accounts for to % of all deaths, infectious disease about %. a prolonged period of dialysis versus having a renal graft and persistent hypertension are mortality risk factors. the prevalence of all sorts of morbidities is high among those who have reached adulthood. nearly % of all these patients suffer from left ventricular hypertrophy and life threatening vascular changes; nearly one third has clinical signs of metabolic bone disease. this accounts for both dialysis and transplanted patients. the chance of getting cancer is times increased as compared to the general population; skin cancer and non-hodgkin lymphomas are most reported. a long period of dialysis at childhood is associated with impairment of both cognitive and educational attainment in adulthood. yet, despite all these negative outcomes, the health perception of young adults with childhood onset esrd is good. unemployment under young adults on chronic dialysis with pediatric onset of disease is higher than among healthy age related peers, but much lower than among dialysis patients of the same age with adult onset of disease. an impaired social development in childhood is associated with an impaired mental health perception at adult age. research and therapy in children with esrd should focus not only on prevention of graft failure but also on prevention of co-morbidity, especially cardiovascular disease, life threatening infections and malignancies. early transplantation, more extended forms of frequent hemodialysis in those who can not be transplanted, a more rigorous treatment of hypertension, avoidance of calcium-containing phosphate binders, reduction of the chronic inflammatory state, and tailor made anti-rejection therapy after transplantation may all be targets to improve outcome in future patients. psychosocial care should be more focused on attainment of independency and preparation for adult life, i. e. schooling and job career. applying regenerative medicine to combat organ shortage laboratory of regenerative nephrology, edmond and lili safra children's hospital, sheba medical center, tel hashomer, sackler school of medicine, tel aviv university, tel aviv, israel organ transplantation has been one of the major medical advances of the past years; however, it is becoming increasingly apparent that the supply of organs is limited and will not improve with current medical practice. regenerative medicine is focused on the development of cells and tissues for the purpose of restoring function through transplantation. when facing late stages of esrd, which necessitate whole kidney transplantation, organogenesis represents an alternative to combat organ shortage. indeed, previous data pinpoints a window of time in human and pig kidney organogenesis that may be optimal for transplantation into mature recipients. "window" transplants are defined by their remarkable ability to grow, differentiate and undergo vascularization, achieving successful organogenesis of urine-producing miniature kidneys with no evidence of trans-differentiation into non-renal cell types, lack of tumorigenicity and reduced immunogenicity compared to adult counterparts. in contrast, when dealing with earlier stages of esrd or acute renal disease, which allow for individual cell replacement, both bonemarrow derived and kidney specific stem cells, might be applicable. accordingly, we show in proof-of-principle experiments that a novel population of multi-potential stem cells derived from the adult murine kidney are capable of re-populating ischemically injured tubular cells, while hematopoietic stem cells (cd +cd +) or hemangioblastic progenitor cells can give rise to peritubular endothelial cells. thus, different types of biological materials (embryonic kidney, adult kidney, adult bone marrow) offer new and powerful strategies for future tissue development and regeneration in renal medicine. k. tory, É. kis, a. szabó, g. reusz st department of pediatrics, semmelweis university, budapest, hungary it is well known that chronic renal failure significantly increases the risk of cardiovascular mortality in adults. transplantation decreases this risk; however, it still exceeds that of the normal population. as the number of children on renal replacement therapy (including transplantation) has significantly increased in recent years, there has been a growing amount of evidence regarding the increased cardiovascular vulnerability of this specific patient group. one important factor of cardiovascular mortality in adults is the dysfunction of the autonomic nervous system, previously designated as autonomic neuropathy. in a series of studies using the conventional ewing tests as well as heart rate variability (hrv) monitoring we were able to show altered sympathovagal balance in children on peritoneal-and hemodialysis, that was at least partly reversible following renal transplantation. according to our data sympathetic overactivity plays a major role in the sympathovagal disequilibrium observed. correspondingly, beta-adrenergic blockade improves the decreased hrv in the young. early, accelerated arteriosclerosis is another important, recently recognized consequence of crf in children. arterial calcification leads to increased arterial stiffness deteriorating the cushioning function of the aorta. arterial stiffness can be assessed by the reproducible and non-invasive measurement of the pulse wave velocity (pwv). in adults, it was found to be a strong, independent predictor of cardiovascular mortality. hypertension, hyperphosphatemia/elevated serum calciumphosphate product and vitamin d deficiency are the principal factors associated with pwv. recently, pwv was also shown to be increased in children on dialysis. however, the difference to the normal population may only be apparent if a control group matched for body dimensions is used, because of the dependence of pwv on body dimensions and uremic children's significant growth deficit. furthermore, increased pwv could also be shown in children following renal transplantation (tx) indicating the persistence of these lesions even following successful tx. the data on the autonomic nervous system and arterial dysfunction in young patients point to the necessity of early prevention in order to avoid the cardiovascular complications of crf. this study was supported by grants otka-t -f -f and ett / . nitric oxide (no) production is reduced in ckd due to decreased renal and widespread decreases in endothelial no production. possible causes of no deficiency are: ). substrate (l-arginine) limitation; ). increased levels of circulating endogenous inhibitors of nitric oxide synthase (particularly asymmetric dimethylarginine [adma]); ). decreased nos protein abundance/activity. decreased l-arginine availability in ckd is likely due to perturbed renal biosynthesis secondary to damage to the renal parenchyma. in addition, inhibition of transport of larginine into endothelial cells and shunting of l-arginine into other metabolic pathways (e. g. arginase) will also decrease availability. elevated plasma and tissue levels of adma in ckd are functions of reduced renal excretion (minor), reduced catabolism by dimethylarginine dimethylamino-hydrolase (ddah) and possibly increased protein methylation. an increase in adma has emerged as a major independent risk factor in many forms of cardiovascular disease as well as end-stage renal disease (and probably ckd). decreased renal nos protein abundance and activity have been reported by us in multiple models of ckd in the rat. the neuronal (nos ) isoform is always reduced in the presence of injury, and is preserved in settings where there is protection from damage (female; wistar furth rat vs. sprague dawley). generalized and nnos specific inhibition accelerates underlying renal injury and in vulnerable animals will cause injury in the absence of underlying renal disease. we also find that relaxin (rlx) mediated prevention and repair of damaged kidneys requires an intact no system in order to function. in summary, no deficiency can cause cardiovascular and renal disease, and ckd results in no deficiency, contributing to a vicious cycle that promotes progression. an intact no system is required for rlxmediated repair of kidney damage. no deficiency in ckd is likely due to many causes: decreased arginine synthesis/availability and transport; increased endogenous adma functioning as competitive inhibitor; decreased enzyme abundance and activity will all lead to reduction in no generation. in addition, the oxidative stress of ckd will further reduce nos activity, switch the nos to become oxidant generators and will scavenge no to form the harmful peroxynitrite. selected glomerulopathies due to single gene defects such as finnish type nephropathy, diffuse mesangial sclerosis alport/thin membrane disease and inherited lipid disorders and will be discussed. finnish nephropathy is due to mutations of nephrin, a major structural component of the slit diaphragm. over nephrin mutations are known associated with variably absent slit diaphragms, originally thought to be specific for constitutional nephrin mutations. however, sporadic minimal change disease and membranous glomerulonephritis may have absent slit diaphragms suggesting that nephrin may participate in the nephrotic syndrome in nonhereditary diseases. dms is one cause of congenital nephrotic syndrome, characterized by podocyte proliferationis shared by wt (denys-drash syndrome), laminin α (pierson syndrome) and galloway-mowat syndrome mutations. alport nephritis is a paradigm in which only a subset of mutations may predict disease severity (col ivα )). heterozygous alport is similar to thin membrane disease (tmd), but % of tmd harbor col (iv) α mutations and a subset has col ivα . nail patella syndrome due to heterozygous loss of lmx b gene which regulates col ivα - expression during kidney development. in classic nail-patella pathology fibrillar collagen bundles within the gbm are identical in severe and mild disease. thus the mutation does not correlate with prognosis. a mutation overlap in factor h gene in lipid disorders such as dense deposit disease (ddd) and lcat underscores glomerular pathologies that ranges from classic ribbon-like deposits in ddd, to lucent gbm deposits characteristic of lcat, or subendothelial lipid pools in lipoprotein glomerulopathy. the importance of genetics underscoring the pathology is amply demonstrated but mutations may not determine prognosis. background genes, post-translational modification and or protein/protein interactions in podocytes or the gbm may act as phenotypic modifiers. acute renal failure (arf) has many different definitions. rifle criteria distinguish "risk, injury, failure, loss and end-stage renal disease" features of this event. classic forms include pathophysiological cases of renal hypoperfusion and direct parenchymal injury, as well as postrenal anatomical obstruction. microvascular mechanism is in general the effect of disturbed balance between vasoconstriction (in response to endothelin, angiotensin ii, thromboxane a , leukotrienes and increased sympathetic nerve activity) and vasodilatation (in response to nitric oxide, pge and bradykinin). endothelial and vascular smooth muscles cells may undergo structural damage and increased leukocytes-endothelial adhesion is a cause of inflammation. cytoskeletal breakdown, loss of polarity, apoptosis, necrosis, desquamation of viable and necrotic cells with tubular obstruction are underlying mechanisms of acute tubular necrosis. ischemic and direct tubular injury dominate as causes of arf, however specific epidemiology is strictly age-related. sepsis and major surgeryrelated events are the most common causes of arf in hospitalized patients. data on genetic background of certain genes polymorphisms and susceptibility to specific risk factors in newborns and infants are conflicting. several prophylactic and therapeutic techniques are available, however not of universal value. appropriate fluid management is crucial in ischemic arf, classic hemolyticuremic syndrome and rhabdomyolysis, however fluid overload is the one of major predictors of poor outcome in children admitted to icu. neither "renal dose" of dopamine, nor loop diuretics change the outcome. involvement of extrarenal organs worsens the overall outcome, which is the poorest in patients with multi-organ failure. early introduced renal replacement therapy is one of the key modalities in icu-treated patients. continuous techniques are of major value. in specific cases, such as hepato-renal syndrome, albumin ("liver") dialysis serves as an effective bridge to liver transplantation. hyperostosis-hyperphosphatemia syndrome (hhs) is a rare recessively inherited disease, manifested by persistent severe hyperphosphatemia and self-remitting episodic bone pain with radiologic findings of periosteal reaction and cortical hyperostosis. hyperphosphatemia in this patient population is not counter-balanced by pth or vitamin d, posing a mirror image of two hypophosphatemic states which result from increased activity of fibroblast growth factor (fgf ). the two hypophosphatemic disorders which result from enhanced urinary phosphate leak are: dominantly inherited hypophosphatemic rickets and tumor induced osteomalacia. this observation was the impetus to study the role of fgf in hhs. affected individuals were found to have low levels of the full length, biologically active fgf , but markedly augmented amounts of the cleaved inactive fragments. patients were found to be homozygous for a mutation in the galnt gene encoding a peptide involved in mucin-type o-glycosylation. decreasing the expression of the galnt gene by rna interference resulted in augmenting processing of the intact fgf . our research indicates that the primary defect in hhs is a state of underglycosylation of fgf- resulting from reduced expression of ppgantase-t , due to mutations in galnt , and leading to augmented processing at the cleavage site. these changes in fgf- would abolish its phosphaturic effect and lead to severe persistent hyperphosphatemia. this study provides the pathogenetic mechanism of the first mucin-type o-glycosylation defect identified. our observation lends further credence to the primary and essential role of fgf in phosphate homeostasis through a pth-independent pathway. this was substantiated most recently by several reports which showed that mutations in the fgf gene are responsible for familial hyperphosphatemic tumoral calcinosis (fhtc) . a further study showed that hhs and familial hyperphosphatemic tumoral calcinosis are allelic disorders with a founder mutation in our region. immune responses govern the outcome of many forms of chronic kidney disease. gene therapy offers the potential to modify immune genes to improve outcome. we will discuss the potential use of gene transduction as a therapy for chronic kidney disease. background: chronic proteinuric renal disease is a major cause of end stage renal disease in man. adriamycin nephropathy is a murine model of chronic proteinuric renal disease where initial chemical injury is followed by immune and structural changes that mimic human disease. foxp is a gene specifically expressed by regulatory t (treg) cells. forced expression of the gene foxp causes transduced t cells to develop a regulatory phenotype. we hypothesised that foxp transduced regulatory t cells could protect against renal injury in adriamycin nephropathy. methods: the retroviral vectors expressing foxp and green fluorescent protein (gfp) (foxp /migr) and gfp alone (migr) were transfected into package cell lines ecopack - , which produced the two retroviruses. cd + t cells were isolated from spleen of balb/c mice and stimulated by anti-cd mab and il- for hours and then were infected with either retrovirus. expression was confirmed and phenotypic and in vitro functional assays demonstrated a regulatory phenotype. one week after infection, the gfp+ positive cells were sorted. foxp and control vector (migr) transduced t cells were administered to adriamycin (adr)-induced progressive renal nephropathy in mice. results: adoptive transfer of the foxp transduced t cells protected against renal injury. urinary protein excretion was reduced; there was less renal injury as measured by glomerulosclerosis, and interstitial infiltrates. serum creatinine, glomerular sclerosis and tubulointerstitial alterations were significantly lower in adr-foxp group, compared to those without treatment (adr) and treated with control vector (migr) transduced group (adr+migr). the foxp transduced cd t cells also showed suppressive activity in vitro. we conclude that foxp induced t reg cells may have a therapeutic role in protecting against immune injury and disease progression in chronic proteinuric renal disease. the italkid project is a prospective, population-based registry that was started in . prevalent and incident cases of chronic renal insufficiency (cri) in children and adolescents were identified throughout italy (total population base: . million children). the inclusion criteria were: i) creatinine clearance (ccr): < ml/min/ . m bsa; and ii) an age of < years at the time of registration. as to december st, a total of patients had been registered. the incidence of cri was estimated . cases per million and the (point) prevalence . per million of the age-related population (marp). the probability of kidney survival at years of age was significantly different depending on the ccr at study entry, being % in patients with mild renal insufficiency (ccr - ml/min), % in those with moderate renal insufficiency (ccr - ml/min) and % in those with severe renal insufficiency (ccr < ml/min). the patients with normal (< . ) and low ( . - . ) upr/ucr compared to those with mild (> . ), showed a significantly slower decline in ccr (deltaccr + . ± . and - . ± . vs - . ± . ml/min/yr) and a higher kidney survival ( . and . vs . %). the incidence of renal replacement therapy (rrt) was . /year/ patients and the casefatality rate on conservative treatment . %. patients showed a significantly different slope of ccr before pubertal growth spurt as compared to after: - . ± . ml/min/ . mq/yrs and - . ± . . a non-linear pattern of decline in the probability of kidney survival, with a steep decrease during pubertal and early post-pubertal age was observed: the overall probability of rrt at age was estimated . %, while . % of the patients will eventually required rrt before the nd decade of life was over. suggesting that pubertal development triggers the progression of cri in children. treatment with angiotensin converting enzyme inhibitors did not significantly modify the naturally progressive course of hypodysplastic nephropathy. ambulatory blood pressure monitoring (abpm) is a relatively new technique of blood pressure assessment in children and adolescents that offers several distinct advantages over traditional methods of blood pressure measurement, including the ability to detect white coat and masked hypertension, as well as the ability to assess nocturnal blood pressure. the role of abpm in the diagnostic evaluation of pediatric patients with elevated blood pressure is well-established, and recent surveys have demonstrated that it is used quite often by pediatric nephrologists and other practitioners during the initial evaluation of elevated blood pressure. it is less well-established, however, what role abpm might play in hypertensive children and adolescents once hypertension has been diagnosed and treatment initiated. studies in adults have demonstrated that abpm can assess whether patients on antihypertensive medications have achieved goal blood pressure, or whether their hypertension has progressed in severity. abpm can be used to follow nocturnal blood pressure in patients with chronic kidney disease (ckd) and diabetes, facilitating early identification of non-dipping, which is a known risk factor for progression of ckd or development of diabetic nephropathy, respectively. abpm can also be incorporated into clinical trials of antihypertensive medications to help assess their efficacy and safety. while additional data supporting these applications of abpm to pediatric hypertension clearly need to be generated from well-designed clinical trials, we propose that there is ample justification to utilize abpm just as frequently after the diagnosis of hypertension as before. childhood obesity is increasing globally in epidemic proportions and affects children in both industrialized and non-industrialized nations. in the last years the percentage of overweight or obese children has increased from % to almost %. if current trends continue, as many as % of children may be overweight or obese by the year . obesity predisposes to development of the metabolic syndrome, which is defined in children as the presence of three or more of the following features: abdominal adiposity (bmi > %ile), serum triglycerides > %ile, serum hdl cholesterol < % ile, fasting blood glucose > mg/dl, and/or hypertension (systolic or diastolic blood pressure > %ile adjusted for age, gender and height). the metabolic syndrome occurs in about % of children, but in - % of overweight children. the presence of the metabolic syndrome increases the risk for cardiovascular disease and chronic kidney disease almost ten-fold in adults. adipose tissue does not just store fat, but also has important endocrine and immune functions mediated through adipocytokines, including leptin, adiponectin, resistin, apelin and visfatin, and classical cytokines such as tnf-a and il- . increased leptin, decreased adiponectin and increased inflammatory cytokines, which occur in obesity, are known to induce vascular endothelial dysfunction and increase blood pressure. increase in adipose tissue also leads to infiltration by monocytes, macrophages and lymphocytes, which are stimulated to produce additional cytokines that may contribute to the systemic inflammation associated with obesity and vascular inflammation associated with hypertension. screening for hypertension and metabolic syndrome in obese children is critical to allow early identification of the metabolic syndrome and aggressive early intervention to reduce the risks for progression to cardiovascular disease and chronic kidney disease in later life. therapeutic strategies must include lifestyle changes of weight loss, healthier diet and regular physical exercise as well as treatment of hypertension, hyperlipidemia or hyperglycemia. blood pressure (bp) regulation is affected by numerous physiologic, biochemical, genetic and environmental factors. it has been suggested that exogenous conditions affecting intra-uterine growth and development may pre-program individuals for hypertension, metabolic abnormalities and cardiovascular morbidity in later life. animal data and human autopsy findings support a link between intrauterine growth, nephron endowment and postnatal hypertension. conceptually, it appears increasingly unclear whether the association of birth weight and bp in later life is mediated by intrauterine growth retardation as suggested by various animal models, whether prematurity per se affects bp programming independent of the fetus, nutritional status, or whether postnatal circumstances statistically linked to low birth weight affect this relationship. we have designed a study to evaluate the relationship between gestational age, birth weight and bp abnormalities by applying abpm in a group of children born preterm with and without intrauterine growth retardation and a local control group of children born at term with appropriate weight. this study represents the first systematic assessment of -hour cardiovascular regulation in children and adolescents born preterm. our findings indicate that a fraction of these preterm born subjects has a selective nocturnal increase in systolic bp, resulting in an elevated prevalence of non-dipping. our analysis suggests that intrauterine growth retardation, rather than prematurity per se, is the major effector of the early cardiovascular abnormalities observed in preterm children. moreover, we have found that nocturnal systolic bp was closely linked to heart rate, pointing to a possible role of sympathetic hyperactivation. while little data is available regarding a link between low birth weight and/or prematurity and sympathoadrenal function in adult humans, a role of the sympathetic nervous system in the programming of adult hypertension has been consistently demonstrated in various animal models of fetal growth retardation. in conclusion, we detected subtle abnormalities of circadian bp regulation in those preterm born children who suffered from intrauterine growth retardation and this may reflect sympathetic hyperactivation. the intrinsic tendency of kidney disorders with reduced nephron mass to progress and the quest for renoprotective strategies are an ongoing focus of renal research. in adults, hypertension is not only a marker but also a major driving force of renal failure progression. renin-angiotensin system blockers (ace inhibitors and at receptor blockers) are preferred antihypertensive drugs in ckd due to their specific renoprotective effects beyond blood pressure (bp) control, mediated by their antiproteinuric, antiinflammatory and antifibrotic properties. it is less clear whether bp reduction to low-normal values has an additional salutory effect on gfr preservation. children suffer from a markedly different spectrum of renal diseases than adults, with a preponderance of hypo/dysplastic kidney malformations. hypertension and proteinuria are common but usually moderate. to elucidate the renoprotective efficacy of ace inhibition and strict bp control in children, the escape trial was launched by a consortium of european pediatric nephrologists. a total of children and adolescents with stage ii-iv ckd received a fixed dose of ramipril and were randomized to intensified (< th percentile) or conventional bp control ( th- th pct). h-bp, proteinuria and gfr were monitored over a -year period. h mean arterial pressure (map) was reduced by ramipril from to mm hg (i. e. from . to sds) on average. subsequently, mean map was lowered further to mm hg at months in the intensified arm, and maintained around mm hg ( . sds) in the conventional control arm (p< . ). on average . antihypertensive drugs were added to ramipril in the intensified and . in the conventional treatment arm (p= . ). treatment tolerability was excellent in both arms, with less than % dropouts due to side effects. in summary, ramipril was effective and well tolerated in children with ckd. it is possible and safe to target low-normal bp in children. final results regarding renal survival will be available in summer and presented at the ipna meeting. nephronophthisis and joubert syndrome: converging on convergent extension? nephronophthisis (nphp), an autosomal recessive cystic kidney disease, leads to terminal kidney failure in adolescence. nphp may be associated with retinitis pigmentosa (rp) in senior-loken syndrome (slsn) or with cerebellar vermis aplasia in joubert syndrome (jbts). we have identified by positional cloning genes as mutated in nphp. the gene product of nphp , nephrocystin- , acts in focal adhesion signaling. by positional cloning we detected mutations in the nphp /inversin gene as causing infantile nphp (type ) with association of situs inversus or rp. we demonstrated expression of nphp , in primary cilia of renal epithelial cells, supporting a new unifying theory for the pathogenesis of cystic kidney diseases (watnick et al. nature genet : , ) , stating that the products of all genes mutated in cystic kidney disease in humans, mice, or zebrafish are expressed in primary cilia, basal bodies, or centrosomes of renal epithelial cells (hildebrandt et al. nature rev genet : , ) . identification of nphp mutations in nphp type also revealed the cause of the renal cystic disease mouse model "pcy", for which treatment has been demonstrated. positional cloning of nphp led to the demonstration that its gene product, nephrocystin- , is conserved in c. elegans and expressed together with nephrocystin- in ciliated head and tail neurons of the nematode. the role of primary cilia function for retinal-renal syndromes was confirmed by identification of the novel nphp gene. recently, several signaling pathways have been implicated in the downstream signaling pathways that connect ciliary/basal body function to the renal cystic phenotype. these include the wnt signaling/planar cell polarity pathways, and the hedgehog signaling pathway. we implicated the planar cell polarity signaling pathway in nphp by positional cloning of mutations in the gene nphp /cep as causing joubert syndrome. abrogation of nphp function in zebrafish caused planar cell polarity (convergent extension) defects and recapitulated the human phenotype of joubert syndrome. further gene identification in nphp will result in the definition of functional networks of primary cilia, centrosomes, and planar cell polarity as they pertain to the pathogenic mechanisms of nphpassociated syndromes and other cystic kidney diseases. hnf b is a transcription factor that is expressed in bile ducts, intestine, pancreas and renal epithelia. germ-line inactivation of the mouse hnf β/tcf gene is embryonic lethal (e . ) due to defective differentiation of the extra-embryonic visceral endoderm. hnf β is later expressed in endoderm derivatives and in the mesonephros. to understand the function of hnf b at later stages of development and during organogenesis, we applied a conditional inactivation based on a (cre-loxp) strategy. with the use of a cre recombinase that is expressed in renal collecting ducts and henle loops (ksp-cre) we found that hnf b inactivation leads to polycystic kidney disease (pkd). this is reminiscent of the renal phenotype of patients carrying heterozygous mutations in tcf /hnf β. these patients suffer from maturity onset diabetes of the young type (mody ) and at the same time from renal cysts (renal cysts and diabetes or rcad). this cystic phenotype is linked to the defective expression of pkhd and pkd , two genes mutated in pkd patients. the cellular and molecular mechanisms underlying pkd are still poorly understood. it was recently speculated that planar-cell-polarity signalling (wnt) could be at the basis of cyst formation. maturation of nephrons during development is accompanied by a considerable lengthening of tubules. this process involves an intense proliferative phase without any increase in tubule diameter. interestingly, we discovered that the progeny of consecutive cell divisions are adjacent one another and oriented in parallel to the axis of tubules. this suggested that upon lengthening, cells divide according the tubule axis. in addition, d image reconstructions revealed that oriented cell division is due to the alignment of the mitotic spindle with the axis of the tubule. we hypothesized that oriented cell division could play an essential role in preventing tubular dilation during the massive proliferative phase that accompanies tubular elongation. indeed, our results indicated that both in ksp-cre-kidney-specific-hnf β-deficient pups and in the pck rats, lacking the expression of pkhd , the mitotic alignments were highly distorted. our results indicate that hnf β plays a crucial role in activating the expression of genes involved in the control of tubular size maintenance during tubular elongation. emerging evidence suggests that the intravenous injection of bone marrow-derived cells improves renal function after acute tubular injury. examination of human transplant biopsies of female kidneys that had been transplanted into male recipients have shown the presence of tubular cells that co-express the y chromosome and epithelial markers. however, controversy exists as to whether the protective effect is due to engraftment of the cells in the injured tubule or an endocrine/paracrine effect of the injected cells. our studies demonstrate that intravenous infusion of whole bone marrow from male mice into female recipients results in the appearance of significant numbers of y chromosome + cells in the kidney interstitium, and rare y chromosome + cells in the tubules. the majority of the interstitial cells express leukocyte markers such as cd . in addition, we have found that i. v. or i. p. injection of bone marrow stromal cells (msc, adherent non-hematopoietic marrow cells) into mice reduced the severity of cisplatin-or ischemia-induced aki. examination of these kidneys demonstrates that mscs enhance tubular cell proliferation and decrease tubular apoptosis after injury. examination of multiple tissue sections at or days after injury failed to reveal any examples of y chromosome cells within the tubules, and only rare examples of y chromosome cells within the renal interstitium. furthermore, exposure to conditioned medium from cultured mscs (msc-cm) significantly diminished cisplatin-induced death of cultured proximal tubule cells in vitro, while i. p. administration of msc-cm in the mouse markedly diminished the rise in bun associated with cisplatin injection. thus our data suggests that hematopoietic cells and their derivatives from adult bone marrow enter the kidney in response to injury where they are primarily localized to the interstitial space as inflammatory cells. in rare instances, these cells may differentiate into, or fuse with, tubular epithelial cells. in contrast, bone marrow mscs fail to enter the kidney in significant numbers, but can protect the endogenous tubular cells from toxic injury by secreting a factor or factors that limit apoptosis and enhance proliferation. renal hypodysplasia (rhd) is characterized by a reduced nephron number, small kidney size and disorganized renal tissue. a hereditary basis has been established for a subset of affected patients, suggesting a major role of developmental genes involved in early kidney organogenesis. gene mutations with dominant inheritance causing rhd, urinary tract anomalies and defined extrarenal symptoms have been identified in tcf (renal cysts and diabetes syndrome (rcad)), pax (renal-coloboma syndrome (rcs)), eya and six (branchio-oto-renal syndrome (bor)) for the most frequent of these syndromes. a recent study on a cohort of patients with rhd and consecutive renal insufficiency demonstrated that % of them had mutations in one gene encoding for a transcription factor. the majority of mutations were identified in tcf (hnf β) (especially in the subset with kidney cysts) and pax . this study demonstrates that subtle extrarenal symptoms in syndromal rhd easily can be missed. genetic testing in children with rhd should be preceded by a thorough clinical evaluation for extrarenal symptoms, including eye, ear, and metabolic anomalies. the presence of these anomalies increases the likelihood of detecting a specific genetic abnormality. in addition, mutations in genes that are usually associated with syndromes can occur in patients with isolated rhd. the ret receptor, its ligand gdnf and the co-receptor gfra play a pivotal role during early nephrogenesis and enteric nervous development. in humans, activating ret mutations cause multiple endocrine neoplasia, whereas inactivating mutations lead to hirschsprung disease. while ret deficiency also causes renal hypodysplasia (rhd) in the mouse model, genetic abnormalities in ret have not been characterized in human isolated renal malformations to date. the ret mutations, y f and s l, reportedly predisposing to medullary thyroid carcinoma (mtc) were found in one and six patients respectively in the same rhd cohort. none of the patients or their carrier relatives had clinical evidence of mtc at the time of the study. our findings suggest that ret mutations predispose to both mtc and rhd, with a low penetrance for either disorder. interestingly, a gdnf mutation was found in addition to a ret mutation and to an eya mutation in a patient with the branchio-oto-renal syndrome suggesting an oligogenic inheritance. mutations in clcn , the gene encoding the chloride/proton exchanger clc- , underlie most forms of dent's disease, an x-linked nephrolithiasis syndrome that is always associated with low molecular weight proteinuria. clc- belongs to the clc gene family of chloride channels and transporters and, in addition to other sites, is expressed in apical endosomes of the proximal tubule. in these vesicles, it co-localizes with the proton pump and with endocytosed proteins. previously thought to be a clchannel, it is now known to mediate electrogenic cl -/h + -exchange. this notion remains compatible with a role in supporting the acidification of endosomes by providing an electrical shunt for the h + -atpase. to clarify the pathogenesis of dent's disease, we created a knock-out mouse model. it displayed low molecular weight proteinuria due to a largely reduced endocytosis by proximal tubular cells (fluid-phase and receptor-mediated). the acidification of renal cortical endosomes was reduced in the ko. the failure of the pt to endocytose pth led to an increased luminal, but not systemic concentration of this hormone. this, in turn, resulted in hyperphosphaturia due to a retrieval of the phosphate transporter napi- a from the pt plasma membrane. nephrolithiasis can be explained by altered renal handling of pth and vitamind, all of which are secondary to the impaired endocytosis. there is an increased prevalence of nephrolithiasis in individuals with obesity, type ii diabetes, and the metabolic syndrome. in particular, uric acid constitutes a much higher percentage of stones in these patients compared to the general stone-forming population. we strived to examine the pathophysiologic connection between the metabolic syndrome and uric acid stones. in the vast majority of cases, the principal abnormality in uric acid stones is not hyperuricosuria but an excessively low urinary ph. uric acid nephrolithiasis is in fact a disease of 'urinary acidification' although there is no systemic metabolic acidosis in the classical sense because acid-base balance is achieved and no excessive acid is accumulated. however, the excretion of protons using low pk closed buffers rather than the high pk open buffer ammonia dictates a low urinary ph. since protonated uric acid has a sparingly low solubility compared to ionized urate, low urine ph promotes uric acid precipitation. thus uric acid nephrolithiasis is an innocent bystander of low urinary ph. the link between the metabolic syndrome and urinary ph as a continuous variable is explored by epidemiologic, human metabolic, and laboratory studies. in population-based studies in stoneformers, low urinary ph is associated with higher body weight. urinary ph is also lower with increasing number of features of the metabolic syndrome (waist circumference, high triglycerides, low high density lipoproteins, hypetension, hyperglycemia) and within each of the features, the severity of each parameter is inversely proportional to urinary ph. in metabolic studies in humans, low urinary ph is associated with low peripheral insulin sensitivity. when studied as in-patients on identical metabolic diets, patients with type ii diabetes and uric acid stone-formers have high net acid generation than normal volunteers. this alone lowers urinary ph although the reason for the elevated acid load is not clear at present. in addition to high acid generation, uric acid stone formers tend to use buffers other than ammonia to buffer protons in the urinary resulting in unduly acidic urine ph. when challenged with an acute acid load, the ammonium excretion response is markedly blunted in uric acid stone-formers. a similar urinary abnormally of acidic urine ph and underutilization of ammonia is seen in the zucker diabetic fatty (zdf) rat compared to their lean counterpart. these animals have peripheral insulin resistance, elevated serum free fatty acid and have significant steatosis in their kidneys. one abnormality in the kidney is reduced expression and activity of the na + /h + exchanger nhe which is the major transporter that excretes ammonium into the urine and its activity is stimulated by insulin. causality is supported by the fact that treatment of the animals with a thiazolidinedione partially reversed the fat infiltration, urinary acidification abnormality and reduced expressed of nhe . the direct effect of fat on the renal proximal tubule was tested in cultured cells. provision of fatty acids beyond the oxidation capacity of the tubule leads to dose-dependent impairment of nhe , generalized dysfunction and eventually cell death. a sub-cytotoxic dose of free fatty acid did not affect baseline nhe activity and expression but reduced the ability of insulin to activate nhe . in summary, the metabolic syndrome is associated with increase acid generation that is independent of diet. this increased acid load is effectively excreted by the kidney. failure to maximally utilize the ammonium buffer system results in lower urinary ph and titration of urate to its insoluble form as uric acid and results in uric acid nephrolithiasis. part of the pathogenic mechanism maybe lipotoxicity from fat infiltration of organs. uric acid nephrolithiasis is an "innocent bystander" which is a sentinel of a more generalized alteration in acid generation and excretion. genetic hypercalciuria recurrent kidney stone production is one of the most common diseases of the bipedal human condition, occurring in up to % of the population in western societies. unlike four-footed animals who likely perish in the wild from a selection disadvantage from a painful calculus, human beings continue to function, and have the ability to express the biologic defects repetitively that result in a stone. idiopathic hypercalciuria, where a specific gene defect has not yet been established, is a shrinking subpopulation of recurrent calcium stone formers, as specific mutations and functional polymorphisms of genes intimately or distantly related to calcium homeostasis arise from the sequencing of the human genome applied to clinical stone disease. other postulated mechanisms can be sought for in this manner as well, and may await larger population-based studies. the familial nature of nephrolithiasis is clear and robust for most calcium-based stone formers, and may have a gender-specificity for that inheritance. the role of environment in its expression remains controversial. the systemic nature of genetic hypercalciuria may be seen through its associated effects on skeletal health and biology. between - % of children with genetic hypercalciuria have abnormally low bone density measured by dual-energy absorptiometry that cannot be explained by correction for height or body mass. further, normalization of urinary calcium excretion with a variety of therapies is associated with improvements in bone density values over time. a proposal for re-classifying hypercalciuria pathogenetically will be presented, and linked to observational data across the world for successful therapeutic approaches. a call for a stone registry and more careful determination of etiology will be sought through the ipna congress. the systems that regulate blood pressure are plastic during development and can be permanently reset. experiments in animals show that it is surprisingly easy to produce lifelong changes in blood pressure by minor manipulations of the mother's diet before and during pregnancy. this phenomenon has been referred to as "programming". epidemiological and animal studies show that programmed effects operate within the normal range of growth and development, and influence the risk of hypertension, coronary heart disease and stroke in later life. a clinical study of people aged years from the helsinki birth cohort showed that two different paths of growth preceded the development of hypertension. people already diagnosed as having hypertension had small body size a birth and low weight gain from birth to two years but grew rapidly after two. at age eleven years their body size was around the average. as adults they tended to be obese and insulin resistant. a second group of people had not been diagnosed but their blood pressures were classified as hypertensive under current definitions. they were short at birth, had low weight gain from birth to two years and remained small after two. at age eleven years they were short and thin. as adults they tended to be overweight and have atherogenic lipid profiles. the first path of growth is similar to that which leads to coronary heart disease in this cohort. the second path is that which leads to stroke. this paper will present data on the maternal and placental influences through which these paths originate. nephron number is a key feature of the conceptual paradigm positing that cardiovascular and metabolic diseases that arise during childhood and adulthood have their origin in events that occur during fetal life. in mammals, nephrons are derived from a subset of cells resident within the metanephric blastema. blastemal cells participate in reciprocal inductive tissue interactions with the ureteric bud. these interactions induce the ureteric bud to grow and branch. in turn, ureteric bud branches induce discrete populations of the metanephric blastema to undergo successive transitions resulting in the formation of mature nephrons. a distinct population of metanephric blastema cells in the stroma modulates branching morphogenesis and nephrogenesis. identification of genes that control both branching morphogenesis and nephrogenesis is providing insight into the molecular pathways that could be targeted by environmental, nutritional and hormonal factors that control fetal programming. this lecture will highlight the morphologic and cellular events critical to renal branching morphogenesis and nephrogenesis, and the gene networks that regulate or counter-regulate these events. these gene networks will then be considered in the light of non-genetic factors that modulate their activities. it is now accepted that early life environment can modulate adult phenotype, including the blood pressure. the likely primary mechanism is epigenetic modulation of gene expression during a sensitive period of fetal maturation, but the pathogenesis of the later development of hypertension is unclear. participation by extrarenal factors such as central regulation and peripheral vascular function has been evoked; however, a strong body of experimental evidence suggests that the "setpoint" for renal regulation of na balance and extracellular volume is altered. because both humans and many experimental models with prenatally programmed hypertension appear to have a decrease in the total number of nephrons, impaired filtration of na has been hypothesized to be an important pathogenetic factor. more recent evidence has suggested that postnatal inflammation and accumulation of reactive oxygen species in the renal interstitium may contribute to the genesis of hypertension by upregulating distal nephron na transport. furthermore, the role of renal vascular function remains to be determined. the different mechanisms are not mutually exclusive; it is conceivable that both a prenatal "priming" and a postnatal "second hit" are required for hypertension to become manifest. j. ingelfinger epidemiological studies published in the late s by barker and his group -and since replicated in many populations -provide evidence of an inverse relationship between birthweight and risk of cardiovascular disease, hypertension, and renal dysfunction in adult life. both clinical studies and animal models have been used to investigate mechanisms underlying these observations [as cited in recent reviews. the concept that changes in the intrauterine milieu affect the growing fetus resulting in alterations in physiology and general health in later life has been termed perinatal programming or developmental origins of health and disease [dohad] . yet, despite a large and burgeoning literature about this phenomenon and its relationship to cardiovascular and renal disease, involved mechanisms remain elusive. maternal malnutrition or exposure to various medications or substances leads to an adverse in utero environment that may impair nephrogenesis, evident in experimental animal studies as well as in clinical reports in humans. nephron deficit at birth persists throughout life, creating "low glomerular endowment, " an important risk factor for hypertension and esrd in adulthood. for a number of years it has been hypothesized that nephron number may strongly influence blood pressure as well as susceptibility to renal disease in later life. recently clinicopathologic observations suggest that a relationship more directly. renal morphogenesis involves complex events in which many genes interact in the formation of the final kidney. when the normal pattern of nephrogenesis is interrupted, renal abnormalities may ensue. during renal development, two major events -ureteric bud (ub) branching and mesenchymal-to-epithelial transformation -greatly impact the outcome of renal morphogenesis. renal malformation accounts for approximately percent of childhood renal failure and represents the end result of failure of fundamental embryonic processes in ub and metanephric mesenchyme (mm) lineages. this presentation will review the data concerning renal responses to perinatal challenges as these occur and later evolve during childhood. we will consider the implications and the data available concerning screening, follow-up and management of at-risk persons. generation of oxidized lipoproteins in obstructive nephropathy -atherogenic or fibrogenic? children's hospital and regional medical center, division of pediatric nephrology, seattle, united states chronic kidney disease, regardless of etiology, is characterized by a relentless progression of fibrosis that gradually destroys the normal renal architecture, particularly in the tubulointerstitium. obstructive uropathy accounts for approximately percent of pediatric patients with chronic kidney disease (ckd) and end-stage renal disease (esrd). after post-natal relief of obstruction, the optimal treatment of children with obstructive uropathies remains unknown and for many the progression of ckd to esrd is inevitable. therapeutic options are limited by an incomplete understanding of fibrogenic pathways in the kidney. the major renal fibrotic pathways identified thus far can be broadly classified into those involved in transforming growth factor beta (tgf-b) activation, macrophage-mediated inflammation, angiogenesis, and extracellular matrix production/degradation. it is becoming increasing clear that key molecules have multiple roles in several of these pathways triggering fibroinflammatory events targeting specific cell types. oxidative stress represents an intersection of many of these fibroinflammatory pathways leading to cellular activation and tissue injury. oxidized lipoproteins accumulate in the circulation and renal interstitium in both experimental models and patients with ckd and esrd. many parallels have been drawn between atherogenesis and the pathogenetic mechanisms of progressive kidney destruction by fibrosis. although ckd is clearly associated with an increased cardiovascular risk, it is not clear whether oxidized lipoproteins amplify fibrogenic pathways in the kidney. research in our laboratory suggests that hypercholesterolemia increases injury severity in obstructed kidneys. scavenger receptors mediate the cellular effects of oxidized lipoproteins during atherosclerosis and activate both inflammatory and oxidative pathways. dietary and antioxidant therapies have clear benefits in animal models but limited efficacy in patients. our studies suggest that blocking key scavenger receptors leads to a significant attenuation of both oxidative and pro-inflammatory pathways during chronic injury by obstruction in hypercholesterolemic mice. interventions targeting scavenger receptor signaling may represent an alternative strategy to attenuate both the progression of ckd and cardiovascular disease. the resolution of injury and promotion of renal repair comprises a delicate balance between cell death and destruction of tissue architecture in relation to cell differentiation, maturation and extracellular matrix (ecm) remodeling. although many studies have focused on the cellular and molecular events leading to the development of renal fibrosis, less is understood about the process of renal repair and regeneration. this is despite the fact that the kidney has a significant capacity for regeneration and cellular replacement following acute damage. the present study describes the structural, functional, and expression profile analysis of endogenous renal repair and the regenerative potential of the kidney following reversal of ureteral obstruction (r-uuo) in the mouse. days after unilateral ureteral obstruction there is renal tubular cell loss, activation of an inflammatory cascade leading to widespread cortical interstitial fibrosis and the loss of normal medullary architecture. following to weeks after r-uuo there was marked tubular repair and regeneration of medullary components, ecm remodeling and decreased inflammatory cell infiltration. the structural repair observed at weeks post-release of ureteral obstruction was associated with a - % recovery of the glomerular filtration rate (gfr). expression profile analysis was performed to visualize patterns of gene expression that were differentially expressed in the repaired and remodeling areas following r-uuo. we are also interested in the regulation of cellular recovery and the processes involved in epithelial cell re-differentiation in regenerating tubules following injury. tubular epithelial cell cilia may play potential roles in directing the orientation of cell division and epithelial differentiation during the endogenous remodeling process. our results suggest that renal cilium lengthening may be an important factor in the response to injury and subsequent recovery of renal function. these studies propose that a lengthening of renal epithelial cilia increases their sensitivity to flow and reduces damaging epithelial dedifferentiation in the injured renal tubules. a better understanding of the key events involved in endogenous renal repair and remodeling may open the way to new interventions based on their manipulations aimed at acceleration of renal regeneration and prevention of scarring. soren nielsen has kindly agreed to present this topic, however was not able to submit an abstract. the final regulation of urinary k excretion in the fully differentiated kidney is accomplished in the distal nephron, including the cortical collecting duct (ccd), where cell k passively diffuses into the urine through apical k selective channels. the prevalence of the sk/romk channel and its high p o at the resting membrane potential has led to the belief that this channel mediates baseline k secretion. less easily detected is the bk channel which is characterized by a low p o at the physiologic resting membrane potential and [ca + ] i . bk channels are activated by membrane depolarization, elevation of [ca + ] i , and/or membrane stretch, and can be selectively blocked by iberiotoxin (ibx). we have reported that flow-stimulated net k secretion (jk) in the adult rabbit ccd is (i) blocked by ibx and (ii) associated with increases in net na absorption (jna) and [ca + ] i , leading us to conclude that bk channels mediate this process. recent studies have examined the acute and chronic regulation of bk channel-mediated flow-stimulated jk. we reported that flowstimulated jk requires an increase in [ca + ] i due to luminal ca + entry and er ca + release, microtubule integrity, and exocytic insertion of preformed channels into the apical membrane. channel expression is regulated long term during postnatal development and by dietary k intake. specifically, an increase in tubular fluid flow rate fails to elicit an increase in jk in the rabbit ccd until the th wk of postnatal life, coincident with appearance of immunodetectable bk channels, whereas flow-induced increases in jna and [ca + ] i in -wk-old ccds are "mature". a role for the bk channel in renal k adaptation has been suggested by the observation that dietary k loading leads to an increase in abundance of bk message in microdissected ccds with redistribution of immunodetectable channel proteins from an intracellular pool to the apical membrane. additionally, ccds isolated from k loaded animals demonstrate enhanced flow-stimulated jk compared to tubules from control fed animals. in sum, emerging evidence suggests that the bk channel plays a prominent role in distal k secretion in response to increases in urinary flow rate and dietary k intake. the late developmental appearance of this channel is compatible with the need of the growing animal to retain k early in postnatal life. recent advances in molecular genetics of hereditary hypomagnesemia substantiated the role of a variety of genes in human magnesium transport. this knowledge on underlying genetic defects helps to distinguish different clinical subtypes and gives insight into molecular components involved in magnesium transport. during the last four decades, numerous reports concerning inherited magnesium losing disorders have been published and their distinctive phenotypic features have been discussed. phenotypic characterization of affected individuals and experimental studies of appropriate animal models have contributed to a growing knowledge of renal magnesium transport mechanisms. the identification of the affected nephron segments, the different modes of inheritance and the observation of additional characteristic symptoms promoted a classification into different subtypes of inherited magnesium losing disorders. in general, primary magnesium wasting disorders are relatively rare. the prevalence of the more frequent entities, for example gitelman syndrome, has been estimated to be approximately : . . for most of the other disease entities, relatively few cases have been reported in the literature. depending on the genotype, the clinical course is sometimes mild or even asymtomatic. therefore, the disease prevalence might be underestimated for some of these syndromes. magnesium transport has been intensively studied in humans and various animal models leading to accepted concepts underlying the pathophysiology of the different forms of hypomagnesemia. however, the electrophysiological characterization of magnesium pathways has been complicated by unintentional simultaneous measurement of other cations so that the molecular correlates mediating mammalian magnesium transport components remained undefined. a different approach to study components of magnesium transport arises from genetic analysis of families affected with magnesium wasting diseases. linkage studies enabled the localization of several genes involved in hereditary hypomagnesemia and in the last decade, a number of genes have been identified by positional cloning. these genes have provided first insight into mammalian magnesium transport molecules. distal renal tubular acidosis may be inherited as an autosomal dominant or recessive trait. mutations in three genes -slc a , atp v b and atp v a -are associated with the various forms of disease, and give rise to a wide spectrum of clinical severity. in general, dominant mutations do not affect ion transport function per se and do not affect hearing, whereas recessive disease is characterized by loss of function and deafness. some unusual functional consequences of mutations in ae and a proteins are mistargeting and loss of protein-protein interaction respectively, and these will be discussed. the heart in pediatric nephrotic syndrome y. frishberg shaare zedek medical center, pediatric nephrology, jerusalem, israel in recent years, the molecular bases of several conditions which lead to steroid-resistant nephrotic syndrome (srns) have been identified. the common denominator shared by these clinical entities is that they all result from structural defects in the glomerular barrier, thus explaining their unresponsiveness to immunosuppressants. for instance, the congenital ns of the finnish type is caused by mutations in the nphs gene encoding nephrin. a recessive form of srns was found to result from mutations in nphs encoding podocin which is specifically expressed in podocytes. we have previously shown that a founder mutation in nphs (r x) is the prevalent cause of hereditary srns ( % of tested are homozygotes) among arab children in israel. interestingly, we noted that a number of patients who are homozygous for the r x mutation in podocin have a co-existing cardiac disorder. only a few case reports described an association between srns and cardiac defects. we questioned whether the glomerular-barrier disorders, which have been considered to be kidney-specific, have implications on other organ-systems. thus, we systematically reviewed the cardiac status of these srns patients at the time of diagnosis while they had normal blood pressure and preserved renal function ( ). cardiac anomalies were detected in % of children, the most common of which were cardiac hypertrophy and pulmonary stenosis. analyzing two control groups enabled us to conclude that cardiac disorders in homozygotes for mutations in nphs cannot be attributed to an association by chance or to a state of persistent ns. because human podocin mrna is expressed in fetal heart, we hypothesize that it may have a role in normal cardiac development and this will be an issue of further investigation. this is the first study showing a role for podocin in extra-renal tissues and therefore recommends early cardiac evaluation for timely medical management. cvd is the world-wide biggest obstacle to long-term survival of children and adolescents with ckd. mortality from cvd is excessively high on dialysis and continues to be a threat after renal transplantation. early diagnosis of the individual risk for cvd would enable preventive measures on an individual basis. however, prospective studies with hard end points -cardiac events -are difficult if not impossible to conduct in children and adolescents. on the other hand, the known high morbidity and mortality in elderly dialysis patients may largely result from pre-existing comorbidity (advanced atherosclerosis has been demonstrated in this age group at initiation of dialysis). for this reason, investigations in patients with childhood onset ckd may provide a diagnostic window to study the pathogenesis of cardiac and vascular changes in subjects without comorbidities. several studies using non-invasive measurements of surrogate markers for cvd have demonstrated a pattern of early systemic cvd, including changes in intima-media thickness (imt) of conduit arteries (aorta, a. carotis) and muscular arteries (a. femoralis), altered function of peripheral resistance arteries (venous occlusion plethysmography) and abnormalities in the heart (echocardiography). patients show a significant decrease in post-ischemic vascular reactivity with evidence of vascular stiffness and frequently have extraosseous calcifications often involving coronary arteries and heart valves. importantly, these studies have found little evidence for correlations with classical risk factors (except hypertension), but with abnormalities of calcium and phosphorus metabolism and their therapy, including the intake of active vitamin d preparations and calcium-containing phosphate binders. thus, patients with childhood-onset ckd are at high risk to develop systemic cardiovascular changes, which may represent a new disease originating from the survival of ckd, a previously deadly disease, and interventions for the prevention of renal osteodystrophy. this therapeutic challenge needs to be addressed with high priority to enable long-term survival of children with ckd. while their mere existence is still questioned by some investigators, lipid rafts have recently gained a large amount of attention because of their apparent involvement in various cellular processes, including signaling, membrane trafficking, polarization, and endo-as well as exocytosis of proteins as well as pathogens. membrane rafts have been defined as small ( - nm) heterogeneous, highly dynamic, sterol-and sphingolipid-enriched domains that compartmentalize cellular processes and that can sometimes be stabilized into larger platforms by protein-protein or proteinlipid interactions. rafts are of special interest for pediatric nephrologists for two reasons: . they play a critical role in immune cell activation, especially in the formation of the immunological synapse (is), and thus in many important disease processes affecting our patients, including -but not limited to -transplant rejection. beyond their participation in is formation, rafts also facilitate signaling through other immune cell receptors, such as the interleukin- receptors, where they may ascertain cytokine selectivity and specificity. . equally important, rafts serve as essential site for proper interactions between nephrin and podocin, thus establishing the integrity of the glomerular filter. general aspects of raft biology as well as their role in immune cell signaling will be reviewed in more depth in this presentation. raft involvement in glomerular filter formation and especially genetic aspects relevant to disturbances of this involvement and of the associated integrity of the filter, as seen in hereditary nephrotic syndromes, are discussed in subsequent presentations in this symposium. reports of familial forms of fsgs date back to , with the observation of an autosomal recessive disease primarily within the finnish population. it is characterized by massive proteinuria in utero, with up to to grams of protein loss per day. nphs encodes a gene product termed nephrin that localizes to lipid rafts within the slit diaphragm of the podocyte. steroid-resistant nephrotic syndrome (srns) is an autosomal recessive nephrotic syndrome and manifests between months and years of age, rapid progression to esrd, and with few cases of recurrence after renal transplantation. the gene product is podocin (nphs ), located on q - . podocin most likely functions in the structural organization of the slit diaphragm and regulation of its filtration function. it has been shown to interact in vivo with both nephrin and cd -associated protein (cd ap), a cytoplasmic binding partner of nephrin. mutations in the alpha-actinin gene (actn ), localized to chromosome q have been associated with autosomal dominant fsgs, characterized by adult onset disease of variable severity and rate of progression to esrd. fractions of the mutant protein have been shown to form large aggregates within podocytes ultimately compromising the function of the normal actin cytoskeleton, both through its abnormal function and toxic accumulation. recently, a disease-causing mutation for hereditary fsgs has been localized to chromosome q - , and identified as the transient receptor potential cation channel, subfamily c, member (trpc ). the missense mutation causes a highly conserved proline in the first ankyrin repeat of trpc to become a glutamine at position (p q). the trpc p q mutation causes increased and prolonged calcium transients in transfected cells. the mutant channel also significantly enhances cation signals triggered by at receptor activation. biotinylation and immunostaining studies reveal that the mutation also appears to cause mislocalization of the ion channel to the cell surface. whereas previously reported mutations such as nphs , nphs and actn have emphasized the importance of cytoskeletal and structural proteins in glomerular diseases, trpc related fsgs suggests an additional mechanism for renal disease pathogenesis. knowledge of trpc mediated calcium entry into cells may offer unique insights into therapeutic options for glomerular diseases. t. huber university hospital, department of nephrology, freiburg, germany the sense of touch relies on the ability of specialized sensory cells to convert mechanical stimulation into ionic currents. mechanoreceptor cells respond to external force by opening ion channels. recent findings highlight now a potential role for the mechanosensitive ion channel trpc at the glomerular filtration barrier. trpc localizes to the slit diaphragm and mutations of trpc cause familial glomerular disease. mutations of the phb-domain protein podocin are the most common cause of hereditary nephrotic syndrome and we demonstrate that podocin and mec- , the closest homologue of podocin in caenorhabditis elegans, bind cholesterol to regulate the activity of associated ion channel complexes: deg/enac channels for mec- and trpc channels for podocin. both the mec- -dependent activation of mechanosensation in c. elegans and the podocin-mediated activation of trpc channels requires cholesterol. our data suggest that the recruitment of cholesterol by podocin and mec- to ion channels plays an important role in regulating their activity. these findings promote the concept that podocin, similar to the function of mec- , may be part of a mechanosensitive protein complex at the slit diaphragm of podocytes. isidro salusky has kindly agreed to present this topic, however was not able to submit an abstract is there a role for bisphosphonates in pediatric bone disease? f. santos hospital universitario central de asturias, universidad de oviedo, pediatria, oviedo, spain bisphosphonates are being increasingly and successfully utilized to prevent bone fractures and treat bone pain in children with severe osteoporosis from different origins. a largest experience has been accumulated with the administration of cycles of intravenous pamidronate in children with osteogenesis imperfecta. in addition, to the bone resorption inhibition mediated by their effects on osteoclasts, bisphosphonates given in large doses inhibit normal and ectopic mineralization. thus, bisphosphonates have also been used in children with hypercalcemia and in the treatment of calcinosis and heterotopic ossification, bisphosphonates have been administered to renal transplanted adults to prevent or treat bone loss induced by chronic administration of glucocorticoids and might also be useful in the management of urolithiasis in selected hypercalciuric patients. the potential clinical utilization of bisphosphonates in the prevention and treatment of vascular calcification in patients with chronic renal failure is now being explored, although no data on children in this clinical setting are available. a number of questions as to the precise clinical indications to start bisphosphonates' administration, the type of bisphosphonate to be used, the duration of the treatment, the best way to monitor its effectiveness and the risk of longterm toxic effects remain to be answered. water is the solvent in which all metabolic reactions occur. body water moves between compartments with diverse compositions that are separated by semi-permeable lipid membranes. water exchanges also occur between maternal and fetal blood separated by several layers of tissue, the so-called placental membranes. the fetus appears to be dependent on placental flow and perfusion pressure for the bulk of his water requirements, and the prostanoids play a significant role in the control of ureteroplacental and umbilicoplacental blood flows. osmotic and hydrostatic forces control placental water flux. the amniotic fluid (af) appears early during gestation and its volume increases rapidly. the net af volume turnover approximates % per day. major sources of af production are represented by fetal lungs secretions, and by fetal urine. the af is initially isotonic, and becomes hypotonic when significant amounts of dilute urine are produced by the fetus. disposal of water is effected by fetal swallowing of af and by the intramembranous (im) pathway, that is the route of absorption between the fetal circulation and the amniotic cavity. this route appears to play an important role in the overall regulation of af volume and composition. the fact that water crosses the im pathway in excess of solutes suggests a role for aquaporin water channels in allowing this transport. circumstantial evidence indicates that the im water flow is regulated by aquaporin . homeostatic changes in placental permeability could thus be up or down-regulated by the number of aquaporin water channels in the membrane. systemic lupus (sle) is a multigenic and multifactorial disease, characterized by b lymphocytes polyclonal activation with decreased tolerance, autoantibodies production and immune complexes formation. dna was initially thought to be the mayor auto-antigen, however, it is not immunogen and injection of dna-anti dna does not induce lupus nephritis. the complex of dna and histones (nulceosome) is provided with a positive electrical charge which favours the binding to heparansulphates in the gbm. in sle high levels of nucleosomes are present in circulation due to accelerated lymphocytes apoptosis or defective removal of apoptotic cells. lupus nephritis (ln) is consequent to deposition of immune complexes, activation of lymphomononuclear cells and reactivity of renal cells. the who classification of lupus nephritis has been recently reviewed by the isn/rps. the new classification takes into account a distinction between forms without endocapillary hypercellularity (mesangial or subepithelial deposits) and others with endocapillary hypercellularity (involving less or more than % with segmental or global distribution). prognosis and treatment of ln need a flexible therapy, tailored on histological picture and clinical data. steroids must be given at high doses for induction therapy but have drawbacks of heavy morbidity and mortality. the addition of immunosuppressive drugs improves the therapeutic index. the nih protocol used cyclophosphamide (cyc) pulses in severe ln (monthly pulse for months followed by quarterly pulses for year). more recent studies, comparing low with high doses cyc pulses, failed to prove a significantly different effect. for maintenance therapy of ln, mycofenolate mofetil may be a good alternative to cya or aza. rituximab, a chymeric monoclonal antibody anti cd , which selectively and profoundly depletes b lymphocytes, has provided very interesting results in sle with poor response to classical therapy or in relapse. the possibility of rotating agents with different side effects may allow to lower the doses of steroids, to reduce drug-specific morbidity, and to improve the compliance of patients. efforts should be done to minimize steroids and cyc which are very effective but are the main responsible of invalidating and even lifethreatening complications. for half a century now, physicians have tried to classify vasculitic syndromes. classification of vasculitides is required to put in perspective the pathogenesis and therapeutic advances and to provide a uniform language, given the variation in the epidemiology of these diseases. the "american college of rheumatology" criteria have been used for classification and the chapel hill consensus criteria for definition purposes in children as well however they are based totally on adult criteria. taking into account the differences in children and the new developments in medicine a group of pediatricians have aimed to revise the classification of vasculitic syndromes encountered in children. the consensus group consisted of a multinational panel of experts who were pediatricians, pediatric rheumatologists and pediatric nephrologists. the delphi and nominal group techniques were used. this project has provided classification criteria for henoch-schönlein purpura, childhood polyarteritis nodosa, wegener granulomatosis and takayasu arteritis. this was an important task since appropriate classification criteria for vasculitis in children has been missing for far too long. we hope that the international and multispecialist composition of the expert group involved will facilitate the applicability of this classification for most vasculitic diseases in children seen around the world and will meet the needs of pediatricians. these criteria are now to be validated using a large registry for childhood vasculitides. anti-neutrophil cytoplasm antibodies (anca) are well established as a diagnostic marker for small vessel vasculitis, including wegener's granulomatosis and microscopic polyangiitis. there is increasing evidence that anca are directly involved in the pathogenesis of vascular inflammation in these disorders. in clinical studies, there is a clear relationship between levels of anca and the activity and extent of disease, and anca positivity confers an increased risk of relapse. rising titres of anca predict relapse, and two studies have shown that pre-emptive treatment of those with rising titres can prevent relapse. of great interest is the recent report of a newborn child who developed glomerulonephritis and lung haemorrhage after transplacental transfer of anca. in vitro experiments have shown that anca can activate cytokine primed neutrophils to release oxygen radicals, enzymes and inflammatory cytokines. this is achieved through both direct f(ab) binding and fc receptor engagement. in co-culture, anca can induce neutrophil mediated killing of endothelial cells. in flow chamber studies, anca can induce neutrophil adhesion and transmigration across endothelial cell monolayers. more recently, anca have been shown to be pathogenic in experimental models of disease. high titre anti-mpo antibodies induced by immunisation of mpo deficient mice can transfer glomerulonephritis and vasculitis to naive recipients. immunisation of rats with mpo induces anti-mpo autoantibodies which lead to crescentic glomerulonephritis. intravital microscopy in this model confirms that anca can induce leukocyte transmigration and microvascular haemorrhage in vivo. however, many questions remain unanswered. some patients may have high levels of anca without disease activity, and others may have typical disease without detectable anca. it seems likely that t cells may be involved, not only in providing help for anca synthesis, but also in mediating tissue damage. it is also possible that an additional inflammatory stimulus, for example an infection is required, to enhance the inflammatory effects of anca. greater understanding of the role of anca in vascular inflammation will hopefully lead to safer and more effective approaches to treatment. hacettepe university, faculty of medicine, department of pediatric nephrology, ankara, turkey the therapy of vasculitic syndromes poses a problem for the caring pediatrician. the treatment of anca associated vasculitides will be presented to cover microscopic polyangiitis, wegener granulomatosis and churg strauss syndrome. treatment of all anca-associated diseases are similar. steroids and cyclophosphamide are the mainstay of induction treatment. in severe patients with kidney involvement steroids can be given in the form of intravenous methylprednisolone for - days ( - mg/kg/d, max. gr), followed by daily oral corticosteroids ( . mg/kg/d, max. mg/d). cyclophosphamide may be given at mg/kg/d p. o. or monthly iv pulses . gr/sqm for at least months. for maintenance treatment there are again many different regimens for oral corticosteroids. along with corticosteroids for maintenance regimen there are a number of protocols suggesting the continuation of cyclophosphamide. the cycazarem study has shown that the replacement of cyclophosphamide with azathioprine at months was also as effective for disease control. methotrexate has also been shown to be an alternative for maintenance treatment. treatment of the childhood polyarteritis nodosa (pan) with systemic disease is similar to that of anca-related vasculitides. there are a number of non-anca associated vasculitides in childhood. the most frequent in childhood are henoch-schönlein purpura (hsp), kawasaki disease (kd) and takayasu arteritis (ta). the treatment of hsp is usually symptomatic. however, for severe kidney involvement with extracapillary proliferation and rapidly progressive disease severe immunosuppressive treatment is indicated. triple treatment with steroids, cyclophoshamide and dipyridamole have been given in various series. for kd intravenous immunoglobulin at a dose of g/kg still remains the first choice of treatment along with salicylates. for ta therapy depends on the extent of vessel invovlement: severe disease necessitates steroids and cyclophosphamide whereas for less intensive vessel involvement methotrexate and steroids may suffice. treatment period depends on the actiivty of the disease. lb. zimmerhackl haemolytic uraemic syndrome (hus) is the most common cause of acute renal failure in children. the syndrome is defined by the triad of microangiopathic haemolytic anaemia, thrombocytopenia and acute renal failure (creatinine over the th percentile). world wide hus is increasing. in a german/austrian multicenter study we follow children with hus occurring in the years to . year follow-up data are now available www. hus-online. at. from this study the following results are obvious. hus affects predominantly children of kindergarten age. the median age at onset is , years. the majority of hus is of infectious origin. shigatoxin (stx) producing escherichia coli (stec, ehec) are present in over % of patients. the predominant shigatoxin type is type ii. hus is classified into two clinical subgroups. "typical" hus usually occurs after a prodrome of diarrhoea (d+hus), and "atypical" hus (ahus), which is not associated with diarrhoea (d-hus). the majority of d+hus worldwide is caused by ehec type o : h , which is transmitted to humans via different routes. however non-o groups are emerging and are predominant in europe. transmission of disease in elder patients is predominantly through food poisoning and direct contact to farm animals. in infants and small children direct transmission from human to human seems to be more likely. currently there are no specific therapies preventing the disease course. anti-shigatoxin antibodies are being tested by several companies. if this may prevent hus is open to study. otherwise the therapy at present is symptomatic. parenteral volume expansion before hus in patients with positive stx or ehec stool culture may counteract the effect of thrombotic process before development of hus and attenuate renal injury. use of antibiotics, antimotility agents, narcotics and non-steroidal anti-inflammatory drugs should be avoided during the acute phase in particular during the prodromal phase. from our own study the prevention is best done by preventing primary ehec infection. however, patients with severe course and long term sequelae should be screened for genetic abnormalities in the complement system. if auto antibodies against complement proteins or the vwf play an relevant role is under discussion. patients under one year of age at onset have a significant worse outcome and should be kept under surveillance. patients below month of age are very likely to have an inborn error of complement or vwf and should be tested specifically. the european registry on hus and related disorders may help to determine these abnormalities: www. haemolytic-uraemic-syndrome. org. in order to improve long term outcome of these patients, increased awareness and an european (international?) task force is mandatory. in adults with chronic kidney disease, protein-energy malnutrition and inflammation are risk factors for death and accelerated cardiovascular disease. the "malnutrition-inflammation-cachexia syndrome" (mics); anorexia, increased basal metabolic rate, and loss of lean body mass is associated with low serum albumin, decreased protein intake, elevated c-reactive protein, and low serum cholesterol levels in adults. in children, mics manifests as growth retardation. clinical research focusing on the evolution of mics in pediatric ckd to understand its causes and consequences and how nutritional interventions alter its course may be the key to improving survival in ckd. baseline cross sectional data from the ongoing chronic kidney disease in children study, of children (n= ) aged - yrs (mean= . yrs) with estimated gfr ± ml/min/ . m (mean iohexol gfr ml/min/ . m ) shows substantial growth retardation in ckd with median height percentile= . greater height deficits are seen at lower gfr's. symptoms of decreased appetite and nausea are reported by % and % of those with gfr < respectively. mean ldl cholesterol is lowest in those with gfr < ( vs mg/dl in gfr ± ml/min/ . m group). serum albumin declines as serum creatinine increases (r=- . ). unlike previous reports in adult ckd, increases in crp were not associated with lower gfr at baseline. further exploration of the mics in pediatric ckd will be presented. the causes of growth failure in pediatric patients with chronic kidney disease (ckd) are multifactorial. it is an open question as to which factors play a key role in diminishing physical growth. it is also unclear which mechanisms may become pace makers for the therapeutic improvement of growth. furthermore, growth failure in children with ckd affects total body height, body proportions and composition as well as organ development. growth failure may also lead to disproportion which can only be identified by detailed anthropometric measurements. we were able to demonstrate that ckd patients have a specific age-dependent pattern of growth and distinct changes in segmental growth (trunk, arm and leg length) from birth to adolescence. leg growth in relation to other parameters of linear growth showed the most dynamic growth changes and emerged as the best indicator of growth in children with ckd. trunk growth had little synchronicity with leg growth. furthermore, we found that anthropometric measurements can be used as a diagnostic tool in distinguishing different sub-groups of ckd patients, for instance, children with syndromic ckd. in the heterogeneous group of patients with focal and segmental glomerulosclerosis, patients with schimke's disease were found to have a dramatically decreased sitting height/leg length ratio. as the disturbance in growth of ckd patients is a marker of the severity of the disease and of the quality of renal care, the annual analysis of growth failure from early childhood to adolescence should be used as a landmark information of the quality of medical care and as a helpful tool in differential diagnosis and of specific courses of ckd in sub-groups of patients. for example, patients with congenital or acquired renal diseases, dialyzed or transplanted patients and in gender differences. in addition, anthropometric measurements are able to identify specific growth patterns in children with ckd, which should be considered in the assessment of treatment efficacy such as in rhgh therapy. b. tönshoff, l. weber, b. höcker university children's hospital, st department of pediatrics, heidelberg, germany it is currently under debate whether steroid avoidance or late steroid withdrawal provides the best overall risk-to-benefit ratio in pediatric renal transplantation. late steroid withdrawal has the advantage over steroid avoidance that immunological high-risk patients and those with unstable graft function can easily be identified beforehand and be excluded from steroid-free immunosuppression. in order to further validate this approach, we performed a prospective randomized open-label multicenter trial in low-risk pediatric renal transplant recipients ( f, m; mean age . yrs; range, . to . ) on csa (target trough level - ng/ml), mmf ( mg/m per day) and methylprednisolone ( ) ( ) mg/m per day), who were randomly assigned > year posttransplant to continue steroids or to withdraw over a period of months. an interim analysis was performed at a mean observation period of mo after study entry; patients had been followed for at least mo. there were drop-outs ( reversible acute rejection episode, switch to sirolimus and to tacrolimus). transplant function as assessed by calculated ccr remained stable in both groups, no graft was lost. prepubertal children off steroids gained relative height from baseline - . ± . sds to - . ± . sds after yrs, while patients on steroids lost relative height (- . ± . sds at baseline, - . ± . sds after yrs); a comparable pattern was observed in pubertal patients. the standardized body mass in patients off steroids declined from . ± . sds at baseline to . ± . after yrs (p< . ), while it tended to increase in patients on steroids (baseline, . ± . sds; after yrs, . ± . ). the rate of adverse events, mainly infections, was comparable in both groups. patients off steroids required less frequently antihypertensive medication ( %) than patients on steroids ( %). a significant reduction of serum cholesterol (by %) and triglycerides (by %) in response to steroid withdrawal was observed. conclusions: this interim analysis indicates that late steroid withdrawal in selected pediatric renal transplant recipients on csa and mmf is safe, allows catch-up growth and ameliorates cardiovascular risk factors. at the ipna meeting, full month outcome data of all patients will be available. u. frei, j. noeldeke renal transplantation faces two major challenges: the organ shortage resulting in extended waiting times and an aging population resulting in increased death with a functioning graft. the eurotransplant senior program (esp) allocates kidneys within a narrow geographic area from donors aged > years to recipients > years regardless of hla. this analysis investigates the impact of the esp on waiting time, graft and patient survival. the esp group (n= , old to old) was compared to two groups allocated via the eurotransplant kidney allocation system (etkas) with either similar donor age [old to any (o/a), donor age > , n= ] or recipient age [any to old, (a/o), recipient age - , n= ]. all patients were transplanted between and . since initiation of the esp ( ), availability of elderly donors doubled and waiting time for esp patients decreased. local allocation led to shorter cold ischemia time ( . vs. > . hours, p< . ) and less delayed graft function (dgf, esp . % vs o/a . %, p= . ) but - % higher acute rejection rates. importantly, graft and patient survival were not negatively affected by the esp allocation scheme. the esp age matching of elderly donors and recipients is an effective allocation system for organs from elderly donors. the effect of age matching on the duration of the waiting time a. rahmel, m. slot, j. smits eurotransplant international, leiden, the netherlands in eurotransplant the proportion of children, i. e. patients aged under the age of at time of registration, with end-stage renal disease (esrd) on the renal waiting list amounts to only . %. despite this small proportion the eurotransplant kidney allocation system (etkas) specially addresses pediatric transplant candidates. in order to increase their chances of receiving a transplant in time children are assigned via etkas extra points for hla matching and receive an age bonus. in order to evaluate this allocation policy, the chances for receiving a kidney for patients in different age groups were evaluated. for the cohort of patients registered in the year , a year followup was obtained. for patients aged under at time of registration [n= ] % and % received a kidney from a post-mortem donor, within year and years after listing. for children aged to [n= ] these rates were at and years after listing % and %, and for children between age and [n= ] % and % respectively. adult patients were less likely to receive an organ: % and % of patients aged between and were transplanted within and years after listing. senior esrd patients can benefit from the eurotransplant senior program (esp), their chances for a transplant were % and % within and years, respectively. the life span of a renal allograft is limited in time. in the eurotransplant experience % of the post-mortem kidneys used for transplantation in children failed within years, compared to % for the living donor renal transplants (rtx). donor age is an important factor associated with long term renal allograft function. age matching between donor and recipient is hampered by the low number of pediatric donors. in the period - , heart beating kidney donors aged under were reported and used for rtx, donors were between and years of age, and donors were between and years old. in the same period adult donors were reported and used for transplantation. in the period - , % of the pediatric donor kidneys ultimately served a pediatric recipient. to improve the allocation of pediatric donors to pediatric recipients, et is in the process of implementing a rule giving pediatric recipients priority in case of pediatric donors. gender and sex hormones are playing a central role in the incidence and progression of different renal diseases. vascular tone, endothelial function and immune response are influenced by gender. in renal transplantation ischemic injury is always present. females are more resistant to postischemic renal failure than males. following ischemia/reperfusion injury renal vascular resistance decreases, allowing fast restitution of blood flow and oxygen supply in females. additionally, stabilization and preservation of tubular function following ischemia is achieved by the protection of na+/k+ atp-ase and heat shock protein activity contributing to the observed gender differences. posttransplant immune reactions also differ between genders. female gender predisposes to more severe acute rejection following kidney transplantation, partly due to differences in the effectivity of immunosuppressants used. ineffective immunosuppression in females, as well as different cytotoxicity profile of the drugs is contributing to more prone immune reactions shortly after transplantation resulting in more severe acute rejection. in contrast, similar to the slower deterioration of other renal diseases, progression of chronic graft failure is less pronounced in females in experimental and clinical settings. estradiol decreases profibrotic processes, preserves endothelial function and modifies influx of immune cells into the graft. the fine balance between alloantigen dependent immune reactions and alloantigen independent factors and its impact on longterm graft function is modified by gender. new evidences supporting the significance of sexual dimorphism following kidney transplantation may present the base of gender modified therapeutic approaches in the future. iga nephropathy: aetiology, incidence, and geographic distribution iga nephropathy (igan) is characterized by mesangial deposits of iga, proliferation of mesangial cells and expansion of matrix. the accumulation of iga and complement fractions within glomeruli was initially ascribed to deposition of iga immune complexes (igaic) due to mucosal immune response with predominant iga synthesis. this hypothesis has offered an explanation of the relationship between infections of the upper airways and gross hematuria. high levels of igaic have been detected in - % of patients, mostly of polymeric iga , and polymeric iga are detectable in renal deposits. this observation is consistent with hypothesis of either bone marrow or mucosal origin. however, no specific viral or alimentary antigens have been found in mesangial deposits, and the qualitative properties of polymeric iga have rather become of interest, particularly the glycosylation pattern of iga . human iga is o-glycosylated with carbohydrate chains of n-acetyl galactosamine (galnac) and galactose (gal) which may be covered with sialic acid (neu ac). patients with igan exhibit circulating iga with reduced gal and/or neu ac and increased exposure of n-galnac. such aberrantly glycosylated iga can circulate in monomeric form or participate in the formation of autoaggregates/true immune complexes. it likely escapes clearance by hepatic receptors and has a preferential renal deposition by virtue of enhanced reactivity with the mesangial matrix components. the role of a triggering event has not ruled out. in recent reports, antigens of bacterial origin and the secretory tract component have been found in renal deposits, making scientists reconsidering again the role of bacterial infections. tonsils recurrent infections may provide a suitable aetiology for igan, and the effect of tonsillectomy on the long term outcome of igan is under evaluation. the prevalence of igan varies in different areas, due to ethnic and environmental factors, being particularly frequent in mediterranean europe, northern europe, asia and australia. it is still debated whether differencies in frequency, clinical features and disease progression among patients with igan from different countries are actually due to uneven distribution of this diseases or these discrepancies are due to the different criteria for performing renal biopsy. definition. igan is characterized by the presence of dominant (or codominant) mesangial deposits of iga on immunofluorescence microscopy, frequently with c and sometimes with igg or igm. classification. the glomeruli display a broad spectrum of histologic changes, related in part to the differences in the indication for the biopsy of the referring nephrologist. a number of classification systems have been used to describe the histologic manifestations of igan. two will be referred to here: the system of m. haas (ajkd : - , ): ) minimal histologic lesion -the glomeruli exhibit no more than a minimal increase in mesangial cellularity, without segmental sclerosis or crescents. ) fsgs-like -the glomeruli display focal segmental sclerosis in a pattern resembling primary focal segmental glomerulosclerosis, with at most a minimal increase in mesangial cellularity and no crescents. ) focal proliferative glomerulonephritis (gn) - % or fewer of the glomeruli are hypercellular. the increase in cellularity may be limited to mesangial areas, or there may be obstruction of glomerular capillaries by proliferated endocapillary cells. crescents may be present. ) diffuse proliferative gn -more than % of glomeruli are hypercellular. the hypercellularity may be segmental or global, and crescents may be present. ) advanced chronic gn - % or more of the glomeruli are globally sclerotic, and/or there is % or more tubular atrophy or loss in the cortex. the system of s. emancipator (heptinstall's pathology of the kidney, lippincott-raven, philadelphia, , pp - ) : a -normal/minimal glomerular lesions b -focal mesangial proliferation c -diffuse mesangial proliferation d -focal segmental endocapillary proliferation superimposed on mesangial proliferation d -focal segmental endocapillary proliferation alone e -diffuse endocapillary proliferation f -diffuse extracapillary proliferation (crescents in > %), with or without endocapillary proliferation g -glomerulosclerosis (> % of the glomeruli are sclerotic) h -unclassifiable or combined lesions diffuse proliferative gn (c) and focal proliferative gn (d ) are the major patterns of expression of glomerular injury. indicators of a poor outcome. these include a high proportion of glomeruli with crescents, numerous sclerotic glomeruli, interstitial fibrosis and tubular atrophy, extension of the iga deposits into the peripheral glomerular capillary walls, and hyaline arteriolosclerosis. differential diagnosis. mesangial iga deposits are present in henoch-schönlein nephropathy, and may be present in lupus nephritis, chronic liver disease, coeliac sprue, certain dermatologic diseases, and some rheumatologic diseases. iga nephropathy [igan] is defined by the presence of mesangial iga, but otherwise the histopathological and clinical features are very variable. we do not yet know sufficient about pathogenic mechanisms to understand whether igan is a single disease. although traditionally called an 'immune complex' disease there is no direct evidence that mesangial iga deposition in igan occurs through classical antigen-antibody interactions. mesangial cells do carry receptors for iga, which may play a key role in iga deposition and subsequent injury, but these are not yet fully characterised. mesangial iga in igan is polymeric iga . there is no evidence of mucosal immune system overactivity, indeed there seems to be underproduction and abnormal t cell control of mucosal iga production, along with overproduction by the marrow of iga iga has a hinge region peptide structure which is a site for o-glycosylation. in igan circulating and mesangial iga both have abnormal o-glycosylation at the hinge region. the same defect is seen in henoch-schönlein purpura only when there is renal involvement. the glycosylation defect is not due to abnormal peptide structure of the hinge; the possibility that there is reduced activity of the key enzyme b , galactosyltransferase in b cells or plasma cells has not yet been confirmed. alternatively the glycosylation changes may reflect a shift in the production of mucosal type of iga to the marrow. while iga deposition is caused by disease mechanisms specific to igan, subsequent inflammatory and fibrotic events are probably driven by mechanisms common to other chronic glomerular disease. in some patients iga deposition is not followed by inflammation, in others inflammation resolves without fibrosis. cytokine and growth factor production by mesangial cells is a sufficient explanation for glomerular inflammation and fibrosis. however little is yet understood of any genetic or environmental influences which protect some patients from progressive renal injury. our recent controlled trials by the japanese pediatric iga nephropathy treatment study group demonstrated that treatment of children with severe iga nephropathy with prednisolone, azathioprine, heparin/warfarin, and dipyridamole for years early in the course of the diseaseprevents immunological renal injury and progression of the disease. the majority of patients with iga nephropathy in our series are diagnosed early in the course of the disease, and the asymptomatic period before the discovery of urinary abnormalities is short. early diagnosis and early treatment is very important in iga nephropathy. . combined therapy for severe childhood iga nephropathy (j am soc nephrol : [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ) . seventy-eight children with newly diagnosed iga nephropathy showing diffuse mesangial proliferation were randomly assigned to receive either the combined therapy of prednisolone, azathioprine, heparin-warfarin, and dipyridamole for two years (group ) or the combination of heparin-warfarin and dipyridamole for two years (group ). urinary protein excretion was significantly reduced in group patients, but remained unchanged in group patients. the percentage of glomeruli showing sclerosis was unchanged in group patients, but significantly increased in group patients. . steroid treatment for severe childhood iga nephropathy (clin j am soc nephrol, : - , ) . in this study we have compared the effects of prednisolone, azathioprine, warfarin, and dipyridamole (combination) with those of prednisolone alone in children with newly diagnosed iga nephropathy showing diffuse mesangial proliferation. patients were randomly assigned to receive either the combination or prednisolone alone for two years. the primary endpoint was the disappearance of proteinuria, defined as urinary protein excretion < . g/m /day. thirty-nine of the patients receiving the combination and of the receiving prednisolone completed the trial. thirty-six of the patients ( . %) receiving the combination and of the ( . %) receiving prednisolone reached the primary endpoint by the two-year follow-up point (p= . log-rank). the percentage of sclerosed glomeruli was unchanged in the patients receiving the combination, but increased in the prednisolone group (p= . ). the frequency of side-effects was similar in the two groups. long-term administration of recombinant human erythropoietin (epo) has become the most common way of treating anemia in chronic renal disease. standard amounts per unit body weight have been recommended for the initial dose. however, several authors have noted that the dose per unit body weight needed for a given response is higher in younger children than in older children or adolescents and that it is increasing with decreasing body weight. furthermore, for a given absolute dose of epo the outcome was investigated in adult hemodialysis patients, but no dependence was found in patients weighing - kg. a similar model to the hemoglobin-time data of children aged - years treated with epo for renal anemia did not find an impact of body weight on response when it was modelled in terms of absolute dose. in a similar analysis to the hemoglobin-time data children and adolescents aged - years were analyzed, in order to more definitively answer the question if, for given absolute doses the hematopoetic response to epo in children depends on body weight. neither the dose response parameter e max and ed showed dependence on body weight. the median hemoglobin response to a standard dose was similar to that reported for adults. it can be concluded that younger and smaller children need relatively more epo than older children. doses for children should be specified as absolute amounts rather than amounts per unit body weight. references: scigalla p. effect of recombinant human erythropoietin treatment on renal anemia and body growth of children with end-stage renal disease. in: baldamus ca, scigalla p, wieczorek l, et al, editors erythropoetic agents are the mainstay of treatment for renal anemia. although there are several different marketed forms of erythropoetin, they are not substantially different in their ability to stimulate erythropoesis. however, darbepoetin, which differs in one amino acid, and has additional glycosylation sites, has a longer half-life and therefore a presumed longer duration of action. this provides a theoretical advantage, suggesting that less frequent injections will be required. clinical experience and studies have confirmed that both erythropoetin (epo) and darbepoetin (dar) are effective to maintain hb values within the recommended range. also, though there is some experience with epo injected every couple of weeks, the overall evidence suggests that dar has a longer duration of action, and injections are required less frequently. for many children, particularly the pre-dialysis population, anemia is successfully controlled with dar injected every - weeks. however, this apparent advantage of dar is somewhat reduced because of the increased pain reported with dar injections compared to epo. both epo and dar have been used successfully in children of all ages. with epo, the doses required to maintain hb values appear to be increased in infants compared to older children; this may not be the case with dar, but there is much less experience with use of dar in infants. also, the administration of dar in infants is hindered by the need to inject portion of a unidose pre-filled syringe, which may introduce inaccuracies in dosing, is wasteful, and is not user-friendly. the side effect profile for each product is similar, and specifically each has been associated with development of hypertension, which is most likely with higher hb values. pure red cell aplasia has also been reported with each product. thrombocytosis has been reported with dar use. overall, there is little to recommend one product over the other. the need for less frequent injections may favor dar for use in most children beyond infancy, whereas it is easier to administer epo accurately in infants. how much iron is needed and how much is toxic? iron deficiency is the primary reason for ineffective erythropoiesis in patients with chronic kidney disease (ckd) who receive an erythropoiesis stimulating agent (esa). reasons for iron deficiency include inadequate dietary intake, blood loss from the gastrointestinal tract, frequent blood tests, loss of blood in the extracorporeal circuit of hemodialysis (hd), as well as the hepcidin related impairment of the intestinal absorption of iron and its release from the reticuloendothelial system. supplementation of iron can be by either the oral or intravenous (iv) routes, although the national kidney foundation-kidney disease outcomes quality initiative (k/doqi) strongly recommends the preferential use of iv iron in children and adult patients receiving hd. the k/doqi recommended target iron indices for all children on dialysis are a serum ferritin > ng/ml and a transferrin saturation (tsat) > %. while the serum ferritin should not regularly be > ng/ml, some such patients will achieve a higher hemoglobin value following an iv course of iron therapy. of the iv iron agents, the non-dextran products appear to be safest, and pediatric dosing recommendations exist for ferric gluconate and are currently being studied for iron sucrose. differences do exist for the clinical (e. g. proteinuria) and subclinical (e. g. oxidative injury) toxicities associated with the currently available iv iron products and should be taken into consideration when prescribed. until recently the major physiological function of erythropoietin (epo) was thought to be the induction of erythropoiesis. however, a growing body of evidence indicates that epo has tissueprotective properties and prevents ischemia induced tissue damage in several organs including the kidney. a main target of epo´s action is the endothelium, and one of the pivotal intracellular pathways mediating the beneficial effects of epo is the activation of akt, i. e. serine/threonine protein kinase b. as a result, akt phosphorylates the proapoptotic factor bad, which in turn causes inhibition of programmed cell death (apoptosis). moreover, experimental studies revelead that epo is a potent regulator of endotheial progenitor cell (epc) proliferation and differentiation. collectively, these data support the hypothesis that epo is a key molecule in the process of endothelial (vascular) repair and neoangiogenesis. treatment with rhuepo or analogues could therefore open new therapeutic strategies in regenerative cardiovascular medicine. introduction: africa as a continent is besieged by many health challenges including malaria, hiv (upwards of % of paediatric admissions), tuberculosis and malnutrition with an infant mortality rate (imr) ranging from (southern africa) to (mozambique). good health facilities are on the whole not available except in the extreme north and south of the continent with doctors/ population in south africa but in kenya only and even lower in other parts of africa. renal disease: renal disease in adults is an unknown quantity with no information being available regarding children's renal disease, where many babies do not even have access to antenatal ultrasounds. situation in south africa: in reality, there are only centres (cape town and johannesburg/ pretoria) doing paediatric dialysis and transplantation in significant numbers with small numbers interspersed in the rest of the country. this raises numerous issues: -accessibility for children to renal care -retaining minimum standards of care for children -both dialysis and transplantation -combined with adult units -central government funding in form of tertiary services grant for paediatric renal care -children not first priority on any transplant program in terms of organ allocation -private facilities vs state facilities -ethical decisions dialysis facilities: peritoneal dialysis (pd) first line therapy for acute renal failure, as can be performed in any setting with minimal equipment and expertise. in the setting at rxh, we have a greater than % survival in infants and children dialysed using pd even in a sophisticated intensive care setting. haemodialysis and chronic dialysis may not be easily available in most settings and realistically need transfer to one of the major centres. transplantation: again limited to only few centres, with at least % living related donations from family members. initial good year ( %) and year ( %) graft survival but results then deteriorating as patients enter their adolescent years often with little support and transfer to adult units in their early teens. controversial issues here include access to one kidney transplant only, no chronic dialysis if not suitable for transplant and transplantation in hiv positive recipients. conclusions: adequate resource allocation is required for paediatric renal care especially where resources are limited. immunosuppression remains the cornerstone of successful transplantation. in developing countries transplantation is mostly from living donors and transplant is thus a once in a lifetime chance. in this backdrop immunosuppression is a challenge as several issues have to be overcome. namely, non-availability of newer drugs, high costs and paucity of drug monitoring facilities. in most countries immunosuppression is based on a triple drug regimen of cyclosporin (cya), prednisolone (pred) and azathioprine (aza). in the last few years mmf and tacrolimus (tac) has been initiated in a few centres. several tailoring strategies have been employed taking into consideration costs, drug availability, tissue typing facilities and drug monitoring. firstly in hla identical transplants which constitute - % of the total, cya based regimen are used. marked reduction to - mg/kg at months and complete withdrawal at one year in rejection free transplants is safe with continuing of aza and pred. secondly several centres selectively use tac and mmf in cases with early rejection or transplants with > mismatches. it is possible to switch to cya or aza after months on individual basis. thirdly induction protocol with atg for days in transplants with > mismatches and in retransplants is cost effective. cost considerations have increased the use of generic calcinurin inhibitors with market share of - % in different countries. co administration of p competitors has reduced doses of cya by - % with considerable cost reductions. siut has been running a living related transplant program for more than years with dialysis and follow-up of recipients and donors. keeping in mind economic constraints a model of government public partnership was developed which provides all facilities including drugs free of cost. we adopted a number of tailoring strategies e. g. strict monitoring, tailoring by hla match and donor age and use of biological agents in risk groups. in first years we used parent drugs, however increasing costs necessitated use of generics after establishing bioequivalence in controlled trials. graft survival rates were maintained at % and % at and years. in conclusion, immunosuppression in developing countries require besides newer drugs, monitoring facilities, affordable costs and regular follow-up as transplantation for majority is once in a lifetime chance and failure equates with death. occurrence of infections following kidney transplantation is a major reason for hospitalization, and an important cause for renal dysfunction & mortality in developing countries. more than % renal transplant recipients get serious infections, with a - % risk of mortality. infections in the first month after transplantation are similar to those in surgical patients; opportunistic pathogens and cmv predominate between - months; and tuberculosis (tb) after months. the risk of tb in patients on maintenance dialysis & following transplantation is between - %. the onset of tb is usually within months of transplantation. clinical syndromes include pleuropulmonary tb, followed by disseminated tb, pyrexia of unknown origin and lymph node disease. demonstration of m. tuberculosis, on microscopy or culture might not be possible. nonrifampicin based treatment regimens (inh, pyrazinamide, ethambutol, fluoroquinolone for months, followed by hef for months) are used. inh prophylaxis ( - months) is advised in patients with tuberculin positivity or contact with active tuberculosis. cmv disease results in considerable morbidity & mortality; its timing is influenced by donor/recipient serological combination, state prior to transplantation, use of antilymphocyte induction therapy or preventive strategies. cmv disease is characterized by a non-specific febrile illness; features of enterocolitis, pneumonia, hepatitis, myocarditis, esophagitis, chorioretinitis & bone marrow involvement are variable; disseminated disease is rare. cmv disease exacerbates the net immunosuppression, increasing the risk for opportunistic infections. patients with cmv disease are also at risk for acute rejection and chronic allograft injury, atherosclerosis & vascular injury. diagnosis of cmv disease is based on a combination of viral serology, shell vial cultures, pp antigen assay and pcr. the cost of prophylaxis and treatment is a major limitation to the use of ganciclovir or valganciclovir. other infections in transplant recipients include malaria, p. carinii and fungi (cryptococcosis, candidiasis, mucormycosis, aspergillosis). infections are an important cause of morbidity & mortality in renal transplant recipients. their management continues to be challenging due to difficulties in diagnosis, unsatisfactory follow-up and cost of medications. ethical issues of renal replacement therapies n. orta, p. zibaoui, e. lara university of carabobo/insalud, pediatric nephrology, valencia, venezuela important ethical issues in pediatric nephrology (pn): genetic and molecular techniques, prenatal therapies for urinary anomalies, treatment of children with chronic renal disease (esrd). ecosonography can detect nephrourological anomalies and studies of amniotic fluid give information on chromosome alterations and renal function. particular situations, can lead to dilemmas related to pregnancy interruption and neonatal dialysis and transplantation (dt) possibilities. renal insufficiency (ri) presents at any age, and peritoneal, hemodialysis or hemofiltration could be applied. patients without structural abnormalities, ri secondary to toxics or isquemic nephropathies have better prognosis. these procedures are complicated and costly and increases, and may have secondary effects with ethical implications. treatment by dialysis developed in the 's and inclusion of children was not considered. this has changed with advances in dt. since 's dt programs were setup for children, but received criticisms and considered unethical, but were continued because of familiar and humanitarian demands and today it is clear that children benefit with that. scientific societies recommend: . children who receive dialysis must meet the following criteria: -diagnosis of esrd, legal authorization, possibility of transplantation, acceptable quality of life; may not be rejected for economic, social or psychological reasons, nor gender, age, race or mental conditions. biopsies are the current 'gold standard' for monitoring transplant patients, but it has been shown that even mild rejection episodes, based on pathology grading, can have poor outcomes and even biopsies with normal early pathology can progress rapidly with chronic allograft injury. there is considerable inter-observer variability of biopsy pathology readings that adds an additional confounder to this method of analysis. identification of non-invasive biomarkers in blood or other fluids would allow for the possible elimination of frequent biopsies. hence, the identification of diagnostic and predictive non-invasive genomic markers will be a worthy tool to aid in the clinical monitoring of transplant patients. the use of dna microarrays as a hypothesis generation tool for determining gene expression differences across thousands of genes in a data set is increasing. recently, the use of microarrays has been applied to the transplant field and holds great promise for unraveling the mechanisms at play in various transplant processes and for identifying new tissue specific and non-invasive biomarkers predictive of clinical outcomes. as microarrays produce large amounts of data, bioinformatics tools are being developed to determine gene expression patterns. gene clustering and class prediction tools aid in the discovery of molecular signatures in different disease processes while literature mining, gene family analysis and pathway analysis help in understanding the biological relevance of these signatures. initial studies in acute rejection and graft dysfunction have produced possible markers for risk stratification of the rejection event and have suggested underlying mechanisms at play, that may now allow us to test novel drugs for treating specific acute rejection episodes. the most exciting application of microarrays lies in our ability to predict clinical outcomes by non-invasive serial monitoring, eliminate the requirement of transplant biopsies and individualize patient management by accurately predicting the patient's sensitivity to immunosuppression-sufficient to suppress the allo-response, yet insufficient to abrogate the innate response. responsible array data handling and accessible reporting will open new doors for transplant researchers through increased use of computers and collaborations towards these kinds of novel insights and treatment options for transplant patients in the future. this talk focuses on dna microarrays, their application to transplantation, and discusses some of their limitations and recent applications, as well as some key research studies where dna microarrays are applied to understanding the molecular differences in acute transplant rejection that segregate and likely control the differences in rejection treatment responsiveness as well as decline in graft function, as well as gaining insights into the different biological processes that govern these differences. the molecular pathogenesis of vur is not well understood. uroplakins (ups) are expressed in the urothelium and are developmentally regulated by rab b and tbx genes. up ii and iiia-null mice exhibit a primary ( o ) vur phenotype. using microarrays and rt-pcr, we analyzed gene expression in surgically-discarded ureteric tissue from children undergoing reimplantation for o reflux, compared with adult living-related transplant donors as normal controls, as well as children with o reflux (megaureter, duplicated ureters, and posterior urethral valves) as age-matched disease controls. we also studied urine protein profiles using -dimensional electrophoresis ( d-page) followed by time-of-flight mass spectroscopy (q-tof-ms). rt-pcr showed partial expression of ureteric upia, upib, upii and upiiia genes in patients with o reflux. protein screening using western immunobloting confirmed that some uroplakins were undetectable. real-time rt-pcr revealed that ureteric up ia, up ib, upii, and up iiia gene expression decreased significantly, whereas upiiib gene expression increased at least -fold compared to controls. compared with patients with o vur, the decrease of upiiia expression in those with o reflux was highly statistically significant (p< . ). the expression of rab b and tbx genes also decreased significantly in patients with o and o reflux as well. total urinary protein concentration increased by -fold in the o vur patients without detectable renal scarring on dmsa scans; and increased further in patients with renal scarring, -fold for o vur and -fold for o vur patients. proteomic analyses of proteinuria revealed an overall increase of protein with mw> . kda in the pi range . to . in patients. q-tof ms identified one predominant urinary protein of ~ kda as sera-transferrin, which was confirmed by elisa quantitation. we hypothesize that the abnormal developmental expression pattern of the up, rab b and tbx genes in vur patients results in abnormal urothelial functions, which lead to leakage and/or secretion of proteins into the urine, and that this occurs in the absence of scarring from urinary infections. further identification of these protein biomarkers may lead to non-invasive diagnostic tests for vur. biomarker discovery in acute kidney injury p. devarajan cincinnati children's hospital medical center, department of pediatric nephrology and hypertension, cincinnati, united states acute kidney injury (aki), previously referred to as acute renal failure (arf), represents a common and persistent problem in clinical medicine. despite significant improvements in therapeutics, the mortality and morbidity associated with aki remain high. a major reason for this is the lack of early markers for aki, akin to troponins in acute myocardial disease, and hence an unacceptable delay in initiating therapy. fortunately, the application of innovative technologies such as functional genomics and proteomics to human and animal models of aki has recently uncovered several novel genes and gene products that are emerging as biomarkers. the most promising of these are chronicled in this symposium. these include a plasma panel (ngal and cystatin c) and a urine panel (ngal, . since they represent sequentially expressed biomarkers, it is likely that the aki panels will be useful for timing the initial insult and assessing the duration of aki. based on the differential expression of the biomarkers, it is also likely that the aki panels will distinguish between the various types and etiologies of aki. however, they have hitherto been tested only in small studies and in a limited number of clinical situations. it will be important in future studies to validate the sensitivity and specificity of these biomarker panels in clinical samples from large cohorts and from multiple clinical situations. such studies will be markedly facilitated by the availability of commercial tools for the reliable and reproducible measurement of biomarkers across different laboratories. a. watson children and young people's kidney unit, notthingham university hospitals, nottingham, united kingdom the achievement of adequate chronic peritoneal dialysis in children requires close attention to clinical, dietetic and psychosocial aspects of care. successful dialysis is dependent upon excellent peritoneal access and swan neck coil catheters with downward facing exit sites are increasingly favoured with many placed laparoscopically. automated peritoneal dialysis is employed in most developed countries but adolescents may be given the choice of capd which may be the only modality available in developing countries. training and support by committed nursing staff are of paramount importance as is regular review by a paediatric renal dietitian. growth parameters should be regularly monitored and supplemental enteral feeding introduced early. many infants are nasogastrically fed, but the preferred route for supplemental enteral feeding is via a gastrostomy which can be placed at the same time as the pd catheter. dialysis fill volumes should be assessed in terms of body surface area and intra-abdominal pressure measurements. there can be discrepancies between urea and creatinine clearances and adequate dialysis includes combining clinical parameters with regular growth measurements as well as biochemical data including phosphate, calcium and parathyroid levels. peritoneal function tests are useful in monitoring progress but the greatest challenges are in sustaining long-term dialysis, particularly in infants where transplantation is likely to be delayed. support for the families with a respite care 'package' may delay or prevent burnout and possibly reduce peritonitis rates. conventonal pd solutions are acidic, contain unphysiological concentrations of lactate and glucose and highly toxic glucose degradation products (gdp), which are substrates for advanced glycation end product (age) formation. repeated administration induces epithelial to mesenchymal cell transition, loss of the mesothel cell layer, progressive submesothelial fibrosis and angiogenesis, ultimately leading to ultrafiltration failure. meanwhile pd solutions with an improved toxicity profile are available. multi chamber pd solutions separate glucose from the buffer at a very low ph, which largely prevents gdp formation. after mixture ph is close to normal. they are equally effective with regard to solute-and water transport, reduce inflow pain and systemic age load. dialysate effluent markers indicate increased mesothelial cell mass, reduced peritoneal inflammation and reduced angiogenesis. animal studies demonstrate preservation of pd membrane morphology and function, respective human biopsy data however are pending. a european paediatric multi centre trial accomplished recently elucidates the impact of the lactate and bicarbonate buffer. a randomized cross over trial in adult patients points to an improved preservation of residual renal function; a korean registry suggests improved technique and patient survival. icodextrin solutions reduce glucose and gdp exposure, improve extracellular fluid status, left ventricular mass and stabilize membrane function in anuric adult capd patients and should be beneficial in children, too. amino acid based solutions achieve similar clearance and ultrafiltration rates, reduce glucose and gdp load and allow for a phosphate free amino acid supply. the nutritional benefit however is questionable. other, thus far experimental strategies include addition of locally active compounds to pd fluids such as gdp scavengers, inhibitors of age formation and antifibrotic agents. surface active phospholipids may increase peritoneal contact area and ultrafiltration. gene therapy appears highly promising but is still far from being clinically applied. in summary, there is substantial evidence for increased biocompatibility of the recently introduced multi chamber and icodextrin based pd solutions. they should improved long term morbidity and mortality of pd patients; this however still needs to be proven. the impact of the ippr on the treatment of peritonitis b. a. warady children's mercy hospital and clinics, pediatrics nephrology, kansas city, united states the international pediatric peritonitis registry (ippr) is an initiative that was established to evaluate the safety and efficacy of largely opinion based peritonitis treatment guidelines in which empiric antibiotic therapy ( st generation cephalosporin and ceftazidime or a glycopeptide and ceftazidime) was stratified by disease severity. forty-seven centers from countries contributed data on children and peritonitis episodes treated in accordance with the guidelines. culturenegative peritonitis accounted for % of all episodes, with a marked regional variability in the incidence of this disorder, as well as in the peritonitis causative organisms. overall, % of cases achieved full functional recovery, a portion following relapsing peritonitis ( %). in-vitro evaluation revealed only % sensitivity of gram-positive organisms to a st generation cephalosporin (eastern europe > north america) and % sensitivity of gram-negative organisms to ceftazidime. in contrast, % of gram-positive organisms and % of gram-negative organisms were sensitive to the combination of either a st generation cephalosporin or an aminoglycoside. whereas the risk of empiric treatment failure was associated with the presence of a gram-negative infection (p= . ), neither the risk factors assumed by the guidelines nor the choice of empiric therapy were predictive of the final functional outcome of the peritonitis episodes. the data collected by the ippr will serve as an important source of evidence to be incorporated into revised pediatric peritonitis treatment guidelines. ch. aufricht medical university, pediatrics, vienna, austria peritoneal dialysis (pd) is a safe, cost effective and widely used form of renal replacement therapy in patients with end stage renal failure. however, up to a third of patients on pd will suffer from technical failure during their course. identification of the patients at highest risk would be of high clinical relevance. cytotoxicity of pd fluids due to low ph, hyperosmolarity, and/or high concentrations of lactate, glucose and its degradation products causes mesothelial cell injury that ranges from minor cellular dysfunction to overt (apo)necrosis. the same physicochemical properties of pdf that cause such cellular injury also induce pathways leading to repair and recovery. this so-called cellular stress response results in a switch of the cellular machinery from routine procedures towards reaction against stressors. the complex machinery of the cellular stress responses not only counteract direct toxic injury caused by pdf but also attenuate inflammation or other potentially deleterious cellular processes. infectious, uremic and toxic injuries might converge in cellular inflammation. whereas inflammatory processes triggered by infection protect the peritoneal cavity against invading microorganism, chronic sterile smoldering 'cytotoxic' inflammation may result in aberrant healing processes and peritoneal fibrosis. recently, polymorphisms of many proteins involved in relevant cellular responses have been described and related to altered resistance and/or susceptibility to pathogenetic processes with potential influence in pd. in this review, we will focus on key effectors of stress responses, of cellular inflammation and of fibrogenesis such as heat shock proteins (hsp), cytokines (il- ), chemokines (il- ) toll-like receptors (tlr) and growth factors. given the recently shown role of these 'players' for the interplay between mesothelial injury, inflammation and cytoprotection, these polymorphisms will likely be relevant for mesothelial cell damage during pd. taken together, the ability to understand -and ultimately modify -the risk profile of a given patient will be essential for tailoring individual pd therapies. the pathologic diagnosis of chronic allograft nephropathy (can) was introduced in by the banff classification system for renal allograft injury. it originally included at least four entities that it was acknowledged could not always be distinguished by biopsy: ) chronic rejection; ) chronic calcineurin inhibitor (cni) toxicity; ) hypertensive vascular disease; ) chronic infection and/or reflux (solez, ki : ) . over the ensuing decade, the definition of can has expanded and fluctuated such that some pathologists have come to use the term to mean a specific pathologic entity comprising "…progressive graft dysfunction accompanied by chronic interstitial fibrosis, tubular atrophy, vascular occlusive changes and glomerulosclerosis. " (nankivell, nejm : , while others have suggested can should be used to describe all causes of renal allograft dysfunction involving fibrosis. the resulting confusion over terminology has in some ways hindered the growing awareness of the multiple discrete, diagnosable and often treatable diseases capable of causing chronic graft injury. these diseases include: ) chronic (primarily antibody-mediated) rejection; ) de novo and recurrent glomerular disease; ) calcineurin inhibitor toxicity; ) interstitial fibrosis and tubular atrophy without evidence of any specific etiology. to this list should be added other recognizable causes of late graft dysfunction such as polyoma virus infection and hypertension. in the new banff classification can will no longer be a diagnostic category (colvin, world transplant congress, ) . instead, the term sclerosis will be used to describe: "interstitial fibrosis/tubular atrophy, not otherwise specified, " or "if/ta nos. " the increasing use of protocol biopsies in clinically stable patients has dramatically increased awareness of the ongoing pathological changes almost every renal allograft appears to be undergoing almost from the first moments of engraftment. techniques are now available in most centers to reliably recognize the presence of chronic antibody-mediated rejection. these include: ) typical morphological findings: lamination of glomerular basement membranes, arterial intimal fibrosis, interstitial fibrosis/tubular atrophy; ) c d staining in peritubular capillaries or glomeruli; ) the presence of circulating donorspecific antibodies (takemoto ajt : . treatment of late, chronic antibody-mediated rejection is in its infancy and may include use of anti-b cell antibody (rituximab), ivig, and/or plasmapheresis. calcineurin inhibitor toxicity can be more reliably identified by focusing on blood vessels in the allograft, primarily the location of hyaline deposits in the arterioles. nodular, peripheral hyalinosis is found almost exclusively in cni toxicity, whereas sub-endothelial and transmural hyaline deposits are non-specific and can be seen in hypertension, aging and diabetic nephropathy. there is increasing concern that recent gains in short-term renal allograft survival and reductions in acute rejection rates have not resulted in improved long-term graft survival. while this is likely due to multiple factors, including infections and malignancies associated with over immunosuppression, unrecognized (sub-clinical) acute cellular rejection (moreso ajt : ), and noncompliance in some patients, much evidence points to the primary role of cni toxicity in many if not the majority of chronically failing allografts maintained on cni's. experience with conversion from cni to sirolimus in adult patients has been reviewed in a recent editorial (betard nephrol dial transplant : editorial comments) . in studies involving nearly patients, between % and % of patients with late allograft dysfunction failed to respond favorably to cni withdrawal and replacement with sirolimus. acute rejection episodes were rare, occurring in only six patients. common adverse effects included dyslipidemia, anemia and proteinuria. in one study, of patients developed proteinuria after conversion, in the nephrotic range. pediatric experience with cni withdrawal has been limited (kerecuk, pediatr nephrol : falger, pediatr transplant : , hocker, pediatr transplant . our recent experience at stanford with cni withdrawal in patients was not favorable, with % of patients experiencing an associated acute rejection episode (weintraub, wtc ) . prior history of acute rejection significantly increased the relative risk of acute rejection after cni withdrawal (rr= . ), and proteinuria was common. patients with advanced chronic graft dysfunction were at increased risk for graft loss. in summary, the use of the term can to describe all causes of chronically failing renal allografts is to be discouraged in favor of a search for specific etiologies whenever possible. antibody-mediated rejection and cni toxicity are major causes of late allograft dysfunction. protocol biopsies are helpful in identifying patients with treatable causes of late allograft dysfunction. cni withdrawal/avoidance may be successful, but optimum patient selection criteria and withdrawal/replacement strategies have not been determined. pediatric experience to date with cni withdrawal has been limited, but it appears that late withdrawal after cni injury and graft dysfunction have become well established may be associated with inferior outcomes. prospective trials in pediatric patients are needed to address these issues. which immunosuppression in pediatric transplantation? p. hoyer university children's hospital, essen, germany recent results in pediatric renal transplantation have reached one year graft survival rates better than %. current immunosuppressive drugs should be classified according to their interference with the immunesynapsis as signal , signal and signal blocking agents. the variety of immunosuppressive drugs does allow more treatment combinations than the potential number of large scale studies in children. the definition of current unmet needs should guide employment of drugs. calcineurin inhibitors (cni) are still the basis of immunosuppression. individual risk profile leads to preferences for cyclosporine or tacrolimus. while in adults cni reduction seems to be the major goal, the search for steroid sparing or avoidance protocols has attracted major interest in pediatric transplantation. growth and body configuration as well as cardiovascular risk factors should be in the focus of research. antibody induction protocols, mainly with il- receptor antibodies, are increasingly popular, but efficacy is less clear than concluded from adult studies and might depend on initial combination therapy. mmf (cellcept®) or mpa (myfortic®) are effective drugs with cni sparing potential. early adequate dosing seems to be of greater importance than the choice of the cni, but the price to pay may be an increase in infectious complications. mtor inhibitors are promising in avoiding nephrotoxic side-effects; specific side effects on male gonadal function and possible interference with growth should be considered before any recommendation can be given. fty would have been of especial interest for children because of maintaining viral infectious response, but phase- studies are on withhold. the vision of tolerance has stimulated research on regulatory t-cells; i. e. cd cd +t-reg cells and the mastergene foxp . the impact of lymphocyte depletion induction protocols with campath on operational tolerance needs further studies. newer drugs in development are isa , a cyclosporine analog without nephrotoxicity; a modified release form of tacrolimus which might improve compliance; the phosphokinase inhibitor aeb with the potential to avoid cnis; the jak inhibitor cyp , which might interfere with signal (il and il -receptor); and lea y (belatacept) with blocks costimulatory signals. according to the new european drug legislation some of these drugs will be subject for mandatory testing in pediatric patients to get marketing authorisation. the future might be a more tailored immunosuppression according to the induvidual needs of the patient. immunosuppression minimization strategies, under the umbrella of a newer generation of more powerful induction and maintenance immunosuppressants, are being increasingly applied to pediatric organ transplantation, with the greatest emphasis on minimization of steroids and calcineurin inhibitor agents. safe elimination of these steroids carry unprecedented advantages for reducing patient morbidity and chronic graft injury, but may also result in unanticipated changes in immunological homeostasis and drug pharmacokinetics, heralding closer surveillance for posttransplant infections and alterations in drug bioavailability and dosing, as well as break-through immunologic responses. in single center studies, pediatric renal transplantation appears safe without steroids. daclizumab first dose doubling and extended use for months replaces steroids effectively without evidence of over-immunosuppression, and may be the pivotal causative for the reduced acute rejection seen in the face of steroid avoidance. this pilot protocol has been tested in a prospective, multicenter randomized us and canadian study. b. maecker, c. klein department of pediatric hematology/oncology, hannover medical school, hannover, germany posttransplant lymphoproliferative disorders are severe complications of immunosuppressive therapy after solid organ transplantation causing significant morbidity and mortality. to define prognostic factors, we have analyzed pediatric solid organ graft recipients (kidney, liver, heart/lung) that were reported to the german ped-ptld registry. ptld was diagnosed at a median time of months post organ transplantation with sigifcantly shorter lagtime in liver versus heart or renal graft recipients. the five-year overall and event-free survival was % and %, respectively. stage iv disease with bone marrow and/or cns involvement was independently associated with poor survival. no differences in outcome were observed between early and late onset ptld, monomorphic or polymorphic ptld, and ebv-positive or ebv-negative ptld, respectively. patients with burkitt-like ptld and c-myc translocations had very short survival. these factors should be important to consider for future prospective interdisciplinary trials that are urgently needed to define rational treatment strategies. cystinosis is an autosomal recessive lysosomal storage disorder affecting children and adults all over the world. in cystinosis cystine is trapped in the lysosomal compartment due to a defect in its egress transport protein cystinosin encoded by the gene ctns. by mechanisms still not fully understood this leads to tubular and glomerular kidney and other organ failures (e. g., thyroid, muscles) if left untreated. kidney involvement is prominent from shortly after birth on as renal tubular fanconi syndrome with the clinical consequences of failure to thrive and rickets. cystinosis is the single most common cause of renal fanconi syndrome in childhood. therefore, any recognition of renal glucosuria, generalized aminoaciduria, phosphaturia, small molecular weight proteinuria, polyuria, and metabolic acidosis (due to renal bicarbonate loss) should lead to prompt consideration of cystinosis as possible cause. this can be done utilizing biochemical analytical methods measuring the cystine content of polymorphonuclear leucocytes. corneal cystine crystals, seen in slit lamp examination, are pathognomic as well, but may not be visible before months of age. left undiagnosed and untreated, patients will develop in addition to the existing tubular insufficiencies pronounced glomerular kidney failure often already present at diagnosis and inevitably leading to end stage renal failure typically at the end of the first decade of life. kidney failure in cystinosis presents differently from other forms of glomerular kidney failure because of the overlap of tubular and glomerular insufficiencies. kidney transplantation will be curative with respect to kidney function. specific treatment with cysteamine to lower the intralysosomal cystine content apparently is as important as before transplantation to prevent or attenuate other organ failures and therefore has to be continued after kidney transplantation. cysteamine treatment has been introduced in the s and has been approved in the s. early diagnosis and diligent treatment is able to prevent or ameliorate major organ complications. unfortunately, until now no newborn screening exists due to the biochemistry and cell biology involved. the high prevalence of a european founder mutation, i. e., a kb deletion in the ctns gene, makes molecular based methods not feasible. lowe syndrome and dent's disease: two ends of a spectrum d. böckenhauer great ormond street hospital for children nhs trust, nephrology, london, united kingdom lowe syndrome and dent's disease are x-linked disorders; the former is a systemic disorder characterized by cataracts, mental retardation and proximal tubulopathy whilst the latter was originally described as an isolated kidney disorder with tubular proteinuria, hypercalciuria/ nephrocalcinosis and progressive renal impairment. mutations in ocrl underlie lowe syndrome, whereas the majority of cases with dent's disease are caused by mutations in clcn . recently, mutations in ocrl have been identified in a subgroup of patients with dent's disease (also called dent- ). it is unclear, why some patients with ocrl mutations get dent's disease, while others develop lowe syndrome. however, careful clinical observation has revealed that dent- patients have evidence of systemic involvement. moreover, the degree of severity of symptoms in lowe syndrome is highly variable. thus, mutations in ocrl can cause a spectrum of symptoms, from tubular proteinuria and hypercalciuria to the full manifestations of lowe syndrome. here, we will review the clinical phenotype of the disorders, what is known about their pathophysiology and discuss genotype/phenotype correlation. fabry disease, the second most prevalent lysosomal storage disorder after gaucher disease, is an xlinked inborn error of the glycosphingolipid metabolic pathway and affects approximately : , live births. mutations in the gene encoding alpha-galactosidase a, lysosomal hydrolase, lead to systemic glycosphingolipid deposition, resulting in profound dysfunction of neurological, renal, cardiac, and cerebrovascular systems. the initial phase begins in childhood or adolescence and is characterized by neuropathic pain, angiokeratomas, and ocular deposits. the later phase is distinguished by progressive cardiac, cerebral, and renal involvement, leading to multi-organ dysfunction and death. few patients have historically survived past their mid s. although renal involvement usually becomes prominent in adulthood, adolescents may develop proteinuria and decreased glomerular filtration rate. timely diagnosis is critical, given that the enzyme replacement therapy likely delays progression of the serious complications of fabry disease and may have potentially preventive benefits. specifically, there is growing evidence that initiation of enzyme therapy slows progression of chronic kidney disease (ckd); it remains unknown whether enzyme therapy in the currently employed doses can prevent ckd. pediatricians have a particularly important role in making the diagnosis, since they are likely to be the first providers to encounter fabry patients and thus initiate therapy before irreversible tissue injury develops. nephrologists should consider the diagnosis of fabry disease when a patients present with ckd with nephrotic or subnephrotic proteinuria, often with skin lesions (but these may be limited in distribution), episodic extremity pain, and/or psychiatric problems. further research is required to determine the efficacy of enzyme replacement therapy to prevent organ damage in children, to identify optimal therapeutic doses and schedules, and to define efficacy of additional treatments for fabry kidney disease, include angiotensin converting enzyme inhibitors and angiotensin receptor blockers. w. van't hoff great ormond street hospital for children nhs trust, pediatric nephrology, london, united kingdom children with a complete deficiency of methylmalonyl coa mutase develop both renal tubular and glomerular dysfunction. the renal tubular dysfunction is characterised by renal tubular acidosis, defective urinary concentration and hyporeninaemic hypoaldosteronism. a chronic interstitial nephritis also develops leading to long-term glomerular renal damage. chronic kidney disaes is not evident on routine testing as muscle mass is reduced and protein intake is markedly restricted. formal measurement of gfr using chromium edta showed that of such mma patients have a gfr < mls/min/ . m ), and by years, of patients had a gfr < . most mma patients with ckd do not have excess proteinuria nor hypertension. although vit b responsive mma patients in general have a more favourable outcome, late onset renal complications have been seen. in addition to ckd, mma patients can develop cardiomyopathy, pancreatitis, gut dysmotility and chronic or acute encephalopathy. management is based on a protein-restricted, high calorie diet, allopurinol to control hyperuricaemia, supplements of carnitine and metronidazole therapy to reduce production of propionate. haemodialysis has successfully cleared plasma mma and improved the metabolic and nutritional status. liver transplantation has been performed in a number of younger children, as enzyme replacement therapy, but is associated with a significant morbidity and mortality (including late neurological deaths). renal transplantation has been reported in a small number of older patients but it is not yet clear how good the graft outcome will be. combined liver-kidney transplantation has been undertaken again in small numbers, with a high morbidity and significant mortality although there are a very few remarkable survivors. so far, there are only centre specific experiences and unfortunately reviewing the literature will not give a full picture of long-term outcome and complications, due to the bias of the reported results towards favourable outcomes. there is a clear need to share data on the management of these rare patients in order to better understand the best approach. estimations of the extent of hiv disease in sub-saharan africa are that million people are currently infected of which the total number of children is . million. worldwide it is thought that . million children are infected so it can be seen that the majority reside in africa. in south africa, we have a minimum of hiv infected children aged less than yrs of age with only on highly active anti-retroviral therapy (haart) at present. currently - % of all paediatric admissions to hospital may be hiv related. hiv associated renal disease, is not yet well documented among children -especially from africa -but now with the growing availability of haart, this information has become more important for appropriate management. hiv renal disease presents in many forms, including including hiv-assoc nephropathy (hivan) and hiv immune complex kidney disease (hivick) amongst others. questions have now been raised as to whether a screening program should be introduced as haart, despite side effects and drug interactions, has revolutionised management if hiv infection detected early enough. transplantation which was thought previously to be an absolute contraindication and potential waste of valuable resource is now possible, provided there is maintenance of haart, hiv viral load is undetectable for > mths and cd > cells/mul. there remains concern about feasibility in children with increased rejection, reduction of calcineurin inhibitors and infections such as recurrence of hepatitis c post-transplant. despite these concerns, studies in adherent adults have clearly shown that adult patients with hiv infection do better following transplantation than on dialysis. of concern, are some studies, showing that certain black patients may have a genetic predisposition to hiv infection. overall, transplantation can be successful in these patients provided the hiv disease is under control. however, hiv disease -including renal disease -remains a major problem in sub-saharan africa due to limited resources and lack of availability of drugs, where other health priorities may prevail. background. previous studies suggest that hiv- induces dysfunction and/or injury of endothelial cells, leading to the systemic release of fibroblast growth factor - (fgf- ). to date, the role that circulating fgf- may play in the pathogenesis of childhood hivan is not clearly understood. objective. here we sought to determine the potential role of circulating fgf- in the pathogenesis of hivan using wild type (wt) and hiv-tg mice. methods and results. to determine whether circulating fgf- induced ultrastructural changes in renal glomerular endothelial cells and podocytes, we injected human recombinant fgf- daily for days into fvbn wt and hiv-tg mice (n= in each group). by electron microscopy we found that fgf- induced endothelial swelling and mild fusion of the foot processes in wt mice. these lesions were more severe in hiv-tg mice, which showed enlargement of podocytes, protein reabsorption droplets, significant fusion of the foot processes, and collapsing glomerulopathy. subsequently, to confirm these findings in a different experimental model system, we used recombinant adenovirus carrying a secreted form of human fgf- (ad-fgf- ). four to five weeks old hiv-tg mice without evidence of abnormal protenuria (urine protein/creatinine ratio (up/uc) < ), and their wild type littermates were injected with x plaque forming units (pfu) per mouse of ad-fgf- or control ad-lacz vectors through the retro-orbital (r. o.) venous plexus (n= per group). all mice were followed for three weeks. all hiv-tg mice injected with rad-fgf- developed heavy proteinuria (up/uc > ). in addition, % showed elevated bun levels (> mg/dl) and renal histological lesions typical of hivan. in contrast, wt mice, developed transient and moderate proteinuria (up/uc < ), without renal failure or permanent renal damage. the number of animals with proteinuria in hiv-tg mice injected with ad-lacz group was consistent with the natural history of the renal disease progression. control wt mice injected with ad-fgf- developed mild proteinuria ( %) that returned to normal values - days after the injection. fgf- induced microcystic tubular dilatation and recruitment of mononuclear cells both in wt type and hiv-tg mice, although the changes were more significant in the later group. conclusion. taken together, these results suggest that the accumulation of fgf- in the circulation of hiv-tg mice induces glomerular endothelial and podocyte injury leading to the development of heavy proteinuria, renal failure, and the typical renal histological features of hivan. we conclude that the elevated levels of fgf- in the circulation of hiv-infected children may be a significant risk factor for the development and/or progression of hivan. human immunodeficiency virus associated nephropathy (hivan) is the third leading cause of kidney failure in young african american adults in the united states. the prevalence and natural history of the disease in children is not well documented. we have examined our experience in children, aged months to years (mean age . ± . years) with predominantly perinataly acquired hiv- infection from their mothers. since , of these children have been evaluated routinely for evidence of renal disease with quantitative assessment of proteinuria by random urine protein to creatinine ratios (upr/cr). renal functional studies included serum creatinine with estimation of glomerular filtration rate (egfr), urinalyses, renal scintigraphy, ultrasound and renal biopsy when possible. the patients were divided according to their level of proteinuria. those with nephrotic range proteinuria (upr/cr> . ) were designated as hiv-ns (n= ; %). those with persistent intermediate range proteinuria (upr/cr: . < . ) were designated as hiv-pp (n= ; %). those with no proteinuria (upr/cr< . ) were designated as having no nephropathy (hiv-non; n= ; %). the great majority of patients were treated with highly active antiretroviral therapy (haart), although those with hiv-ns had less time on treatment when their proteinuria was discovered. moreover, the virulence of the hiv infection as measured by viral load (vl) was significantly greater in those patients with proteinuria. also, viral load correlated positively with degree of proteinuria (r= . ; p< . ). mortality as shown by kaplan-meier survival curves was significantly greater in the hiv-ns group as compared to the pp and non groups. renal failure occurred only in the group with nephrotic range proteinuria. during the past years we have dialyzed children with hiv infection in our end stage renal disease (esrd) program for a total of patient dialysis months. since , all patients are managed on hemodialysis due to the high occurrence of fungal peritonitis in our initial experience. survival has improved remarkably during the past years with a median survival of months (range to months). the next stage is to begin renal transplantation in those patients with adequate control of the hiv infection. aim: to determine the spectrum of severe renal disease in our hiv infected children; excluding severe sepsis and septic shock syndromes. indications for their referral, renal biopsy and histology relating to outcome. methods: retrospective analysis of all children referred to the paediatric renal service from the general wards and hiv clinic from january to december . analysis includes age of presentation, sex, nutritional status, symptoms, renal function, histology, associated diseases including infections and follow-up. results: total of children with a mean age of . ± . years with a male: female ratio of : . . there was an overlap of symptoms but the commonest presenting symptom was haematuria in %, severe urinary tract infection and pyelonephritis in %, anasarca with or without any nephrosis in %, acute renal failure in %, chronic renal failure in %, severe electrolyte disturbances in %. renal biopsy was performed in ( . %) children. histogically % had immune complex disease (icd) of which . % had lymphoid interstitial pneumonitis (lip). . % had fsgs of which one had lip but also had icd, . % had severe interstitial nephritis, associated infectious changes in . % and atn in . %. one patient each had minimal change, mpgn, abdominal kaposi sarcoma and kidney/bladder stones. . % had or were treated for pulmonary tuberculosis. mean follow-up was ± . months. death occurred in . % ( ). all patients with fsgs with some renal dysfunction and severe sepsis demised. conclusion: despite the high burden of hiv disease, severe renal complications have a low prevalence. good correlation of icd and lip ( . %) but prognosis is good. pulmonary tuberculosis and infection is the main complications resulting in high mortality in nephrotic syndrome with fsgs. hiv associated nephropathy (hivan) is one of the most common causes of renal failure in hiv seropositive african americans. in the usa, hivan has become the third leading cause of end stage renal disease (esrd) in african americans over the age of . while the introduction of haart has decreased both the mortality and infectious complications of hiv infection, the incidence of hivan has reached a plateau and has not decreased. with reduced mortality, the prevalence of seropositive patients in the esrd program continues to increase dramatically. the histopathological findings of hivan include focal segmental glomerulosclerosis of the collapsing variant combined with microcystic tubule dilatation. the most common other diagnosis is mesangioproliferative glomerulonephritis associated with hepatitis c infection, a common comorbid condition. typical features of hivan include renal enlargement and echogenicity by ultrasound analysis. microscopic findings include coexistent microcystic tubule dilatation and glomerular involvement. usually there is mild to moderate tubulointerstitial inflammation, interstitial edema, and fibrosis as well. glomerulosclerosis is usually focal and segmental with collapse of the glomerular tuft and hypertrophy of visceral epithelial cells. hivan is caused by renal epithelial infection by hiv- in a susceptible host. clearly there are genetic factors, based on the racial predilection of this disease. patients with hivan are . times more likely to have a relative with renal failure. in susceptible individuals, hiv infection induces renal epithelial proliferation and apoptosis. the kidney represents a tissue-specific compartment in which hiv- can replicate in a previously unrecognized reservoir. while hivan is not currently considered to be an aids-defining condition, patients with hivan should be treated with haart. in some instances, haart has completely reversed the disease process, although it does not rid the kidney of virus. thus, in patients with hivan, the kidney is a true reservoir for replication competent hiv. whether this occurs in other forms of renal disease associated with hiv infection or in patients without renal disease remains to be determined. prenatal administration of dexamethasone causes hypertension in rats when they are studied as adults. renal sympathetic nerves directly innervate renal tubules and blood vessels and plays a role in the regulation of glomerular filtration rate and renal sodium excretion. we examined if renal nerves play an a role in mediating the hypertension in prenatal programming. pregnant sprague-dawley rats were injected daily with intraperitoneal dexamethasone between th and th day of gestation. renal norepinephrine concentration was measured at weeks of age. renal denervation was preformed at age weeks of age in control and prenatal dexamethasone treated rats and blood pressure was measured at age of weeks. renal norepinephrine concentration was ± ng/gr in controls and ± ng/gr in the group that received prenatal dexamethasone (p< . ). systolic blood pressure at weeks of age was ± mmhg in sham operated controls, ± mmhg denervated controls (p=ns). blood pressure was elevated to ± mmhg in dexamethasone treated sham operated group (p< . ), but was normal at ± mmhg in the dexamethasone treated denervation group. in conclusion, prenatal dexamthasone results in elevated renal norepinephrine levels. bilateral renal denervation normalized the systolic blood pressure in rats that received prenatal dexamethasone. these data are consistent with the renal nerve playing an important role in mediating the hypertension in prenatal programming by dexamethasone. objective: evaluation of clinical outcomes in surgically treated children with renovascular hypertension (rvh). methods: rvh patients treated surgically at a single centre between and were retrospectively reviewed: % were male, . - . (median . ) years of age, with systolic blood pressure (sbp) mmhg ( - mmhg). results: bilateral renal artery stenosis was present in %, midaortic syndrome(mas) in %, intrarenal disease in % and coexisting cerebral disease in % of patients. surgical procedures (n= ) included: a) nephrectomy (n= ), b) autologous surgery for both aortic reconstruction (n= ) and renal revascularisation (n= ) (renalartery reimplantation (n= ), renal bypass (n= ) and autotransplantation (n= )) and c) synthetic graft interposition for renal revascularisation (n= ), aortic reconstruction (n= ) or both (n= ). the majority ( %) of patients who received synthetic grafts had vascular anatomy too complex for autologous surgery. technical failure leading to secondary nephrectomy occurred in patients. postoperative complications were haemorrhage (n= ), septicaemia (n= ), and chylous ascites (n= ). there were no operative deaths. patients from the uk were followed up for . ( . - ) years. sbp post-surgery improved ( mmhg, range - mmhg, p< . ). outcomes were normal sbp without treatment ( %), improved ( %) or unchanged sbp ( %). reduction of sbp led to loss of contralateral kidney in patient. children required re-interventions ( angioplasties and surgical procedures) for progressive disease (n= ), narrowing of the synthetic graft (n= ) and re-stenosis of the autologous bypass (n= ). conclusion: rvh is a progressive disease of extensive nature. surgery benefited % of children when performed in conjunction with conservative therapy and, if indicated, interventional radiology. h. wong unlike adults with predominant primary hypertension (htn), the majority of children diagnosed with htn traditionally suffered from secondary forms of htn. however, substantial changes have occurred to the demographics of pediatric population over the past years. in addition, our definition, awareness and understanding of children with hypertension has also changed. we therefore retrospectively reviewed the current causes of htn in children followed in a single tertiary care pediatric nephrology referral center between january and december . patients who were either diagnosed with or treated for htn at the time of their last visit where included. gender, height, weight, age at the time of diagnosis, causer of htn and casual blood pressure were recorded. out of patients, ( . %) were diagnosed with htn. the majority were males (n= , %). median was years ( month- years) age at time of diagnosis and . years ( . months- years) at time of the last follow-up. secondary htn was the most common cause of pediatric htn (n= , %) followed by primary (n= , %) and then white coat (n= , %). renal htn was the most common cause of secondary htn ( / , %). for patients referred initially for assessment of htn (n= ), primary (n= , %) and secondary (n= , %) were the two most common diagnosis followed by normotension (n= , %) and white coat htn (n= , . %). twenty two ( . %) patients were diagnosed before the age of year. out of renal transplant patients, had htn ( %). renal htn remains the most common cause of pediatric htn overall and continues to represent a large portion of children referred for htn. all children suspected of having htn should continue to have thorough investigations of renal disease to identify the underlying cause. m. sinha , c. booth , j. simpson , n. dalton , s. qureshi , c. reid , s. rigden evelina childrens hospital, guys and st. thomas's nhs foundation trust, department of pediatric nephrology, london, united kingdom evelina childrens hospital, guys and st. thomas's nhs foundation trust, department of pediatrics cardiology, london, united kingdom king's college london, department of medicine, london, united kingdom background: hypertension (ht) is a frequent complication in paediatric tx patients. the evolution of end organ damage and its relationship to ht in these patients is not well described. aim: to study the predictive value of an abnormal -hour abp profile for end organ damage. methods: patients underwent simultaneous casual blood pressure (cbp), abpm, echocardiogram (lvh if lvmi > g/m . ) and ecg assessment, with measurement of several biochemical cardiovascular risk markers. cbp data for -months prior to study date was analysed as time averaged z-score. results: we present initial results of a -year prospective study. patients ( male) aged . y± . (mean±sd) and . y± . since tx were studied. on the day of study all patients had normal cbp. % had lvh of whom % had abnormalities on abpm. overall, % patients had both abnormal abpm and lvh. % had other findings: % abnormal abpm but no lvh; % normal abpm but no lvh; % normal abpm and lvh. data were analysed for differences between groups of patients, with and without lvh. bp alone was significantly associated with increased lvmi. time averaged cbp was normal in all patients although differed significantly between the groups: systolic bp z-score [mean (ci)] . ( . , - . ) with lvh; -. (- . , - . ) without lvh. there were significant differences by abpm criteria relating to several components of the abpm profile including mean arterial pressure, systolic and diastolic bp load. no difference was found between the groups for hb, ca*po product, ipth and cgfr. conclusions: we have found the majority of our renal transplant patients have normal cbp but have abnormal abpm in association with lvh. this suggests better control of hypertension should be achieved in patients who have abnormal abp profiles and lvh. a new group of patients with normal abpm but lvh has also been identified. background: obesity is an independent risk factor for renal failure. therefore, we compared the body composition of pediatric nephrology patients with the general child population over two decades. methods: , patients with a mean age of . ± . years were studied. in , patients ( . %), sufficient data were available to analyze body composition. body composition was measured as body mass index (bmi) z-score because of the age dependency, calculated on the basis of data from the national (usa) center for health statistics ( ) . results: enuresis ( . %), hematuria ( . %), recurrent urinary tract infections ( . %) and proteinuria ( . %) were the most common diagnoses. the bmi z-score of the pediatric nephrology patients increased significantly from . ± . in - to . ± . in - and . ± . in - . while the rate of this increase was not statistically different from that seen in the normal population, they consistently demonstrated a significantly higher bmi z-score (average + . ) over time. nephrotic edema, non-nephrotic proteinuria and hypertension were not confounding factors. conclusions: patients seen in our pediatric nephrology service over two decades had a higher bmi than the average child population. this implies that these patients are at even greater risk for development of chronic kidney disease later in life. we recommend therapeutic intervention to address this potentially modifiable risk factor. objective: b cell dysregulation is believed to be involved in the development of childhood-onset systemic lupus erythematosus (sle). there is limited evidence regarding efficacy and safety of interventions targeting b cell in children. in our study we evaluated efficacy and safety of b lymphocyte depletion therapy. methods: data of children ( % male) with sle aged . years ( . - . ) treated with rituximab in a single centre were retrospectively reviewed. biochemical parameters were evaluated before and after treatment, and the normalisation of the parameters was assessed as a primary outcome. results: prior to rituximab therapy all patients received extensive immunosuppressive agents. indications for rituximab therapy were chronic (n= ) or acute illness, in either relapsing sle (n= ) or first presentation (n= ). rituximab mg/m was intravenously administered twice within a -week period in combination with cyclophosphamide. patients were followed up for . years ( . - . ) . no serious side effects were seen, except for viral infections such as herpes zoster (n= ). all patients with high creatinine (n= ; ± mmol/l) prior to rituximab showed a decline within months (mo), achieving a stable level by mo ( ± mmol/l, p< . ). all patients with hypoalbuminaemia (n= ; . ± . g/l) improved ( mo: . ± . g/l, p< . ). low c level ( . ± . g/l) as seen in patients prior to treatment resulted in an increase up to mo ( . ± . g/l, p< . ). a decline of previously high anti-dsdna (n= ; ± iu/ml) was observed in all patients ( mo: ± iu/ml, p< . ). conclusion: rituximab is safe and effective when used in combination with standard immunosuppressive agents. further prospective studies are essential to evaluate the longterm safety of the drug. outcome of severe henoch-schönlein purpura nephritis treated with longterm immunosuppression m. shenoy, m. bradbury, l. lewis, n. webb royal manchester children's hospital, department of nephrology, manchester, united kingdom aims: to look at the long-term outcome of all children with severe henoch-schönlein purpura nephritis (hsn) treated with long term immunosuppression in a single centre over a ten year period. patients and methods: retrospective review of the records of children ( male) with iskdc grade b, , and hsn managed at our institution from / / to / / results: the mean age at presentation was . years (range . - . years). the median estimated glomerular filtration rate (egfr) at presentation was ml/min/ . m (iqr . - . ) and urine protein: creatinine ratio (up: uc) was mg/mmol (iqr - ). the indication for biopsy was nephrotic syndrome in , nephrotic range proteinuria in , sub-nephrotic range proteinuria in , acute nephritis in and nephritic-nephrotic syndrome in . a total of patients were treated with weaning dose of steroids, of whom were also commenced on long-term azathioprine (mean duration . months). of these children received an - week course of oral cyclophosphamide ( - mg/kg/day) prior to azathioprine therapy ( - mg/kg/day). outcome: after a mean follow-up period of years, ( %) have made a complete recovery, ( . %) have persistent proteinuria but normal egfr, ( . %) have persistent proteinuria and are on anti-hypertensive therapy with normal egfr and ( . %) have progressed to esrd. older age at presentation was the only independent risk factor for poor outcome ( . years vs. . years, p= . ). conclusions: despite treatment with cyclophosphamide, long-term steroids and azathioprine, a majority of children with hsn grade - b on initial biopsy have persistent renal abnormalities on long term follow-up. only older age at presentation was associated with poor outcome. background: resent advances in podocyte biology indicated that the main cause of the heavy proteinuria in nephrotic syndrome (ns) is a dysfunction of slit diaphragm. on the other hand, the classical charge selective barrier is not likely to have a place in slit diaphragm. therefore we reevaluated the charge selective barrier function in ns and chronic glomerulonephritis using recently established charge selectivity index (csi; takahashi et al, pediatr res : , ) in comparison with dent disease. patients and methods: csi is a clearance ratio of igg (stokes einstein radius - , pi . - . ) and iga (stokes einstein radius , pi . - . ) . the assay of serum and urinary igg and iga was performed using laser nepherometry and enzyme immuno-assay. in order to evaluate the csi of normal glomerular filtrate, we measured the csi of dent disease. the urine of dent disease is considered to be a concentrate of filtered protein from normal glomerulus, without having a process of tubular protein reabsorption. thirty eight patients with podocyte diseases (focal and segmental glomerulosclerosis , finnish type congenital nephrotic syndrome , steroid sensitive nephrotic syndrome ), patients with chronic glomerulonephritis (iga nephritis , henoch-schönlein purpura nephritis , mesangiocapillary glomerulonephritis , alport syndrome ) and patients with dent disease, were analyzed. results and conclusion: csi (mean±sd) of podocyte disesses, chronic glomerulonephritis and dent disease was . ± . , , ± . and . ± . respectively. the results apparently indicated that the charge selective barrier of gcw is working strongly in normal glomerulus, less strongly in podocyte diseases and not working in chronic glomerulonephritis. objectives: nphs mutations have been reported in familial and sporadic srns. we investigated the prevalence of nphs mutations among south-east asian chinese and their association with clinical outcomes. methods: genomic dna from patients with primary sporadic srns (mean age at onset . ± . years, range . - . years) and cord blood controls were screened on all exons and exonintron boundaries using direct sequencing. results: a missense heterozygous c>t mutation in exon was identified in only one patient. polymorphisms t>c and a>g in exon were detected in both groups. in the patient group, the genotypic frequency of tt, tc, cc at position was . , . and . , and aa, ag and gg at position was . , . and respectively, consistent with hardy-weinberg expectations. there was no significant difference in allele frequencies between patients and controls. using binary logistic regression analysis, individual polymorphisms did not appear as informative predictors of poor clinical outcome, defined as persistent proteinuria or renal failure (p> . ). on analyzing composite genotypes, carriers of at least a copy of the c allele were significantly associated with poor outcome (p= . , or= . , % ci: . - ), while heterozygotes for a>g were associated with good outcome (p= . , or= . , % ci: . ± . ), suggesting possible interactions between the polymorphic sites. further analysis showed that the genotypic combination of tc/cc with aa was more likely to have a poor clinical outcome. no significant linkage disequilibrium was detected between the two polymorphisms. conclusion: the concomitant occurrence of at least a copy of the c allele and the aa genotype may be associated with poor clinical prognosis in srns but larger studies are needed to confirm these findings. renal hypodysplasia (rhd) is characterized by a reduced kidney size and/or maldevelopment of the renal tissue following disturbed organogenesis. numerous deletion mouse models of developmental genes have been established presenting with anomalies of the kidneys resembling rhd, among these the knock-out of bmp and six . here, we report on the first human mutations in bmp and six identified in children with rhd, among these three different mutations in bmp in five unrelated patients (ser cys, thr ser, asn lys) and three different mutations in six also in five unrelated individuals (leu phe, pro leu, asp asn). overexpression assays in zebrafish demonstrated that ventralization and dorsalization caused by bmp and six overexpression, respectively, could be diminished after overexpression of mutant constructs expressing the human mutations identified. morpholino knock-down of zebrafish bmp and six . reveals specific roles of these genes for pronephric development, affecting the expression of wilms tumor- (wt ) and glomerular development. rna analysis of cos and hek transfected with different bmp constructs showed a lower level of mrna abundance in bmp mutants, indicating a possible negative feedback of the mutants on their own mrna expression and/or stability. nonreducing western analysis revealed that s c-bmp forms alternative protein complexes as compared to wildtype-bmp , due to the formation of extra disulfide bonds. these studies implicate six and bmp as important players in the development of the renal system, and suggest that defects in these proteins could affect kidney development at multiple stages leading to the congenital defects observed in rhd patients. apoptosis is important in normal renal development in which regulation of cell numbers is critical. studies have shown that apoptosis occurs in non-cystic tubules in pre-uremic pkd kidneys, thus providing the mechanism whereby expansion of cysts is accompanied by loss of normal nephrons. to date, it is unclear which initiating factors (intrinsic, through mitochondrial damage or extrinsic, through ligand activation of death receptors) are responsible for apoptosis in pkd and whether they are the same in ad-and arpkd. aim: to elucidate the sequence of activation of intracellular apoptotic pathway(s) in both ad-and arpkd. methods: proteins were extracted from tissues of human ad-and arpkd kidneys and normal adult (nhk) and fetal kidneys (hfk). quantitative western immunoblot analysis was carried out for markers of intrinsic and extrinsic apoptosis. immunohistochemical staining for these markers was performed on tissue sections of the same kidneys. results: markers of extrinsic apoptotic pathways, caspases and , were significantly increased in ar-and in adpkd tissue by comparison to nhk and hfk tissues. these increases were seen in early stages of adpkd and were more pronounced later in the disease. for the intrinsic pathway, caspase and bid were increased in hfk tissue, but unchanged in ad-and arpkd tissue compared to nhk tissue. staining for caspase was found in hfk, but was absent in all other kidney tissues. staining for caspase was seen in early adpkd and endstage (es) adpkd as well as in es arpkd. caspase was identified as the main executing caspase of fetal development and adpkd, but wasn't seen in arpkd, where caspase predominated. conclusion: induction of extrinsic pathways of apoptosis predominates in pkd and occurs early in the disease process in adpkd, but only later in arpkd. intrinsic apoptosis predominates during development. intrauterine growth restriction (iugr) is a risk factor for an aggravated course of renal diseases in later life. the influence of postnatal factors, eg. accelerated catch-up growth, is not well understood. we therefore analysed the influence of postnatal nutrition after iugr on the developement of later renal inflammation and fibrosis in the rat. iugr was induced by low protein diet ( % vs. %) in pregnant wistar dams. litter size was reduced to or male animals in iugr (lp , lp ) and control animals (np , lp ), respectively. animals were sacrificed on day . mean arterial blood pressure was similar in all four groups. lp -( . ± . ml/h/ g) and np animals ( . ± . ml/h/ g) showed reduction of endogen creatinine clearance by % (vs. np and lp ) (p< . ). renal mrna expression of il ( , x), tgfβ ( , x) , endothelin ( , x) und osteopontin ( , x) was significantly higher in lp than in np . lp showed the highest glomerulosclerosis-score (( . ± . ) (vs. np ( . ± . ), lp ( . ± . ) and, np ( . ± . )) (p< . ). as marker of extra cellular matrix expansion glomerular collagen-iv deposition was significantly higher in lp ( . ± . %) (vs. np ( . ± . %), lp ( . ± . %) and np ( . ± . %)) (p< . ). postnatal nutrition modifies the consequences of iugr in the kidney. increased postnatal nutrition of the individual animal is associated with aggravated renal inflammation and fibrosis after iugr. unilateral renal agenesis (ura): how intensively do we need to investigate and follow-up? s. rhodes, a. watson nottingham university hospitals, children and young people's kidney unit, nottingham, united kingdom a single kidney is one of the commonest urinary tract abnormalities in the general population. concerns remain about long-term outcomes with a reduced nephron mass and hence intensity of investigations and duration of follow-up. we identified cases with ura (ectopic and pelvic kidneys excluded) from our nephrourology database between and . ( %) occurred in males and ( %) had left ura. ( %) were detected antenatally with / ( %) recognised in the last years. median age of detection for postnatal ura was mths (range . - mths) with uti ( %) as the main indication for ultrasound scan (uss). % patients were classified as simple ura with no associated abnormality and % as complex with problems such as vesicoureteric reflux (vur)( %), hydronephrosis or scarring. all cases reviewed had uss which showed compensatory hypertrophy in / ( %). / ( %) had dmsa scan and / ( %) micturating cystogram. of those antenatally detected single kidneys with normal initial uss none had vur, scarring, hypertension or proteinuria. these patients were discharged from follow-up at the median age of mths (range - mths). all complex cases have continued under follow-up. conclusions: our data suggest that the incidence of antenatally detected ura may be increasing. investigations need to be individualised depending upon the initial uss. the value of routine dmsa and mcug in simple cases is questioned. most of these patients can be discharged after adequate documentation of compensatory hypertrophy of the normal kidney, absence of proteinuria, normal blood pressure and renal function. autosomal dominant pdk (adpkd) in childhood j. crocker, p. wornell, p. acott iwk health centre/dalhousie univeristy, division of nephrology, halifax, canada autosomal dominant polycystic kidney disease (adpkd) is the most common genetic kidney disease with in adults progressing to end-stage renal disease (esrd). a program for intervention in childhood at presentation with adpkd was developed and instituted in . our long-term objective is to modify clinical parameters that may contribute to risk of development of esrd in adulthood. seventy children with adpkd (average age . yr) were followed, of which ( %) had nephromegaly +/-cysts on antenatal ultrasound. modifiable risk factors were common including hypertension ( %), hyperlipidemia ( %), and proteinuria ( %). ace inhibitors were first line therapy for proteinuria and/or hypertension. ace inhibitors may modify cyst progression so they have been made available to non-hypertensive children as well. most patients with hyperlipidemia responded to dietary intervention with one patient developing gallstones. in the past years we have focused on renal calculi, as this is a known risk for a subgroup of adults with poor prognosis. we noted patients ( %) have glycinuria, which is a precursor to oxaluria. four patients have passed calculi with two of these being diagnosed by genetic linkage analysis for adpkd without radiographic cysts present. cerebral vascular studies of patients with severe headaches revealed two with vascular structural anomalies. all adolescent females received counseling regarding appropriate contraception and their pregnancy risks of hepatic cyst progression. an early intervention program targeting modifiable risk factors of adpkd patients during childhood and adolescence may modify adult renal failure risk in this population. background: techniques of chronic infant dialysis have evolved during the past decades but morbidity and mortality are not well described. methods: a retrospective review was performed on infants - months of age with end stage renal disease (esrd) treated with maintenance dialysis during the past years. the experience was divided into era ( era ( - (n= ) and era ( era ( - . dialysis modality, morbidity, and long term survival were assessed and compared between the eras. results: all patients were begun on peritoneal dialysis (pd). there were males and females. age at initiation of dialysis was , months. the predominant diagnoses were dysplasia/obstructive uropathy (n= ), autosomal recessive polycystic kidney disease (arpkd) (n= ), congenital nephrotic syndrome (cns) (n= ), other (n= ). overall survival is % ( / ) with current age of survivors ranging from months to years. mortality between era = % and era = % was not significantly different. fifteen ( %) survived to receive a kidney transplant. overall median survival is . years (era = . years; era = . years; p= . ). conclusions: although long term survival is possible in infants with esrd, mortality and morbidity remain high. improved technologies for automated pd should address the needs of the infant < kilograms. joubert syndrome and related disorders (jsrd) are a group of autosomal recessive conditions characterized by a complex neuroradiological malformation resembling a molar tooth on imaging. clinically, jsrd are characterized by overlapping phenotypes presenting neurological signs and variable involvement of other organs such as kidneys (mainly nephronophthisis -nph), retina and liver. seventy-nine italian jsrd patients from unrelated families were recruited in pediatric nephrology and neurology centers. medical records and brain mri were reviewed. patients without chronic renal failure (crf) underwent measurement of their glomerular and tubular function, a ddavp urine concentration test and a renal ultrasound. retinal examination was performed in most patients. seven patients younger then years had normal renal function but were not fully tested. of the remaining cases, had no evidence of renal disease, had developed crf mostly in their second decade of life, and were younger then years of age and had urinary concentration defects, of whom also had hyperechogenic kidneys by renal ultrasound. when comparing this latter group with age-matched jsrd patients, no other tubular function abnormality was detected. in multiplex pedigrees, no discrepancies in renal involvement between affected family members was observed. retinal involvement was significantly associated with renal disease. conclusions. evidence of interstitial renal disease was observed in one third of italian patients with jsrd. renal involvement should always be suspected in these patients, particularly if they have evidence of retinal dysplasia or other family members with symptoms related to nph. these patients should be assessed with a urine concentration test. we examined the course of children with primary obstructive megaureters (pom) treated in our hospital from - . pom occurred more often in boys ( %, p< . ) and on the left side ( %, p< . ). pom ( %) were only treated conservatively. four underwent immediate surgery following the first mag renography. one of these was nephrectomized after unsuccessful urinary diversion and persistent renal hypertension. of the kidneys primarily managed conservatively, needed a ureterocystoneostomy later on due to increasing obstruction. surgical correction of pom required a mean of days of hospitalization (incl. temporary urinary diversion, removal of catheters and treatment of complications). one child required surgical revision of early post-operative ureteric stenosis. urinary tract infections (uti) were a common complication (n= , mean . per patient). as utis occurred mainly in infants, hospital admission was commonly required ( %). only children never acquired a uti ( %). eight patients had a poor outcome as defined by partial kidney function < % on the affected side (n= ), atrophy on final ultrasound (n= ) or nephrectomy (n= ). the most potent predictor of reduced unilateral kidney function was a small kidney present from birth. secondary kidney growth failure occurred only in one case. the initial degree of obstruction on renography, but not the degree of hydronephrosis or size of megaureter predicted outcome. also, prenatal diagnosis of pom, surgical treatment and the occurrence of utis showed no association with outcome. in summary, the long-term prognosis of pom appears favorable. adverse outcomes were more closely related to congenital kidney size deficit than to the degree of obstruction. surgical interventions and the high uti incidence led to significant hospitalization times. r. bhimma, m. adhikari, k. asharam university of kwazulu-natal, maternal and child health, durban, south africa background: steroid resistant (sr) forms of ns have a poorer outcome in blacks compared to other racial groups. methods: children with srns - years old were analysed retrospectively for the period - . treatment schedules included oral cyclophosphamide with prednisone only (n= ); prednisone on alternate days with methylprednisolone and oral cyclophosphamide (n= ); oral prednisone on alternate days, doses of intravenous methylprednisolone on alternate days and monthly doses of intravenous cyclophosphamide (n= ) or cyclosporine adjusted to a trough level of - mg/ml (n= ). we compared the clinical, biochemical characteristics and outcome of these children using different forms of therapies. results: ( . %) underwent renal biopsy. ( . %) were indian and ( . %) were black. ( . %) had minimal change ns, ( . %) had focal segmental glomerulosclerosis (fsgs), ( . %) a proliferative form of ns, and ( . %) had other forms of ns. / ( . %) indian children biopsied were in complete remission and / ( . %) with mcd who were treated with oral cyclophosphamide and prednisone only achieved complete remission. / ( %) indian children not biopsied who received only oral prednisone and cyclophosphamide achieved complete remission. / ( . %) black children who were biopsied achieved complete remission. none of the eight black children who were not biopsied given only oral cyclophosphamide and prednisone achieved complete remission. conclusion: since % of indian children with srns responded to a trial of oral cyclophosphamide and prednisone but none of the black children did, we propose the use of oral cyclophosphamide therapy in non black children before embarking on renal biopsy. mj. kemper, c. moeller, n. rink, m. van husen, de. müller-wiefel university of hamburg, pediatric nephrology, hamburg, germany introduction: ssns is often complicated by a refractory clinical course with frequent relapses and steroid dependency despite aggressive alternative immunosuppressive regimens. since recent immunological findings suggest an alteration of not only t-but also b-cell immunity in ssns (kemper (kemper , we hypothesized that that immunological targeting of b-cells with antibodies directed against cd (rituximab) is able to maintain remission (rm) in treatment refractory patients with ssns methods: a total of six patients with complicated courses of ssns had severe steroid-dependency and toxicity. all patients had previously been treated with cyclophosphamide, two patients relapsed on maintenance therapy with cyclosporine, one relapsed on additional levamisole and one on mmf. treatment was initiated at a median age of (range - . ) years and rtx was given at steroid induced rm at a dose of x mg/m bsa within weeks. results: a complete b-cell depletion was induced for at least months in all patients. rm could be maintained in all patients and steroid treatment could be discontinued after a median of . months (range - . ) . also csa could be discontinued in the two patients on maintenance treatment. at current follow-up of . months (range - . ) the two patients after csa discontinuation relapsed after . and . months, respectively, but responded after steroid induced rm-to a second course of rtx. all other patients remained in remission off treatment so far. no significant clinical side effects were noted. conclusion: in summary and conclusion, rtx seems to be a therapeutic option in complicated ssns. long-term follow-up and future prospective studies are necessary to further define the role of rtx in the treatment of refractory steroid sensitive nephrotic syndrome. efficient control of secondary hyperparathyroidism can be achieved by calcimimetics. they increase calcium sensing receptor (car) sensitivity to extracellular calcium. in r- -treated uremic rats, proteinuria has been significantly reduced by calcimimetics. thus, we examined the potential direct effect of r- on podocytes. the car was expressed in cultured immortalized podocytes (quantative rtpcr, western blot) and in podocytes obtained from healthy and subtotally nephrectomized rats (immunohistochemistry). glomerular car abundance was increased by uremia and r- . the car colocalized with the plasma membrane and intracellular filaments in cultured podocytes, but not with the caveolin -and -rich membrane fractions. we then studied the effect of r- on the mitogen-activated protein kinase (mapk) family. jnk was not activated. p showed a biphasic response pattern, whereas erk / (and further downstream, p ribosomal s kinase) showed dose-( - nmol/l) and time-dependent phosphorylation, resulting in the activation of the transcription factor camp response element binding protein (creb). creb phosphorylation induced bcl-xl expression and bad phosphorylation, both of which have prosurvival activity. specificity was confirmed by addition of mek / inhibitor u , which completely blocked r- -induced creb phosphorylation. facs analysis revealed a significant, % decrease in puromycin-induced apoptosis in podocytes treated with r- for , and hrs. in conclusion, calcimimetics induced prosurvival gene expression in podocytes via mapk, protecting them from apoptosis. calcimimetics may have a direct renoprotective action beyond control of hyperparathyroidism in chronic kidney disease patients. we report our experience with plasma therapy in a family of three sisters from whom two are homozygous twins (patients b and c), presenting a missense mutation of the exon of the human complement factor h gene (hf- ). the factor h concentration has always remained normal and no systemic complement activation has ever been detected. in a ten years period, the followings have been observed: / no use of plasma exchange lead to immediate esrf of native kidneys (patient a); ) conventional plasma therapy ( sessions at presentation followed by repeated ml/kg plasma infusions when relapse of hemolysis and thrombopenia) could not impede esrf (patient b); ) the use of intensive pe at presentation (daily pe ( ml/kg ffp until plasma creatinine normalization followed by one pe/ w indefinitely) lead to a normal gfr years after presentation despite relapses (patient c); / no prophylactic pe for tx lead to immediate hus relapse and transplant loss (patient ); ) prophylactic pe allowed a successful tx in patient b (pl. creat mcmol/l after years); ) early and intensive pe allowed complete normalization of several hus relapses after tx (patient b). conclusions: in fh mutation-related atypical hus, ) intensive and indefinitely prolonged pe can allow a normal function of native kidney at long term; ) prophylactic pe allows successful kidney tx; ) early and intensive pe allow reversion of hus relapse after tx. the success of plasma therapy is bound to the followings: a/ the use of pe and not plasma infusion. b/ the prolongation of daily pe after normalization of hemolysis parameters, and further prophylactic pe. c/ the use of pe prophylaxis from before tx. d/ a minimum pes frequency of one/week in case of prophylactic treatment for tx. e/ immediate intensification of pe frequency in case of relapse. objectives of study: heparan sulfates (hss) are highly polyanionic sugar chains in the glomerular basement membrane (gbm) and have been reported to play an important role in the chargeselective permeability of the kidney. alterations in hs expression have been reported in a number of renal pathologies. in this study, we evaluated if degradation of hs in the gbm resulted in proteinuria in rats, using a controlled in vivo approach. methods: heparinase iii and neuraminidase were injected i. v. in -month old wistar rats at t= hr and t= hr, and kidneys were removed at t= hr. urine samples were taken at various time points. cryosections were stained for hs using specific antibodies, and for hs stubs (generated by heparinase). in addition, hs was evaluated at the electron microscopical level. neuraminic acid expression was analysed by peanut agglutinin lectin. the hs content in urinary samples was evaluated by agarose gel electrophoresis. urinary neuraminic acid was studied by an enzymatic colorimetric assay. presence of urinary albumin (proteinuria) was investigated by sds-page and by a competition elisa. results: injection with heparinase iii resulted in an almost complete absence of glomerular hs staining. cupromeronic blue staining was also greatly reduced in the gbm, further indicating that hs was largely degraded. staining for the hs proteoglycan core protein agrin was unaltered. in the urine a strong increase in hs was found, already at the first point in time of urine collection ( hr after the first injection). however, no urinary albumin or other proteins could be detected at any point in time analysed. injection of rats with neuraminidase resulted in a major increase of albumin in the urine. conclusion: in conclusion, removal of hs from the gbm does not result in acute albuminuria, whereas removal of neuraminic acids does. introduction and methods: children undergoing deceased ( ) or living ( ) donor kidney transplantation were randomized to receive tacrolimus, azathioprine, steroids and two doses of basiliximab (tas+b) or tacrolimus, azathioprine and steroids(tas). previously reported six month follow-up biopsy-proven acute rejection rates were . % (tas+b) and . % (tas). patient survival was % and graft survival % in both arms (am j transplant ; : - ) . in this investigator-driven follow-up study individual outcome data were submitted annually to the coordinating centre. results: two year follow-up data were obtained for ( . %) of the who completed the six month study. there was one death in the tas group occurring at month . there were graft losses in the tas+b arm and in the tas arm. all graft losses in the tas+b arm occurred within the first months. kaplan-meier estimates of year graft survival were . % for tas+b and . % for tas (p= . breslow generalised wilcoxon test). episodes of biopsy proven acute rejection occurred in in tas+b and in tas, kaplan-meier estimates of freedom from rejection being . % and . % respectively (p= . ). renal function did not differ significantly between the two arms; the median (iqr) plasma creatinine levels were ( - ) in tas+b and ( - ) in tas (p= . ). similarly there was no evidence of a difference in either systolic or diastolic blood pressure between the two arms. there was one case of b cell ptld in the tas+b arm at months in addition to two cases in the tas arm previously reported in the month study. conclusions: the addition of basiliximab to a regimen of tacrolimus, azathioprine and steroids does not appear to result in an improvement in either acute rejection rate or graft survival at two year follow-up. further data collection is ongoing. chronic renal dysfunction is a major complication after heart transplantation (htx). the pathophysiology is not yet fully understood but is thought to be in part due to calcineurin inhibitor (cni) toxicity, and reducing cni exposure has become one of the main strategies aimed at ameliorating renal outcome in htx recipients. we previously reported a significant improvement of renal function in htx children with biopsy-proven cni nephrotoxicity and chronic renal failure, year after the reduction of cni dosage with a concomitant replacement of azathioprine by mycophenolate mofetil. we ought to determine whether this improvement was persistent after years of follow-up, despite the histological lesions of chronic cni nephrotoxicity. gfr evaluated by annual inulin clearance had improved from a mean of . ± . ml/min/ . m (range - ) at time of the switch to . ± . ml/min/ . m (range - ) (p= . ) one year after ( % improvement), and remained stable at . ± . ml/min/ . m (range - ) (p= . ) years after the switch. maximal urinary osmolality followed the same increase profile from ± mosm/kg before the switch to ± at one year and ± after years (p= . ). meanwhile, the occurrence of serious adverse events such as infectious episodes, acute rejection and chronic allograft dysfunction as assessed by clinical examination, echocardiography and endomyocardial biopsies were not different from a control group of patients whose treatment was unchanged. no malignancy was observed in either group. in conclusion, reduction of cni dosage and replacement of azathioprine by mycophenolate mofetil lead to a safe and long-lasting improvement of renal function in children with heart transplants and cni-induced nephropathy. previous studies have demonstrated reduced bone mineral density (bmd) in some patients with idiopathic hypercalciuria (ih). reduced bmd during childhood may impact adult peak bone mass. bisphosphonates employed in adults with ih and reduced bmd resulted in conflicting outcomes. we evaluated the effects of oral bisphosphonate, alendronate (ale), in patients with persistent ih and reduced bmd. patients presented at ages , , yr, with hematuria/dysuria, had recurrent urolithiasis, and all had ih (uca > mg/kg/ hr). despite maximal traditional rx with low na/high k diet, thiazides, k-citrate, ih persisted ( . - mg/kg/ hr). at ages , and . yr, dxa showed reduced bmd, and ale , and mg/once weekly was given for , and months, respectively. after months of ale, uca decreased significantly compared to baseline (mean±sd, . ± . vs. . ± . mg/kg/ hr, p< . ). compared to baseline, bmd z scores year after starting ale improved at the spine (- . ± . vs. - . ± . , p< . ) and hip (- . ± . vs. - . ± . ) . the decline in uca during ale rx correlated with the increased bmd z scores in the spine (r=- . , p= . ) and hip (r=- . , p< . ). height z scores, serum creatinine, ca, p, electrolytes and pth remained normal throughout the rx period and no further hematuria or new stones occured. in summary, ale normalized uca previously resistant to traditional rx, eliminated urinary symptoms and improved reduced bmd in children with ih. the use of a single oral weekly dose appears adequate and safe. larger prospective studies are needed to confirm these preliminary results. in addition to its classical role in the regulation of calcium (ca) and phosphate (po ) homeostasis, vitamin d has important immunomodulatory and anti-inflammatory effects, that in turn can influence atherosclerotic vascular disease. we studied the impact of vitamin d levels and inflammation on vascular structure and function in children on dialysis. children (age . ± . yrs) on dialysis (mean duration . ± . yrs) were studied. all children received α-hydroxyvitamin d (alfacalcidol) . cumulative data on ca, po and pth, doses of po binders and alfacalcidol were recorded. , -dihydroxyvitamin d (vit d) and high-sensitivity crp (hs-crp) levels were measured by i radioimmunoassay and elisa respectively. all children had carotid intima-media thickness (cimt), pulse-wave velocity and cardiac ct for coronary calcification. ( %) children had vit d deficiency (levels< pmol/l), ( %) hadnormal levels ( ± pmol/l) and ( %) had high levels (> pmol/l). vit d positively correlated with serum ca, caxpo and alkaline phosphatase. both cimt and calcification showed a bimodal distributionpatients with vit d levels < or > pmol/l were significantly more likely to have calcification or raised imt than those with vit d levels in the normal range. hs-crp levels independently predicted cardiac calcification (p= . ) but not cimt. there was a strong inverse correlation between vit d levels and hs-crp (p< . , r=- . ). patients with vitamin d levels< pmol/l and hs-crp levels> mg/l had -fold greater calcification scores than subjects below these cutoffs. in conclusion, vit d deficiency is common despite treatment in children on dialysis. vit d may be an important mediator of vascular damage both through its hypercalcaemic and anti-inflammatory actions. severe growth failure remains one of the challenging problems in the care of children suffering from chronic renal failure (crf). although, rhgh has been proven to increase final adult height in prepubertal crf patients only limited data on its efficacy in the pubertal age-range are available. in addition, the impact of the underlying renal disease and the mode of renal replacement therapy on final height in these patients remain unclear. we report on final height data of ( female) severely growth-retarded crf patients (standardized height <- sds; database: kigs medical outcomes, pfizer). mean age at start of rhgh therapy was . ± . years, standardized height was - . ± . sds and duration rhgh therapy was . ± . years (range . to . years). at baseline % of the patients were on conservative treatment, % were on dialysis and % had a functioning renal allograft. in the whole study population mean standardized height was increased in the first treatment year and at attainment of final adult height by + . sds and + . sds, respectively (each p< . vs. baseline). prepubertal children aged less than years at start of rhgh therapy showed the best growth response (+ . sds). in pubertal patients mean increase in standardized height was + . sds, whereas growth response in patients with delayed onset of puberty (>+ sd) was significantly lower (+ . sds; p= . vs. other groups). the duration of rhgh therapy was positively associated with cumulative height gain. growth response was significantly lower in patients on long-term dialysis and in patients with nephropathic cystinosis. conclusion: rhgh therapy in severely growth retarded prepubertal and pubertal crf patients results in an increased final adult height. growth response is diminished in crf patients with markedly delayed onset of puberty. tightly regulated rankl/opg system is essential for normal bone remodelling. however, the exact roles of those osteogenic markers in uremic bone disease have yet to be defined. we therefore assessed the potential relationship of the rankl/opg system in bone biopsy proven secondary hyperparathyroidism (hpt) in dialyzed children. methods: patients aged ± years were on ccpd for ± months. s-ca, p, alk p'tase, pth, opg and rankl levels were measured. bone biopsies were obtained after double tetracycline labeling and none of the patients were treated with vitamin d for four weeks prior to biopsy. results: s-ca levels were . ± . mg/dl, p: . ± . mg/dl, alk p-tase: ± u/l, pth: ± pg/ml. bone biopsy findings revealed high turnover bone disease in patients, patients had normal bone formation rate (bfr). mean opg and rankl levels were . ± . and . ± . pmol/l, respectively (reference control=opg: . ; rankl: . ). opg correlated with bfr (r= . , p< . ) and adjusted apposition rate (r= . , p< . ), while inversely correlated with osteoid maturation time (omt) (r=- . , p< . ) and mineralization lag time (r=- . , p< . ). rankl/opg ratio was negatively correlated with mineral apposition rate (r=- . , p< . ) and positively with omt (r= . , p< . ). pth was correlated with bfr (r= . , p< . ) and resorption area (r= , , p< . ), but not with any mineralization markers. there were no correlations between pth and opg or rankl. conclusion: opg, in contrast to rankl, exerts a dual effect on the skeleton by promoting mineralization and increasing bfr. these osteogenic markers might be of benefit in characterizing the turnover, mineralization and volume of the skeletal lesions of secondary hpt as recently recommended by kdigo. "sevcan bakkaloglu was supported by tÜbitak (scientific and technological research council of turkey). this study was supported by usphs grants dk- , dk- and mo -rr . " pth values are widely used to guide therapy for renal osteodystrophy in patients treated with maintenance dialysis yet target values are based on cross-sectional studies and discrepancies between bone formation rates (bfr) and pth have been described during intermittent calcitriol rx. thus, we evaluated the relationship between serum biochemical parameters and bone turnover during treatment with intermittent vitamin d sterols. patients aged ± yrs with biochemical and bone biopsy (bbx) proven nd hpt received months of vitamin d ( , d or d ) given in twice weekly oral dosing and phosphate binders. dose of vitamin d was titrated upwards monthly to maintain st pth-ima(nichols r ) levels between - pg/ml. bbx was then repeated. s-ca, p, alk p-tase and pth by st and nd pth-imas were obtained monthly throughout therapy. baseline values were: p: . ± . mg/dl, ca: . ± . mg/dl, alk p-tase: ± iu/l, st pth-ima ± pg/ml, nd pth-ima: ± pg/ml. final values were: p: . ± . mg/dl, ca: . ± . mg/dl, alk p-tase: ± iu/l, st pth-ima: ± pg/ml, and nd pth-ima: ± . bone formation rate (bfr/bs) decreased from ± to ± um /mm /d (nl: - . ); % achieved normal bone turnover. nd pth-ima values were - % lower than st pth-ima levels; there was no difference in predictive capability of the two assays. patients achieving normal bfr/bs had st pth-ima values of ± pg/ml. the sensitivity, specificity and ppv of a st pth-ima range of - pg/ml for normal bfr/bs were % ( % ci: - %), % ( - %), and % ( - %) respectively. during therapy with intermittent vitamin d sterols, maintaining pth levels higher than currently recommended results in normal bfr/bs and prevents adynamic bone. maternal diabetes will induce abroad array of congenital malformation. consistently with these hypotheses, we observed the defects of renal development of diabetic pregnancy from late phase of embryogenesis to postnatal period in animal model (c bl/ j mice). histological analysis of phenotypes revealed decreased glomerular numbers, glomerular hypertrophy and hypercellularity, as well as renal tubular detachment in sequential late phase of kidney development in the offspring of diabetic female mice. tunel assay showed signficinatly increased cell apoptosis in fetal kidneys of hyperglycemic group. rt-pcr and fish study of kidneys of fetal and newborn mice revealed that gdnf and early growth response alpha (egr-α) are two of crucial genes inhibited in hyperglycemic ambience. in human, we presumed that children of gestational hyperglycemic mothers have the same defects of renal development as our animal model similarly, thus we measured and compared echogram of kidney/liver echoenic ratio in children born to gestational hyperglycemic mothers and health children. interestingly, our human ultrasonic study indicated that after age of months, the diabetic children had increased echogenic ratio of kidney/liver than the healthy age matched children (p< . ). we also found that . % of diabetic children had nonobstructive hydronephrosis. this simple sonographic procedure may provide a permissive was for clinicians to obtain the basis of long-lasting follow-up of these high-risk children as early as possible. keywords: diabetic embryopathy, renal development, glial cell line-derived neurotrophic factor, early growth response alpha, renal sonogram. genetic inactivation of spry in mice results in increased number of ub branches and expanded gdnf, c-ret and wnt- expression domains (basson et al., dev. cell, ) , indicating that spry is a negative regulator of the gdnf-ret-wnt pathway. ang ii induced ub branching morphogenesis, partly via stimulation of egfr tyrosine kinase activity (yosypiv et al. jasn, ) . we tested the hypothesis that ang ii stimulates the gdnf-ret pathway via repression of spry . cd mice metanephroi were dissected on embryonic (e) day e . , grown on filters in the presence or absence of ang ii ( - m, n= /group) for hours and subjected to whole-mount ish with digoexigenin-labelled spry , c-ret, wnt- and gdnf crna probes. spry mrna was expressed in ub branches and in condensing mesenchyme. c-ret and wnt- were expressed in ub tips, and gdnf-in the metanephron mesenchyme. ang ii downregulated spry expression in the ub. in contrast, c-ret and wnt- were induced by ang ii in the ub tip cells. gdnf expression in the mesenchyme was also upregulated by ang ii. in addition, ang ii stimulated ub tip cell proliferation, as determined by in vivo brdu in corporation ( . ± . vs. . ± . ; p< . ) compared to control. these findings suggest a model in which ang ii-mediated inhibition of spry gene expression releases. ret tyrosine kinase activity leading to upregulation of c-ret and its downstream target gene, wnt- . enhanced wnt- expression, in turn, induces gdnf in the adjacent mesenchyme. this causes focal bursts of ub tip cell proliferation and branching. these results support the hypothesis that abnormal collecting system development in angiotensinogen, renin, ace or at -deficient mice is at least partly due to aberrant regulation of the ub branching morphogenesis program. objectives of study: nephrogenesis requires a fine balance of many factors that can be disturbed by intrauterine growth restriction (iugr), leading to a low nephron endowment. our previous studies have shown that offspring born to mothers supplied low protein diets during pregnancy have fewer glomeruli than normal at birth in sd rats. the aim of this study was to identify the possible pathogenesis of abnormal nephrogenesis and decreased glomerular number in iugr by comparative proteomic approach. methods: iugr was induced in sd rats by isocaloric protein restriction in pregnant dams. kidney proteins were obtained from neonatal normal rats (control group) and iugr rats (iugr group) respectively. a series methods including -de, silver staining, mass spectrometry and database searching were used. the -de test was repeated three times in each group. results: after silver staining, the -de image analysis detected average ± spots in iugr group and ± spots in control group. the average matched rate was % and % respectively. the differential proteomic expression analysis found eleven protein spots were expressed only in iugr group and one in control group. seven protein spots were up-regulated more than folds and two down-regulated more than folds in iugr group compared with those in control group. these protein spots were preliminarily identified, which were structural constituents of cytoskeleton including vimentin, cytokeratin , perlecan and b-actin, transcriptional factors including splicing factor, rho gdp dissociation inhibitor alpha and cell division proteinkinase , enzymes including retinal dehydrogenase , transketolase and so on. conclusions: data from this study may provide, at least partly, valuable experimental evidence of proteins involved in the pathogenesis of abnormal nephrogenesis and decreased glomerular number in iugr. the aim of the study is to describe the natural history of tcf /hepatocyte nuclear factor- beta linked disease in children. prenatal and postnatal renal evolution and extrarenal manifestations of patients were reported. thirty one had prenatal diagnosis of developmental nephropathy: bilateral foetal hyperechogenic kidneys or a hyperechogenic kidney with a controlateral multicystic dysplastic kidney. % had cysts. the mean prenatal renal length was normal ( , sd) . intrauterine growth was normal with median birth weight of . kg (range . - . ) and % were small for gestational age. after a mean follow-up of months, the renal growth was impaired with a mean renal size of - . sd. patients with a solitary functioning kidney showed no compensatory hypertrophy. thirty one patients developed bilateral nephropathy and isolated unilateral multicystic kidney. twenty eight patients had cysts, mainly cortical bilateral microcysts. the mean gfr was . ± . ml/min/sc. sixteen patients had stage chronic kidney disease (ckd), four were classified as stage , eleven as stage or ckd and two were diagnosed with end stage renal failure. annual decline of the glomerular filtration rate was . ml/min. extrarenal manifestations included patients with diabetes, one with exocrine pancreatic insufficiency, one with pancreatic hypoplasia without clinical symptoms and with cholestasis. we found a complete heterozygous deletion of the tcf gene in patients and nine different point mutations. three patients had the g c mutation, with unilateral mcdk and with bilateral severe hypoplasia leading to early renal dysfunction. tcf gene anomalies are associated with low renal function decline but in some patients end stage renal failure appeared early in life. long term follow-up is needed to determine the incidence of extrarenal symptoms, particularly diabetes. objectives: although it has been observed more than one hundred years ago that the urinary tract is very resistant to infection, its antimicrobial mechanisms have not yet been systematically characterized. we sought to elucidate the expression and relevance of the antimicrobial peptide cathelicidin in this area. methods: in order to investigate the expression of cathelicidin in health, urine samples from healthy children, pieces of healthy renal tissue, and cell cultures were analyzed. to evaluate the expression of cathelicidin during infection, urine samples from children with urinary tract infection, a mouse model of ascendant pyelonephritis and cell culture experiments were employed. the relevance of cathelicidin production was tested by bacterial challenge of cathelicidin-deficient and neutropenic mice. in addition, we studied the in vitro effects of cathelicidin on the growth and multicellular behavior of bacteria as well as we tested sensitivity of clinical e. coli strains to the peptide. results: cathelicidin is expressed by epithelial cells of healthy urinary tract and excreted into urine in low concentrations. during urinary tract infection, the secretion of cathelicidin by epithelial cells significantly increases within minutes. invading neutrophils are the source of the second wave of cathelicidin. epithelial cathelicidin protects the urinary tract against bacterial infection while neutrophil-derived cathelicidin influences the severity of infection. cathelicidin displays multiple effects on bacteria. low concentrations of cathelicidin inhibit multicellular behavior, e. g. biofilm formation of e. coli, and high peptide concentrations kill bacteria. bacteria resistant to cathelicidin have an increased ability to invade the urinary tract. conclusion: the antimicrobial peptide cathelicidin is a key factor of the mucosal immunity of the urinary tract. the predictive value of procalcitonine (pct) plasma level for renal scarring after an acute pyelonephritis (apn) is still debated. during apn, the bacterial lipopolysaccharide of the membranes induce the release of tnf, il and il . these cytokines lead to inflammation syndrome and fibrosis sequellae resulting from cell apoptosis induced by nitric oxide (no) release that is catalysed by no-synthase. the aim of this work was to clarify the physiological role of pct in renal parenchyma apoptosis and fibrosis caused by apn. we conducted a prospective study in children with a first apn episode (fever> . c°, crp> mg/l, monomicrobial urine positive culture> . fcu/ml). we excluded patients with any concomitant infection, renal dysplasia or obstructive uropathy or grade - vur children were enrolled (age . m, median m). on admission, pct, crp and phospholipase a (pla ) were quantified in serum. scintigraphy with m tc-dmsa was performed on day and months later in case of initial abnormalities. fisher's test was performed and statistical significance was defined as p< . . results: on day , ( %) presented renal parenchyma alterations, at m underwent control scan and ( %) had renal scars. pla and pct levels were correlated with early dmsa lesion but not with renal scars at m. paradoxically, initial pct level was significantly lower in the presence of renal scars ( . vs . ng/ml, p< . ). significant pct increase was observed in favourable progress (recovery . vs aggravation . ng/ml, p< . ) and no difference between recovery and improvement evolution. these results suggest the protective effect of pct against apoptosis resulting from down-regulation of nitric oxide release; so high pct values could be interpreted with caution in apn. acute pyelonephritis (apn) may lead to renal scarring with later risk of hypertension and renal insufficiency. the aims of this study were to analyse prospectively renal scars progression with time and their impact on renal growth. methods: patients (pts), aged from to years who presented scars on dmsa at months after apn were included. in these children a second dmsa was done after years. evolution of scars was analyzed following pre-established criteria independently by observers. scar progression was classified as follows: =no change, =partial improvement, =total resolution. in addition a renal ultrasound was repeated to assess kidney growth using z-score. results: renal units ( pts: f, m) were studied. the incidence of vesicoureteral reflux (vur) was . % ( / ). per renal units, vur were observed in / ( %); ( % vur grade (g) i, ii and % g iii, iv). there were scars observed month after apn which evolution over years was as follow: = % ( / ), = % ( / ) and = % ( / ). incidence of vur was higher in children presenting scars; / ( %) against / ( %) in those with or scars. to identify factors interfering with renal growth, we analyzed potential confounding variables using robust linear regression. z-score was worsened with increased number of scars observed at month after apn p< . ) and improved with disappearance of vur ( . ci . - . ; p< . ). conclusion: between month and three years after apn, % of scars improved. in our population, the number of scars secondary to pna was the most important factor affecting renal growth. the second prognosis criterion was the correction of vur. prevention of pna and rapid treatment to avoid kidney scars seems to be the essential aim to preserve optimal kidney growth. v. smolkin , , r. halevy , , w. sakran , , y. kennes , a. koren , ha'emek medical center, pediatric b, afula, israel ha'emek medical center, pediatric nephrology unit, afula, israel ha'emek medical center, bacteriology and microbiology laboratory, afula, israel the ruth and baruch rappaport school of medicine, haifa, israel febrile urinary tract infection (uti) is a relatively common infection disease in childhood. children consider at risk for uti commonly receive prophylactic antibiotics to prevent recurrence of this urinary tract disease because of the risk of kidney scarring, which may lead to complications such as hypertension or end-stage renal disease. compliance with antibiotic prophylaxis after uti was assessed in children, using a parent questionnaire and a urine test for antibacterial substances. thirty six children ( st group) received prophylactic treatment during the period of months (range - months) and the other patients ( nd group) received antibiotic prophylaxis for a longer duration ( months, range - months). in the first group of patients, ( %) of parents reported giving the antibiotics every day in comparison with ( %) in the nd group. twenty nine ( %) of urine tests were positive for antibacterial substances in the st group but only ( %) in the second group. in the st group of patients the difference in recurrent infection between regular takers and non-takers was statistically highly significant. no significant difference was found in recurrent uti rate in takers and non-takers in the nd group. failure to understand the reason for prophylaxis and forgetfulness was found to be a main reason for non-compliance. imaging studies evaluating the kidneys and urinary tract are performed routinely after a febrile uti. evidence of their value in changing management or affecting long term outcome is limited. as part of a multicentre, rct (iris ) evaluating different antibiotic regimes in the treatment of first febrile urinary tract infections, we undertook as a secondary objective, an evaluation of the diagnostic protocol. the imaging modalities (ultrasound, dmsa scintigraphy within days and voiding cystogram within - months) were assessed for their ability to predict long term parenchymal damage. children of years of age or less at the time of investigation and who had normal renal function and antenatal ultrasound, were considered suitable for analysis of the diagnostic course. us was performed in children with ( %) normal, minor changes were noted in the remainder, apart from case requiring a change in management in the form of a pyeloplasty for pelvi-ureteric obstruction. the cystourethrogram was performed in of the children with ( %) demonstrating vur. the cystogram was a poor predictor of long term damage, being positive for reflux in only of the children who subsequently developed scarring. an acute dmsa scan performed in all children, exhibited findings consistent with acute pyelonephritis in ( %). a repeat dmsa scan at months in those with evidence of acute pyelonephritis demonstrated a scarring rate of %. the data did not demonstrate the clinical efficacy of routinely performing scintigraphy in the acute phase or a cystourethrogram. our recommendations for a reasonable diagnostic work up in small children with their first episode of uti are ) performance of a scintigram months following the acute infective episode, and ) close surveillance to identify eventual recidivists. introduction: focal segmental glomerulosclerosis (fsgs) has a high recurrence rate after renal transplantation (rtx). recurrence can lead to tx loss. disease recurrence (dr) seems to be influenced by genetic background. methods: patients with childhood onset of biopsy proven fsgs who were transplanted were evaluated. genetic investigations of the nphs gene were done in patients ( . %). results: mean age at diagnosis was . years. first renal transplantation was performed at age of . years. patients received a living related (lrd), a deceased donor (dd) graft. patients data under investigation. p ( . %) recurred after a mean time of , years, p with lrd ( . %) , p with a dd ( . %). patients ( . %) lost their graft after , years, patients due to recurrence. a second rtx was performed in patients, with dd, with lrd, patients data under investigation, with % dr. a third transplantation was performed in patients and a fourth in one patient. screening for nphs mutations revealed patients with mutation in the nphs gene, homozygot, heterozygot. all patients with a homozygote nphs mutation did not recur and only the one patient with a heterozygous mutation ( / ) recurred compared to / without a mutation (p< . ). conclusion: living related transplantation was advantageous to decreased donor transplantation. patients with nphs mutations had a lower risk of recurrence after transplantation compared to patients without mutations. patients with fsgs should be screened for nphs mutations. objective: prospective ebv surveillance post tansplantation reduces incidence of acute rejection and risks of post transplant lymphoproliferative disorders (ptld). methods: prospective screening of ebv by polymerase chain reaction (pcr) and serology in all patients transplanted between - . results: patients transplanted between may and september . were cadaveric and live-related transplants. recepient ebv serology status was known but not on donors. basiliximab was used for induction and maintenance comprised of tacrolimus/azathioprine (aza) until and mycophenolate (mmf)/tacrolimus from . all received corticosteroids. had mmf/tacrolimus, aza/tacrolimus. ebv screened within first week post transplant, weekly for a month, monthly for months. when ebv pcr lv > . , mmf/aza was withdrawn, tacrolimus levels kept between - ng/ml. pcr/ serology is checked weekly for months, monthly for , until lv falls < . and vca igg becomes positive. the mmf/aza is reintroduced. patients with ebv pcr lv < . are kept on full immunosuppression while viral load and vca igg monitored. ebv viraemia detected following prospective screening. was re-activation. were symptomatic. onset varied to . months post transplant (mean . months). were on mmf/tacrolimus received aza/tacrolimus. had pcr lv> . consequently maintained on tacrolimus an alternate day steroids for period of time. cmv patient and donor status was known and antiviral prophylaxis given to nonimmune. the use of antivirals made no impact on viral load. conclusion: no patient experienced acute rejection or ptld despite modification of therapy with our prospective screening programme. antivirals have no role in protecting or reducing viral load in already infected patients. graft attrition rate is highest in the first three months after renal transplantation. we analysed data in a recent cohort from all dutch centres for pediatric renal transplantation to determine incidence and causes of such early graft failure. methods: data from all pediatric renal transplants performed between - - and - - were analysed retrospectively. a common immunosuppressive protocol was used in all centres. thrombosis prophylaxis was given according to centre policy. early failure was determined as graft failure within months after transplantation. prevalence of possible risk factors of graft failure identified by literature search were extracted from patient charts. data were analysed with univariate and multivariate logistic regression. results: the cohort consisted of transplants. age of the recipients was - yrs (mean . ). there were early graft failures ( . %). major causes of graft failure were thrombosis ( . %) and are( . %). univariate analysis identified an association of early failure with complications during surgery (or . , p= . ), cold ischemia time (or . , p= . ), side of graft donation (or . , p= . ) and diuresis in the first hour after transplantation (or . , p= . ). multivariate regression analysis showed that complications during surgery were associated with the risk of early failure (or . , p= . ), as were side of graft donation (or . , p= . ) and diuresis in the first hour after transplantation (or . , p= . ) . only the occurrence of complications during surgery was significantly associated with early graft failure due to thrombosis (or . , p= . ). conclusion: thrombosis is the major cause of early graft failure after renal transplantation in dutch children, especially after surgical complications. prospective studies are needed to determine whether early failure can be decreased by more rigorous prophylaxis. background: interleukin (il)- is a major contributor to inflammation and cell death during ischemia-reperfusion (ir) injury and its deleterious effects are mediated mainly by nuclear factor-κb (nf-κb) activation. receptor binding and signalling of il- can be blocked by the il- receptor antagonist (il- ra). the aim of our study was to characterize the effects of il- ra administration on inflammation, apoptosis and infiltration in renal ir injury. methods: renal ischemia was induced in lewis rats (n= /group) by clamping of the left renal artery for min followed by reperfusion of h or five days respectively, when kidney were removed for histological and molecular analysis. results: treatment with il- ra ameliorated ischemic renal tissue injury and inflammatory infiltration. futhermore, the number of apoptotic tubular cells was lower in il- ra treated animals h after ischemia, which was paralleled by a bax/bcl- mrna ratio towards anti-apoptotic effect. il- ra reduced the expression of monocyte chemoattractant protein- (mcp- ) mrna h and days and that of intracellular adhesion molecule- (icam- ) expression h after reperfusion in the kidney. conclusions: our results indicate that il- ra treatment ameliorates renal ir injury and this protective effect might be mediated by reduced induction of nf-κb mediated mcp- , icam- and the decreased ratio between bax and bcl- mrna expression. k. satomura, y. santo osaka medical center for maternal and child health, pediatric nephrology and metabolism, izumi, japan many studies have reported that angiotensin-converting enzyme inhibitor (acei) and angiotensin receptor blocker (arb) show renoprotective effects in adult patients with acquired renal diseases. however, these effects have not been studied in children with renal hypoplasia or dysplasia (rhd). in this study, we explored the renoprotective effects of these drugs in children with rhd. patients and methods: participants of the study were patients with rhd aged less than years. a follow-up for more than one year was conducted in our outpatient clinic. the patients had chronic renal failure, and had not received acei or arb in the past. the change of glomerular filtration rate (gfr) per year, urinary protein/creatinine (up/cr) ratio, serum potassium levels, and blood pressure before the treatment with trandolapril or candesartan were compared with those of one year after the treatment. the estimated gfr was calculated by the schwartz formula. wilcoxon rank sum test was applied to evaluate the statistical significance. results: eleven patients were eligible for this study. the mean age of the patients was . ± . years and the estimated gfr was . ± . ml/min/ . m when trandolapril or candesartan was administered. the change in the estimated gfr for a year significantly improved after the treatment with trandolapril or candesartan compared with the pre-treatment period (- . ± . vs. . ± . ml/min/ . m /year, p= . ). the up/cr ratio significantly decreased at one year after the treatment compared with that before the treatment ( . ± . vs. . ± . , p= . ). the blood pressure and serum potassium level showed no significant changes. conclusion: these data suggest that treatment with acel or arb has beneficial effects on the renal function in children with mild to moderate renal failure due to rhd. objective of the study: postischaemic arf is influenced by sex hormones. dehydroepiandrosterone (dhea) pretreatment diminishes postischemic injury. previously we demonstrated that after renal ischaemia-reperfusion (i-r) injury the expression and activity of na, k-atpase (nka) is impaired in male rats. here we tested the impact of dhea on postischaemic survival, renal damage, mrna and protein expression of nka. methods: left renal pedicles of dhea ( . mg/kg/day) and propylene glycol, as vehicle (pg) treated male rats (g dhea and g pg , respectively) were clamped for min followed by (t ) and (t ) hours of reperfusion. survival rate, histological damage, serum creatinine (cn) and urea nitrogen (bun) were investigated. the mrna expression and protein level of nka α and β subunit were also determined. sham operated animals served as control. results: dhea treatment was associated with better postischemic survival (p< . g dhea vs. g pg ). postischaemic cn and bun were higher and renal histology showed more rapid progression vs. controls, however there was no difference between g dhea and g pg groups. mrna expression of nka α subunit was higher in g dhea vs. g pg at every time points, however it was decreased in i-r groups vs. controls (p< . ). similar changes were observed in nka α protein level (p< . , g dhea vs. g pg in controls, t , t ). mrna and protein expression of α subunit were different only at t (p< . , g dhea vs. g pg ). conclusions: our study indicates that nka is more protected from the detrimental effects of i-r injury in dhea treated animals, which might be a contributing factor of improved postischaemic renal function and could help to preserve cell and organ homeostasis even in male animals. the work was supported by otka f -t , bolyai and semmelweis grants. objective of study: recently bnp has been identified as a useful cardiac marker for risk stratification in adults. whether bnp has a similar diagnostic potential in pediatric population with ckd has to be established. the aim of the study was to assess the value of bnp to predict the cardiac dysfunction in children with ckd. methods: to test this suggestion, the relationship between plasma concentrations of bnp, echocardiographic parameters and cardiovascular risk factors (lipid profile, hypertension, secondary hyperparathyreoidism) has been evaluated. a cohort group consisted of children and young adults ( pts mean age x= . ± . years; controls mean age x= . ± . years). out of studied pts children were with ckd stage and k/doqi ( pts ckd stage ; dialyzed pts) and transplanted subjects with stable graft function (gfr= . ± . ml/s/ . m ). results: no association was found between bnp and gfr and/or s-creat (p= . ; p= . ; p= . ). the highest bnp plasma levels have been found in dialyzed children ( . pg/ml; resp. . pg/ml in tx; resp. , pg/ml in ckd stage group) as compared to controls ( , pg/ml p< , ). bnp was independently related to left ventricular mass (r= . ; p< . ) as well as to ejection fraction (r=- . ; p< . ) and preload (r= . ; p< . ). significant correlation between bnp and hypertension (r= . ; p< . ) has been observed. more over, bnp correlated with ipth (r= . ; p< , ) and diastolic dysfunction (r= . ; p< , ). plasma bnp concentrations did not significantly differ before/after dialysis procedure (p= . ). conclusions: bnp is a sensitive marker for cardiac dysfunction in ckd children. however, prospective studies in larger group of pts are needed to confirm our preliminary data. we have reviewed the data of patients with nephropathic cystinosis (nc) followed in our department since . overall, patients have died during the follow-up period. the mean follow-up was , ± , yrs (range , ) . / patients have initiated dialysis and / received a cadaveric renal transplant. univariate analysis showed that the time to reach a serum creatinine value of mg/dl was significantly associated with the patient's age at the last follow-up (o. r. , /yr; p< . ), the age at the beginning of cysteamine (mea) treatment (o. r. , /yr; p= . ), the dose of mea (o. r. , /g, p= . ) and the use of ace-inhibitors (o. r. , ; p= . ). by multivariate analysis, only the period of treatment (or , , p= . ) and therapy with ace-inhibitors (or , , p= . ) were significantly associated with better outcome. similar results were obtained when assessing the time to dialysis. there was a significant correlation between the dose of mea with intra-leucocytic cystine levels (ilc). by univariate analysis, the dose of mea expressed in mg/m correlated more with the outcome then the dose expressed in mg/kg. statural growth was significantly associated by multiple correlation analysis only with growth hormone (gh) treatment (p< . ). altogether, these results indicate that the renal prognosis of nc has been improving over the past two decades. this improvement may not be solely attributable to the introduction of mea for the treatment of nc. our data suggest that the overall management of these patients has improved, including more efficient symptomatic treatment of the fanconi syndrome and the use of medications such as ace inhibitors and gh. background: the chronic kidney disease in children (ckid) cohort study, targeted to enroll children aged - yrs with chronic kidney disease (ckd) by estimated gfr (egfr schwartz) of - ml/min/ . m aims to assess risk factors for kidney disease progression in children. objective: to describe the characteristics of the ckid cohort at study entry. design/methods: at the ckid baseline visit, gfr is measured by plasma disappearance of iohexol. children undergo physical exam, standardized bp measurements, blood and urine testing and parent and child interview. results: as of / / , children had completed the baseline visit, median age . yrs, % caucasian, % african american, % male and % hispanic ethnicity. median age-adjusted height and weight percentiles were % and %, respectively. underlying cause of ckd was urologic, cystic or hereditary in %, % had acquired glomerular disease. median egfr at study entry was . ml/min/ . m , % higher than the median iohexol-based gfr . ml/min/ . m . % of participants reported a history of hypertension, % anemia, % seizures, and % depression. symptoms of headache, nausea, loss of appetite and weakness steadily increased in prevalence with lower gfr. assessment of family history in parents and grandparents revealed: high blood pressure %, high cholesterol %, kidney disease %, dialysis %, and kidney transplant %. conclusions: children with stage iii ckd have significant height deficits, hypertension, anemia, and seizure disorders. cross-sectionally, increasing non-specific symptoms are associated with lower gfr. collection of plasma, serum and genetic material will facilitate understanding of novel risk factors and biologic mechanisms underlying kidney disease progression and associated morbidities. aim: increased glomerular filtration rate (gfr) has been implicated in the development of diabetic nephropathy. large normal interindividual variations of gfr hamper the diagnosis of renal hemodynamic alterations. we examined renal functional reserve (rfr) in children with insulindependent diabetes mellitus (iddm) to assess if hyperfiltration occurs. methods: the renal hemodynamic response following dopamine infusion was examined in iddm children ( . ± . y) with a mean duration of diabetes of . years and compared to controls. results: mean baseline gfr in diabetic children did not differ from control population ( . ± . vs. . ± ml/min/ . m ), whereas renal plasma flow was significantly lower ( . ± . vs. . ± ml/min/ . m , p< . ) and filtration fraction was increased ( ± vs. ± %, p< . ), compared to controls. the mean rfr was lower (p< . ) than in control subjects (- , ± vs. ± ml/min/ . m ). conclusion: the observation that rfr is reduced or absent suggests that all children are in a state of glomerular hyperfiltration with increased intraglomerular pressure regardless of the baseline normal values of gfr. while measurements of rfr may be helpful in diagnosing the presence of hemodynamic changes, the relevance to development of diabetic nephropathy remains unknown. only - % develops diabetic nephropathy, suggesting that glomerular hyperfiltration is only a concomitant risk factor. lp diet induces ischemic renal injury involving epithelial cells from osom. here, we tested whether hsp would stabilize renal na+k+atpase attachment to the cytoeskeleton during recovery from lp. after weaning, rats (n= ), were fed for days with a lp diet ( %), then were recovered by means of a normal protein diet ( %rp) each group had an age-matched control group ( %, np). tissues from cortex and osom were homogeneized in buffer plus . % triton x- . protein levels were measured by western blot. in vitro coincubation of solublen on cytoeskeletal and insoluble cytoskeletal-associated fractions in the presence or absence of anti-hsp antibody was performed. interaction between proteins was determined by coimmunoprecipitation. increased na+k+atpase dissociation was shown in soluble fraction from osom as a result of lp diet vs. np ( . ± . vs. ± . , p< . ). meanwhile, decreased hsp levels in the same fraction was shown (lp: . ± . vs. np . ± . , p< . ). translocation of hsp to the cytoeskeletal injured fraction associated with stabilization of na+k+atpase was shown in osom from lp, after in vitro coincubation of the cytoskeletal fraction of lp and non cytoskeletal fraction of rp. these effects were abolished by the addition of anti-hsp antibody. coimmunoprecipitation showed that the amount of hsp coprecipitating with na+k+atpase increased in lp osom, in rp results were similar to control. in cortex, absence of significant differences was shown in the na+k+atpase and hsp expression at in vivo and in vitro experiments among groups. in lp and rp cortex tissues, interaction of both proteins was similar to control. our results allow us to suggest that hsp has a critical protective role in the integrity of the cytoskeletal anchorage of na+k+atpase during recovery from ischemic lp injury in osom. tubular reabsorption of mg + occurs predominantly by paracellular flux in the thick ascending limb of the loop of henle. it is mediated by the, tight junction, mg + channel protein, paracellin- , which is encoded by the gene pcln- . cyclosporin a (csa), a widely used immunomodulatory drug, decreases tubular mg + reabsorption leading to urinary mg + wasting and hypomagnesemia. the exact molecular mechanisms of this modulation are unknown. in this study we examined the effect of csa on the paracellin- gene in renal cell lines and mouse kidney. the effect of csa on the pcln- gene promoter was examined. a plasmid, containing the human pcln- (hpcln- ) promoter ( . kb) upstream to a luciferase reporter gene, was transfected into opossum kidney (ok) and human embryonic kidney (hek ) cells prior to exposure to micrograms/ml csa for hours. mice received csa ( mg/kg/day) for up to days. at h intervals blood/urine mg + and ca + levels were determined and kidneys harvested for paracellin- mrna quantitation (real-timepcr) as well as protein quantification (western blot) and visualization (immunofluorescence). csa decreased hpcln- promoter activity by %- % in transfected ok and hek cells, compared to control cells. csa-treated animals displayed hypomagnesemia with increasing urine mg + and ca + levels paralleled by a - % decrease in pcln- mrna after and days of csa exposure. a similar effect on paracellin- protein expression inthe renal tubule was evident in response to csa treatment. csa may influence paracellin- -mediated mg + transport at the transcriptional level. involvement of the calcineurin-dependent tonebp pathway or the calcineurin-independent map kinase pathway in this response is subject to future research. this effect of csa on the paracellin- gene may play a role in the renal magnesium wasting and hypomagnesemia induced by csa. it is well established that proteinuria induces tubular injury, which is closely associated with progressive decline of renal function. megalin has an important physiological role in the reabsorption of a variety of low molecular weight proteins along the proximal tubule. in this study, we examined whether megalin mediates tubular injury secondary to glomerular diseases. we utilized megalin knockout (ko) mice, in which % of proximal tubular cells have mosaic nullmutation in the megalin gene. to induce glomerular injury, these were mated with a transgenic line, nep , in which selective podocyte injury can be induced by injection of immunotoxin, lmb . megalin ko/nep mice were injected with lmb ( . ng/g bw) and analyzed weeks later. they showed moderate proteinuria (upro/cr= , vs . before lmb ) and mild tubular injury, which were comparable to those observed in nep mice with intact megalin gene injected with the same dose of lmb . in the latter, megalin was still detectable in injured tubules. within each megalin ko/nep mouse, we compared megalin-intact (+) vs deficient (-) proximal tubular cells by immunostaining. the majority of megalin+ cells showed enhanced staining for albumin. in contrast, most megalin-cells were not stained for albumin. aquaporin- , which is highly expressed in normal proximal tubules, was diminished in . % of megalin+ cells, whereas it was diminished in only . % of megalin-cells. some proximal tubular cells expressed mcp- . in that, % of mcp- expressing cells were megalin+. the results suggested that megalin plays an important role in the reabsorption of massively filtered proteins in glomerular diseases, thereby contributing to proximal tubular cell injury. objectives of study: the hallmark of nephropathic cystinosis is lysosomal cystine accumulation, primarily leading to fanconi syndrome. although all tissues haveelevated cystine levels, it is not known why the kidney is first affected. it is postulated that decreased atp production in cystinosis results in defective proximal tubular reabsorption, a process driven by na, k-atpase. to study this hypothesis, we have monitored atp levels and viability in conditionally immortalized proximal tubular cells (ptc) of cystinosis and healthy controls. methods: urinary sediment of cystinotic patients and healthy controls was suspended ins supplemented culture medium. primary cultures were transfected with sv ts a t antigen allowing proliferation at °c and maturation at °c. to confirm the proximal origin of the cells ) expression of aquaporin- (aqp ) and dipeptidyl-peptidase iv (dpp-iv) was demonstrated using immunoblot technique and ) morphology was determined using em. ptc were matured at °c for - days, followed by cystine measurement using hplc and atp determination using luciferase assay. results are expressed as nmol/mg protein. results: colonies of cystinotic and control cell lines (n= ) with cobblestone morphology developed after weeks and expressed aqp and dpp-iv, confirming their proximal origin. in cystinotic ptc, cystine levels increased from . at °c to . after days at °c compared to . in controls. intracellular atp decreased in cystinotic ptc during days from . to . , while atp levels in controls remained stable (range . - . ). atp levels inversely correlated with cystine accumulation in cystinotic ptc (r=- . , p= . ). conclusion: decreased atp levels in conditionally immortalized ptc during days maturation suggest that alterations in atp levels are involved in tubular dysfunction in cystinotic patients. aquaporin ( aqps have been identified to date. aqp conveys % of the peritoneal water transport in pd. cell migration and angiogenesis are altered in aqp ko mice; erythrocyte pco depends on aqp . human peritoneal mesothelial cells (hpmc) from non-uremic patients and a human mesothelial cell line (met- a) were incubated with conventional (c-pdf), icodextrin (ico), bicarbonate (b-pdf) and lactate based double chamber pd solution (l-pdf). mrna was measured by real time rtpcr, and protein by western blot and immunocytochemistry. hpmc and met- a express aqp , , and . incubation of met- a and hpmc with c-pdf, ico and l-pdf did not change aqp and expression compared to medium. in contrast, incubation with b-pdf increased aqp and mrna and protein in both hpmc ( h aqp mrna: ± , aqp : ± %) and met- a (aqp : ± , aqp : ± %). the effect on aqp was in part explained by differences in ph, the effect on aqp was largely independent of ph. addition of mmol/l of bicarbonate to l-pdf increased aqp and mrna (l-pdf+bic: aqp : ± , aqp : ± %). aqp expression was suppressed by all three pd fluids (b-pdf: ± . , l-pdf: ± . , c-pdf %: ± %), aqp was up regulated by b-pdf ( ± %). b-pdf improved hpmc migration. we for the first time demonstrate the expression of four different aqps in peritoneal mesothelial cells. they are markedly regulated by pd-solutions. the upregulation of aqp , , and by bicarbonate based pdf may have important implications on long term peritoneal membrane function, wound healing and neoangiogenesis. the regulation of cx cl (fractalkine) by thromboxane a in inflammation there is marked leukocyte infiltration into the damaged tissue. chemokines recruit and direct leukocytes to the injured site. the chemokine cx cl is up-regulated in renal inflammation such as glomerulonephritis and allograft rejection. thromboxane a (txa ), a potent vasoconstrictor in the kidney, is also pro-fibrotic. txa is up-regulated early in inflammation and its effects are mediated by binding to the tp receptor. the aim of this study was to examine the effect of txa on cx cl expression. we previously showed that cx cl recycles between the cell surface and an internal compartment. cell surface cx cl is cleaved by the enzyme, tace, to yield the soluble species of the chemokine. we generated human ecv- cells stably expressing cx cl and treated cells with a tp agonist. levels of cx cl were quantitated by western blotting. cx cl decreased by - min after tp stimulation, but recovered by h. using flow cytometry, we found that cell surface levels of cx cl decreased by min, but began to recover before levels of total cx cl were replenished. to verify if early recovery of cx cl was due to redistribution from the internal to the plasma membrane compartment, we used fluorescence recovery after photobleaching (frap). after min tp stimulation decreased endocytosis of cx cl was seen. we postulated that loss of cell surface cx cl is due to cleavage by tace. accordingly, a tace inhibitor prevented early loss of cx cl after tp stimulation. in summary, txa induces rapid proteolytic shedding of cell surface cx cl by tace, but later increases expression of cx cl at the cell surface by inhibiting internalization of the chemokine. this could release the soluble chemotactic protein from the cell adhesive transmembrane protein, promoting leukocyte recruitment initially, whilst promoting leukocyte adhesion later in the time course. the response to steroid therapy is used to characterize idiopathic nephritic syndrome (ins) as steroid sensitive (ssns) or steroid resistant (srns). ssns pathogenesis has been associated with activation of t-cells and srns has been associated with activation of tgfb and progression to chronic kidney disease. our objective was to determine differences in the urinary excretion of inflammatory cytokines; opn, icam and tgfb , between ssns (n= ), srns (n= ), and controls (ctr, n= ) in an attempt to identify specific biomarkers of steroid sensitivity or lack thereof. for this purpose, we used a protein array high-throughput technique and confirmed the findings by elisa. in addition, we performed immunohistochemistry (ihc) for the above cytokines on renal biopsy samples. mean age, gender, race, body mass index, and estimated glomerular filtration rate were not statistically different among three groups. there were no statistically significant differences between ssns and srns in regard to the presence of hypertension, ace treatment, and renal histology (p= . , . , and . , respectively) . urinary excretion of icam , opn, and tgfb were statistically significantly higher in ins subjects vs. ctr. urinary icam and opn were higher in ssns than in srns (p= . and p= . , respectively). however, the urinary excretion for tgfb was similar in ssns and srns. the ihc failed to reveal differences in renal tissue expression of the studied cytokines. there was no correlation between urine and kidney tissue expression. in summary, our preliminary data suggest that urinary opn and icam may serve as biomarkers of ssns. this assumption needs to be tested prospectively. methods: this is an interim report of this single center study on proteinuria in hiv positive children. there are children aged - yrs. registered in our hiv clinic. all children attending the outpatient clinic or seen on admission are studied. questionnaires included bio and clinical data. blood pressure was measured in all children. a clean catch or bag urine is obtained from all and urine biochemistry done on an aliquot. patients found to have proteinuria + or above are referred to the nephrology unit. their urine is quantitated (timed urine collection), renal function, renal ultrasound and cd count estimated. anf, le cells, fbc including platelet count and genotype will be assayed. a renal biopsy will be performed for nephrotic range proteinuria. result: eighty children positive for hiv have been studied. there were males and females giving a ratio of . : . their mean and median ages were . yrs and . years respectively. all had normal blood pressures, renal ultrasound, and renal function. fifteen of the children ( . %) had - mg/dl proteinuria; ( . %) haematuria. their mean cd + cell count was . /mm , range - . there was no significant difference between low cd + count and the presence of proteinuria (p> . ). seventy seven of the patients had vertical transmission of hiv; two acquired the infection from blood transfusion; one from scarification marks. conclusion: there is a high prevalence of proteinuria among children with hiv infection in our region. hiv positive children should be screened and intervention instituted to avert or delay the onset of chronic renal failure. carotid intima media thickness (cimt) and brachial artery flow mediated dilatation (fmd) are novel indices of subclinical atherosclerosis. we studied these indices in children with nephrotic syndrome (ns) using high resolution ultrasonography (hrus). children with ns ( ssns; srns) of - months duration and normal sibling controls underwent cimt and fmd determination using a . mhz us probe. routine biochemistry, lipid profile and hscrp were carried out to look into associations with cimt and fmd. statistical analysis was carried out using epiinfo . . cases and controls were similar in age, sex, growth and egfr. mean maximum cimt (+- % ci) (in mm) was higher in the ns group ( . +- . ; range . - . ) vis-a-vis controls ( . +- . ; range: . - . ) (p< . ). srns and ssns cases were similar ( . +- . vs . +- . mm, p= . ). nephrotic children showed significantly lower fmd ( . +- . % vs . +- . %, p= . ). cimt and fmd varied with frequency of relapses in last months ( . + . mm, . +- . % (no relapses); . +- . mm, . +- . % (> relapses). children with ns had mean hscrp of . +- . mg/l. on univariate analysis, cimt correlated with disease profile at onset (r= . , p< . ), fmd (r=- . , p= . ), male sex (r= . , p= . ), bmi (r= . , p= . ), cyclosporine exposure (r= . , p< . ), total cholesterol (tc) (r= . , p< . ), ldl (r= . , p< . ), vldl (r= . , p< . ), triglycerides (r= . , p< . ), atherogenic index (ai) (r= . , p< . ) and creatinine (r= . , p= . ). fmd correlated with systolic blood pressure, age, bmi, weight, total cholesterol, vldl and triglycerides (p< . ). to conclude, hrus can detect early atherosclerosis using fmd and cimt as the indices in children with nephrotic syndrome with disease duration of years and more. a ten-year old girl, who presented with biopsy proven acute severe changes of type membranoproliferative nephritis (mpgn ) appears to have shown complete resolution of her disorder after nine months mycophenolate moffetil (mmf) (cellcept -roche) added to relatively rapidly reducing steroids. she presented aged nine years with incidental finding of significant proteinuria and upper tract haematuria when presenting with abdominal pain. blood pressure, chemical renal function and haematology were normal. c and total haemolytic complement were at the lower limit of normal. renal biopsy showed light microscopy (lm) changes of markedly enlarged glomeruli with significantly increased mesangial cellularity and matrix, together with 'double contours' of basement membrane. inmmunofluorescence (if) was strongly positive for igg and c . electron microscopy (em) showed mesangial cell interposition into the basement membranes. she was treated with iv pulse methylprednisolone, followed by high dose oral prednisolone (pnl). after one month, mmf mg bd was added as pnl was tailed to alternate day therapy. pnl was reduced more quickly than usual due to difficulty with side effects and excellent clinical response. within three months of mmf, proteinuria and haematuria had disappeared. blood pressure and renal function have remained normal throughout treatment. after nine months, while on . mg/kg alternate day pnl and mg bd mmf, repeat biopsy showed normal sized glomeruli on lm with no significant changes, no positive staining on if and normal em without mesangial interposition. this case suggests that mmf may be a key drug in management of mpgn . g. stringini, e. malagnino, f. emma bambino gesu children's hospital and research institute, department of nephrology and urology, rome, italy serum creatinine values may vary considerably between normal subjects. these variations are in part secondary to differences in muscle mass, body composition and creatinine tubular secretion. in addition, low nephron number, which is influenced by genetic and intrauterine factors, is associated with increased incidence of arterial hypertension, late-onset proteinuria and chronic renal failure. despite compensatory glomerular hypertrophy, autopsy data indicates that kidneys with fewer glomeruli tend to be significantly smaller. on these bases, we have hypothesized that a significant part of the variance of normal serum creatinine levels is related directly to individual differences in renal size. to test this hypothesis, we have reviewed the data of renal ultrasound examinations performed at our institution between and . patients were selected if they had conditions that should not influence renal size (low tract uti, enuresis, bladder instability, idiopathic hypercalciuria), if they had normal gfr and an ambulatory blood pressure measurement. analyses were performed after expressing renal length, serum creatinine levels and blood pressure values as standard deviation scores (sds) corrected for gender, age, height and weight, by multiple nonlinear regression analysis. a significant negative correlation was found between serum creatinine levels and renal length (p< . ). when renal length measurements were grouped in quartiles, serum creatinine sds was on average . sds higher in the st quartile (small kidneys), in comparison with the th quartile (large kidneys). no correlation was found between kidney length and single measurements of ambulatory blood pressure. these data indicate that renal size is accountable for a significant part of the variance in serum creatinine levels that is observed in the normal pediatric population. henoch-schönlein purpura (hsp) is the commonest small vessel vasculitis of childhood. henoch-schönlein purpura nephritis (hspn) is the major determinant of long term prognosis in hsp. the objective of this randomised controlled trial was to determine the effect of early prednisolone treatment on the development and progression of nephropathy in children with hsp. methods: children under years of age, with a diagnosis of hsp, presenting to secondary care centres in england and wales were randomly assigned to receive either placebo or prednisolone ( mg/kg/day (max mg) for days, followed by mg/kg/day for days (max mg)). patients, parents, paediatricians and investigators were 'blinded' to assignment of treatment or placebo. the primary outcome measure was the determination of the presence or absence of proteinuria, defined as urine protein: creatinine ratio (up: uc) > mg/mmol, months after initial presentation in treated and untreated patients. results: children with hsp were randomised. patients were assigned to receive prednisolone (group a) and patients were assigned to receive placebo (group b). patients in group a and patients in group b did not complete the study. there was no difference in the incidence of proteinuria at months, in patients receiving prednisolone ( / ) compared with those receiving placebo ( / ) or= . , % ci . - . , p= . . conclusions: this is largest prospective randomised placebo-controlled trial of the role steroids in hsp in the literature to date. this study provides compelling evidence of absence of a beneficial effect of early treatment with prednisolone in the development of nephropathy months after disease onset in children with hsp. while quality of life (qol) is generally assumed to be poor on dialysis and to improve markedly after kidney transplantation, systematic assessments of qol in children have not been performed to date. to date, we have examined general and health-related qol in children and adolescents with esrd aged - years treated by hemodialysis (hd; n= ), peritoneal dialysis (pd, n= ) or renal transplantation (tx, n= ), using a well-established instrument (kindl) comprising an ageadapted set of questionnaires (kindl). the obtained measures of overall and item-specific qol were transformed to standard deviation scores (sds). general qol was close to normal and did not differ significantly between hd (- . ± . sds), pd (- . ± . ) and tx (- . ± . ). psychological well-being was better in children on pd ( . ± . ) than after tx (- . ± . , p= . ) and on hd (- . ± . , p= . ). physical wellbeing did not differ between treatment groups (hd: - . ± . , pd: . ± . , tx: (- . ± . ). qol related to family life tended to be compromised in dialyzed (- . ± . ) vs. tx children (- . ± . , p= . ) . social interaction with friends was considered moderately impaired by all patient groups (hd: - . ± . , pd: - . ± . , tx - . ± . ). self-esteem was close to normal in all groups (hd: - . ± . , pd: - . ± . , tx . ±. ). in summary, our preliminary results suggest that subjective qol is remarkably good in children with esrd, with surprisingly small differences between treatment modalities. tx appears to be perceived beneficial with respect to the integrity of family life but provides poorer psychological qol than pd, possibly due to the constant concern with graft loss. background: gfr is determined in the ckid cohort study by plasma disappearance of iohexol (igfr). updated serum creatinine (scr)-based formulas (sgfr=k ht/scr) are needed for bedside clinical use. objective: derive formulas based on enzymatic scr to estimate gfr in the ckid study in children aged - yrs with sgfr of - ml/min/ . m . methods: from children, height (ht, meters), igfr, and scr & bun (mg/dl) by bayer advia were obtained. gfr was estimated from regression models: a(ht/scr) b ( /bun) c where a is gfr if ht=scr and bun= ; b and c are exponents. results: % (n= ) were male; median age= , scr= . , bun= and igfr= . formulas ranged from an updated schwartz formula (a= . , b= , c= ; r = . ), to sex-specific (a= . , b= . , c= in girls, and a= . , b= . , c= in boys), which yielded r = . , to the most complex (a= . , b= . , c= . in girls, and a= . , b= . , c= . in boys), which yielded r = . , higher (p< . ) than the r of the updated schwartz formula. by random selection of of subjects in independent trials, we assessed the predictive ability of each formula on the other observations. sex-specific formulas produced unbiased results and increasing precision with increasing complexity. the updated schwartz underestimated igfr in boys by % (p< . ) and overestimated igfr in girls by % (p< . ). conclusions: scr, ht, sex, and bun together provided unbiased estimates of igfr and explained % of its variability in children with igfr of to ml/min/ . m . extrapolation to ht/scr of (normal body habitus and kidney function) and bun of yielded predictions of ml/min/ . m for gfr in girls and boys. including cystatin c and broadening the gfr range to include normal levels are data being collected by ckid to extend the formulas and provide wider clinical utility. f. hussain, m. mallik, a. watson nottingham university hospitals, children and young people's kidney unit, nottingham, united kingdom considerable variation exists between units in terms of techniques used for renal biopsy. the bapn agreed an audit using published standards and a questionnaire was sent to all uk paediatric nephrology centres. agreed to a prospective audit between / / and / / . the survey revealed information leaflets are sent pre-biopsy in ( %) centres with only one using play preparation. ( %) routinely perform biopsies as daycase procedures (dc); ( %) use general anaesthetic (ga). realtime ultrasound is the favoured method in ( %) of centres. biopsies are performed by nephrologists only in ( %), nephrologists with radiologists in ( %) and radiology alone in ( %). of biopsies ( native), ( %) were performed as a dc with ( %) being done under ga. the mean age of patients was yrs (range . ± . yrs). the standard for the number of passes of native kidneys (< in %) was achieved in . % with no significant difference between grade of operator or nephrology/radiology speciality. standard number of passes in transplanted kidneys (< in %) was achieved in . %. adequate tissue was obtained for diagnosis in . % (standard > %). the significant complication rate (macroscopic haematuria and/or delay indischarge) was higher than the set standard of < % at . %. there was no significant difference in complication rates whether the biopsy was performed as a dc or inpatient procedure (p= . ) or whether ga or sedation was used (p= . ). conclusions: the survey highlights significant variation in practice with limited use of preparation materials and dc. the results may enable individual units to reflect upon their techniques and complication rates and has stimulated constructive debate about indications and training issues. objective: to characterize bp in children enrolled in the ckid study, an observational cohort study of children - y old with schwartz estimated gfr of - ml/min/ . m . design/methods: bp's were obtained using an aneroid sphygmomanometer. gfr was measured by iohexol disappearance. bp was classified according to the th report on bp in children. hypertension (htn) was defined as bp- th percentile (uncontrolled), or as self-reported htn plus current treatment with antihtn meds. pre-htn was defined as bp th- th percentiles. results: children (mean age ± y; % male) were studied. mean gfr was ± ml/min/ . m and mean ckd duration was ± y. for sbp, / ( . %) subjects had htn of these, subjects ( %) had uncontrolled htn. additional subjects ( %) had pre-htn. of subjects with systolic htn, only % had measured sbp< th percentile, and among the subjects with measured sbp> th percentile, only ( %) were taking antihtn meds. for dbp, / subjects ( . %) had htn of these, subjects ( %) had uncontrolled htn. subjects ( %) had pre-htn. of subjects with diastolic htn, just % had measured dbp < th percentile, and among the subjects with measured dbp> th percentile, only ( %) were taking antihtn meds. among children with gfr< ml/min/ . m , the prevalence of systolic or diastolic htn appeared to increase with decreasing gfr. conclusions: a significant proportion of children enrolled in the ckid study suffer from elevated bp. nearly % of children with ckd had measured bp> th percentile, and more than % of these children were not receiving antihypertensives, indicating that htn in pediatric ckd is frequently under-or even untreated. long-term follow-up of the ckid cohort should reveal the effect of elevated bp on ckd progression. background: we recently demonstrated elevated excretion of the putative urinary biomarkers tgf-β and et in a large cohort of children with ckd. tgf-β excretion was highest in kidney disorders associated with marked tubulointerstitial fibrosis, such as obstructive uropathy, nephronophthisis and pkd. aim: to investigate the course and predictive value of urinary tgf-β and et excretion in children with ckd undergoing ace inhibition (acei). methods: to date, patients have been followed for years and patients for years in a prospective, interventional trial investigating the nephroprotective efficacy of acei w/out intensified blood pressure control. results: average bp was reduced to the mid normal range. proteinuria initially decreased by %, but gradually reincreased to baseline levels within years. urinary tgf-β excretion, which was initially elevated -fold above healthy controls, continuously decreased during treatment from . ± . ng/g creatinine to . ± . , . ± . , and . ± . after , , and years, respectively (p< . ). in contrast, et excretion increased by % within the first years of follow-up. neither baseline nor the change in tgf-β and et excretion during treatment predicted the short-or long-term antihypertensive, antiproteinuric response to acei or ckd progression rate. conclusions: the marked reduction of urinary tgf-β excretion probably reflects the antifibrotic effect of acei but, at least over yrs of observation, does not predict the early and late course of proteinuria and ckd progression. hence, urinary tgf-β appears to be a biomarker of tubulointerstitial disease activity rather than of global disease progression. the surprising increase of et excretion may reflect the induction of compensatory hemodynamic mechanisms during acei. cardiovascular complications are the most important cause of death in pediatric patients with endstage renal disease. therefore early diagnosis and treatment are very important. brain natriuretic peptide (bnp) is released in response to volume overload or conditions that cause ventricular stretch. the aim of the study was to investigate whether bnp can be used for early diagnosis of cardiac complications in pediatric patients with esrd. twenty-four patients on peritoneal dialysis (mean age . ± . years), patients on hemodialysis (mean age . ± . years) and sex and age matched healthy children (mean age . ± . years) were included the study. plasma bnp levels were significantly higher in the patient group than those in the control group ( . ± . vs . ± . pg/ml, respectively, p< . ), but there was no significant difference between hemodialysis and peritoneal dialysis patients. in patients with hypertension, bnp levels, left ventricular systolic and diastolic diameters were significantly higher than those in the patients without hypertension. in patients with higher crp levels, bnp levels were significantly higher than those in the patients with low crp levels. bnp levels had a positive correlation with left ventricular mass index (r= . , p= . ) and a negative correlation with ejection fraction (r=- . , p< . ) and shortening fraction (r=- . , p< . ) significantly. there was no significant relation between bnp levels and anemia, dialysis duration, and dialysis modality. in conclusion, high plasma bnp level is significantly correlated with dilated left ventricle and it may be useful as a biochemical marker for identification of pediatric dialysis patients with cardiac dysfunction. we observed a high prevalence of left ventricular hypertrophy (lvh) and impaired lv contractility in children with stage ii-iii chronic kidney disease (ckd) (jasn , jasn . in a prospective, open-label assessment in children receiving ace inhibition (ramipril mg/m /d) with or without additional antihypertensive medication, we evaluated by echocardiography lv mass (lvm), geometry and myocardial mechanics at baseline and after (n= ) or mos (n= ) of treatment. lvh was defined by lvm index> g/m and concentric geometry by relative wall thickness> . ( th normal percentile). lv systolic function was assessed at the midwall level by circumferential shortening (ms). normalized h mean arterial blood pressure (bp) was reduced from . ± . at baseline to . ± . and - . ± . sds after and mos respectively. lvmi was reduced significantly after (from . ± . to . ± . g/m . , p< . ) and mos (from . ± . to . ± . , p< . ). of those patients presenting with lvh at baseline, lvm regressed to the normal range in / ( %) after mos and in / ( %) after mos. the prevalence of concentric lv geometry remained unchanged (baseline: %, mos: %, mos: %). age and afterload-corrected myocardial function increased from ± % to ± % at mos (p< . ). the changes in lvm and myocardial performance were independent of the randomized bp target and gfr. change in lvm was correlated with change in hemoglobin level (r= . , p< . ) and change in myocardial function with change in bp level (r= . , p< . ). in conclusion, fixed-dose ace inhibition and tight bp control induce regression of established lvh in the majority of children with stage ii-iii ckd. this is associated with a normalization of myocardial contractility. objectives of the study: periods with insufficient erythropoietic activity may occur during the erythropoietin (epo) treatment in chronic haemodialysis (hd). we determined the effects of a short-term suspension of epo therapy on various oxidative stress parameters during a -week follow-up in hd patients. methods: the antecedent epoetin beta (eb) treatment was suspended for days. after that, patients received eb two times a week and patients received darbepoetin alfa (da) once weekly. concentrations of whole blood oxidized and reduced glutathione (gssg, gsh) and various haematological parameters were determined weekly. erythrocyte malondialdehyde (e-mda) and the activities of erythrocyte superoxide dismutase, catalase and glutathione peroxidase were determined at weeks , and . results: the ratio gssg/gsh was increased in both groups after continuation of the suspended epo therapy (p< . and p< . week vs. the baseline in the da and eb group, respectively) and also at week (p< . and p< . vs. the baseline in the da and eb patients, respectively). the activities of the antioxidant enzymes were increased at week in both groups (p< . vs. the baseline for da and p< . vs. the baseline for eb), and returned to their week levels by week . the e-mda level decreased in both groups (p< . week vs. the baseline for da and p< . weeks and vs. the baseline for eb). conclusions: a short-term suspension of epo therapy caused characteristic time-dependent changes in the oxidative stress. the ratio gssg/gsh increased at weeks and . activities of the antioxidant enzymes were elevated at week , resulting in an improvement in lipid peroxidation. these results might have implications in certain conditions with transient alterations in the erythropoietic activity in hd patients. rrf has been associated with better nutritional status both in adults and children on peritoneal dialysis and in adults on chronic hd. there are no data on the influence of rrf on nutrition in children on chronic hd. three-days dietary reports and simultaneous urea kinetic monitoring of children, adolescents and young adults on chronic hd (age: . - . years) were retrospectively analyzed. protein catabolic rate, an index of nutrition adequacy, was normalized by body weight (npcr). in patients with rrf, total kt/v (kt/vtot) was calculated summing hd kt/v(kt/vhd) and rrf (evaluated by residual urea clearance ku-). in all patients, npcr and dietary protein intake (ndpi) were significantly correlated (p< . ). kt/vtot was correlated with npcr(p< . ) while correlation between kt/vhd and npcr was not significant (p: . ). in patients with rrf, ku resulted significantly associated with npcr (p< . ) while kt/vhd was not (p: . ). npcr was significantly higher in patients with rrf ( . ± . vs . ± . g/kg/day; p< . ). patients on recombinant growth hormone (rhgh) treatment showed npcr higher than those without rhgh ( . ± . vs . ± . g/kg/day; p< . ). however, in a multiple regression model including age, the use of rhgh, rrf, kt/vtot and kt/vhd, npcr resulted significantly associated only with rrf (b: . ; p< . ). inconclusion: in children, adolescents and young adults on chronic hd treatment, rrf is associated with better nutrition. rrf positively affects nutrition independently from hd efficiency and rhgh effects. possible hypothesis are a more selective (although decreased) depuration and the positive influence of water excretion maintenance on food intake. more efforts have to be made in order to maintain rrf in children on chronic hd. during the past three years, six women have undergone chronic haemodialysis during pregnancy at the pediatric renal unit of the adelaide women's and children's hospital. five have delivered normal infants at between and weeks gestation; one is presently at weeks gestation, with an apparently normal fetus. four were already receiving chronic haemodialysis at the time of conception; the others began dialysis at weeks gestation. the protocol includes six days per week dialysis for at least two hours per treatment. a number of practical and emotional issues have arisen, with major potential psychosocial hazards, including: unplanned pregnancy due to ignorance of fertility; precipitation onto the dialysis program; acceptance of increased dialysis time; concerns regarding effects of drugs and dialysis/kidney failure on the fetus; the likelihood of prematurity; the perceived difficulties of motherhood while on a chronic dialysis program; loss of income, social networks and independence. the program has been successful due to the cooperative approach from the multidisciplinary team consisting of nephrologists, obstetricians, obstetric physicians dialysis nurses, midwives, dieticians, physiotherapists, psychiatrists and social workers. the social worker has provided counselling and coordinated transport and assistance with housework, childminding and other day to day tasks. although the program has had overall success, there have been a number of pitfalls worth discussing, including those arising from the complex interactions between the members of the various disciplines, and those involved in maintaining the balance of clinical and psychosocial needs of the women. (median . ) , weight from . to . kgbw (median ). the vascular access was a central catheter (kt) in children, an arteriovenous fistula (avf) in , avf and kt alternatively in patients. duration of hd ranged from to m (median . ). dual lumen tunnelled cuffed kt were inserted in children through the internal jugular vein [ijv]), surgically in , percutaneously in . all kt have had an immediate good function. nine kt were exchanged over a guide wire for dysfunction. kt infections with positive blood culture were successfully treated in cases. duration of kt ranged from to m (median ). at the end of the follow-up, kt were still in function, removed for a mature avf, after renal transplantation (rt), for improved gfr and failed. patency of the venous network after withdrawal of kt was assessed in children (doppler , mri ) and showed normal patency in , ijv thrombosis in , brachiocephalic thrombosis in and stenosis in . thirty avf were created in children, distal in ( %). immediate patency was obtained in all cases except . the median blood flow ranged from to ml/min/m (median ). following the primary surgery, repeated surgical procedures included a superficialization of the vein in , refection for stenosis or thrombosis in , reduction of overflow in , nd avf creation in and ligation after rt in . percutaneous transluminal angioplasty was performed in children. duration of patency ranged from to m (median . ). in conclusion, hd is feasible in small children. nevertheless, kt are associated with risk of venous occlusion and obtention of a reliable avf frequently need several interventions, altogether leading to a limitation of hd indications in young children. - , ( %) were < years of age. the underlying disorders were congenital nephropathies in % (malformations %, hereditary %) and acquired diseases in %. living related donation (ld) was performed in % and preemptive tx in %. immunosuppressive (is) protocol varied considerably between the countries and over time. -year graft survival (gs) was % in ld and % in grafts from deceased donors (dd). gs improved significantly for dd grafts with time. the number of acute rejections (ar) during the first year posttx was significantly lower in ld recipients, in tac-treated children and during the second half of the study period. this improvement over time was also seen in separate analysis of cya-treated children. the proportion of rejection-free patients increased in all countries. median height sds at tx was - . (- . to + . )(boys - . , girls - . ). height sds increased to - . at years posttx. conclusions: gs results were excellent and the frequency of ar low, especially in children with ld grafts and tac treatment. interesting differences between the countries concerning donor source, preemptive tx, is and use of protocol biopsies were found. n. marcun varda, a. gregoric maribor teaching hospital, department of pediatrics, maribor, slovenia objectives: essential hypertension (eh), identifiable in children, is associated with cardiovascular (cv) diseases in adulthood. the aim of our study was to evaluate the presence of some traditional and non-traditional cv risk factors in our children and young adults with eh in the search for additional cv risk. the prevalence of metabolic syndrome (ms) was also investigated. methods: a total of children and young adults, diagnosed with eh, were included in our study. they were compared with a control group of healthy children, matched for sex and age, with regards to specific aspects in the history, body mass index (bmi), waist: hip ratio, full blood count, crp, serum cholesterol, hdl cholesterol, ldl cholesterol, triglycerides, uric acid, glucose, insulin, fibrinogen, homocysteine, apolipoprotein a , apolipoprotein b and lipoprotein (a). in addition, the prevalence of ms was calculated. ms was defined as having three or more ms components according to the national cholesterol education program's adult treatment panel iii criteria, tailored for children. results: the differences in values of bmi, crp, platelets, triglycerides, uric acid, apolipoprotein a , apolipoprotein b and homocysteine between the hypertensive patients and the controls were statistically significant. in all hypertensives positive family history of hypertension in the first or second generation was revealed. overweight (bmi > th percentile for age and sex) was identified in %, obesity (bmi > th percentile) in %, abnormal glucose homeostasis in %, high serum triglycerides in % and low hdl in % of the hypertensives. ms was present in % of these children and in % of our controls. conclusion: we demonstrated that children and young adults with eh differ from the population of healthy children in some specific cv risk factors, and are therefore at an increased cv risk. background: rtd is a rare autosomal recessive disease of differentiation of fetal kidneys with poorly developed proximal tubules. fetal and neonatal findings include oligohydramnios, preterm birth and neonatal death due to pulmonary hypoplasia, anuria and hypotension. mutations in genes in the renin-angiotensin system (ras), encoding for angiotensinogen, renin, angiotensin converting enzyme and angiotensin ii receptor type , have been revealed. we report the first rtd patients surviving the neonatal period and still being alive. both patients had affected siblings demised in utero or neonatally. case : oligohydramnios, birth at weeks, grams. neonatal course: pulmonary hypoplasia, pneumothorax, hypotension and anuria with ventilation ( weeks) and dialysis ( days) . current findings at years: creatinine umol/l, normal blood pressure. genetic and functional analysis: homozygous mutation of angiotensinogen gene ( g-a); very low angiotensinogen concentration ( . ng/ml; normal - ), absent plasma renin activity (normal . - . ng/ml/h) despite very high active renin ( pg/ml; normal - ). case : oligohydramnios, birth at weeks, grams. neonatal course: mild respiratory distress, hypotension and anuria with oxygen ( day) and dialysis ( months) . current findings at years: renal transplantation at age years, good graft function. genetic and functional (as neonate) analysis: homozygous mutation of renin gene ( g-a); very low active renin (< . pg/ml; normal - ). conclusions: rtd is caused by inactivating mutations in genes encoding the ras resulting in chronic low perfusion pressure of the fetal kidney. genetic and functional analysis of ras contributes to diagnosis of rtd. this observation extends the rtd phenotype from a uniformly fatal to a more favourable disease. objectives of study: to evaluate the relationship between serum uric acid (ua), new onset essential hypertension (eh) and endothelial dysfunction (ed) in the youth. methods: subjects with abpm proved new onset eh (aged , ± , years, bmi , ± , kg/m ), overweight/obese normotensive youth (oo) matched for age and bmi, and age matched healthy normotensive controls (nt) with normal weight were enrolled. ua, total cholesterol, hdl, ldl, triglycerides and creatinine were analyzed in blood, glomerular filtration rate (gfr) was calculated according to schwartz formula and endothelial function was assessed using flow-mediated dilation (fmd, %). results: new onset eh was associated with overweight/obesity in % of subjects. serum ua levels were significantly higher in eh than oo ( ± vs. ± umol/l, respectively, p< , ), in eh than nt ( ± vs. ± umol/l, respectively, p< , ), and in oo than nt ( ± vs. ± umol/l, respectively, p< , ). total cholesterol, hdl, ldl and triglycerides were significantly higher in eh and oo compared with nt (p< , ). no significant differences were found in lipidograms between eh and oo. serum creatinine and gfr did not differ significantly between the groups. fmd was significantly lower in eh comparing with oo and nt ( , ± , vs. , ± , vs. , ± , %, respectively, p< , ) and in oo comparing with nt ( , ± , vs. , ± , %, respectively, p< , ). conclusions: new onset eh in the youth is associated with overweight/obesity, higher serum ua and ed. ua may play a causal role in the pathogenesis of eh and commonly with eh and proatherogenic serum profile contributes to ed in overweight/obese hypertensive youth. objective of study: fibromuscular dysplasia (fmd) is a systemic arteriopathy of the small and medium sized vessels. it is the first cause of renal arterial stenosis (ras) in childhood. the aim of this study was to describe the natural history of fmd in children. we analysed all the data of children with fmd. results: mean age at diagnosis was years months old. hbp was discovered fortuitously in cases, after symptoms of malignant hypertension in . in all cases bp values corresponded to severe hypertension (mean bp of / mmhg). extra renal localizations were found in half of the patient, and the most frequent pathological arteries were the superior mesenteric and the carotida. the mean number of arterial stenosis at diagnosis was per patient. seven patients had a primary fmd with familial history for patient. in the others fmd were associated with polymalformatif syndromes: reported by grange ( ), moya-moya disease ( ), neurofibromatosis type i ( ). after a median follow-up time of months the number and severity of stenosis increase at arteries per patient. these lession, although to a lesser extend, were already observed as soon as months of follow-up. percutaneous transluminal renal artery angioplasty were proposed in cases when the bp was uncontrolled indeed a multi antihypertensive therapy with severe renal stenosis (> %) or when renal growth was impaired. prognosis is severe with cardiologic complications ( / ) and death. conclusions: intimal form of fmd accounts for the majority of multivisceral fmd. at diagnosis several hypertension is almost present. vascular ultrasonography imaging techniques is usefull in follow-up. a conservative treatment has to be privilegied. this disease is evolutive with increase of pathological arteries number, aggravation of stenosis degree and sometimes renal function impairment. objective: the effect of over weight on blood pressure elevation (bp) is more frequently present in childhood. several studies have demonstrated the efficacy of angiotensin-converting enzyme inhibitors (acei) therapy in obese hypertensive adults, but data on children are very limited. methods: obese (bmi: z score > . sd) primary hypertensive (systolic ordiastolic blood pressure > th) children (aged - years) were enrolled to this single centre prospective study. patients received ramipril ( . - . mg/bwkg/day) once daily. office and ambulatory bloodpressure measurements and serum biochemical analysis were performed at start and after and months of treatment. patients ( , %) hadimpaired glucose tolerance (igt) on oral glucose tolerance test (ogtt). results: ( , %) patients completed the six months ramipril therapy. reduction in -hour mean arterial pressure (map) was , mmhg (- , sd) after month and , mmhg (- , sd) months treatment respectively. bp was reduced with equal efficacy during day-and night time. / ( , %) patients were lost during the follow-up. ( , %) patients with high uric acid levels also were treated with allopurinol. eleven patients ( %) received second antihypertensive medication because of the blood pressure remained uncontrolled. ( pts metoprolol, pts amlodipine) ( , %) patients suffered recurrent cough, but otherside effect has not observed. the serum glucose and insulin levels havenot changed significantly during the follow-up. conclusion: oncea day given ramipril significantly decreases the blood pressure inobese hypertensive children. it is effective, tolerable and safe bloodpressure lowering monotherapy in childhood. further studies and longer follow-up are necessary to prove its long term beneficial effect in the childhood metabolic syndrome combined with hypertension. hw. zhang, j. ding, f. wang, yf. wang peking university first hospital, department of pediatric nephrology, beijing, people's republic of china objectives of study: females with x-linked alport syndrome (xlas) have variable phenotypes, from microscopic hematuria to chronic renal failure, which can not be clarified solely by mutation features of col a gene. x-inactivation has been suspected to be one of the responsible reasonsfor this phenomenon, but no definite correlation has been demonstratedso far. in order to confirm whether the phenotypes of xlas femalescorrelate with x-inactivation, we analyzed the xinactivation patternsin peripheral blood cells in xlas females and in skin fibroblasts in xlas females. methods: the x-inactivation analysis was performed using hpaiipredigestion of dna followed by polymerase chain reaction (pcr) of thehighly polymorphic cag repeat of the androgen receptor (ar) gene. results: results showed that the average x-inactivation levels of the mutant allele decreased while the degree of proteinuria increased, there was anegative correlation between the degree of proteinuria and thex-inactivation ratios of the mutant allele in blood cells (r=- . , p= . ). however, there was no correlation between the degree of proteinuria and the x-inactivation ratios of the mutant allele in skin fibroblasts (r=- . , p= . ). though of patients ( . %) had the similar x-inactivation ratios in both blood cells and skin fibroblasts, there was also no correlation between the x-inactivation ratios of the mutant allele in skin fibroblasts and that in peripheral blood cells (r= . , p= . ). conclusion: we concluded that the x-inactivation ratios in blood cells correlated with the degree of proteinuria, which might explain partially the diverse phenotypes in female xlas patients. more studies, including post-transcription regulation, environmental factors, and so on, are still needed. objective: to report frasier syndrome (fs) with wt mutation and abnormal expression of podocyte molecules which is the first case in mainland china. methods: peripheral blood cells were analyzed for chromosome karyotype and wt gene mutation. the ratio of +kts/-kts isoforms was quantified with genescan and genescan software. expressions of podocyte molecules were detected by immunohistochemical staining. result: the patient presented with steroid-resistant fsgs and male pseudohermaphroditism. the wt ivs + g>a mutation was found in one allele in the proband, but not in her parents. the ratio of +kts/-kts was . in the proband, and was . and . in her mother and father, respectively. podocyte molecules expression altered in normal-and abnormal-appearing glomeruli. wt expression showed diffuse nuclear staining with less obvious speckles compared with that in controls. wt (antibody against c-terminal) displayed strong, normal, faint and negative stained podocyte nuclei within the same glomerulus. the staining intensity of wt (antibody against the n-terminal) was very faint. conclusion: taking clinical data, pathology, karyotype analysis and genetic testing together, we diagnosed the first case of fs in mainland china, which prompts there might be more cases underdiagnosed. wt displayed diffuse nuclear staining with less visible speckles compared to controls, supporting the view of the differential nuclear localization of kts isoforms. our study further confirmed that wt mutation resulted in abnormal expression of podocyte molecules in glomeruli of fs, though we did not know whether this phenomenon directly or indirectly resulted from loss of wt regulation. dent disease is an x-linked disorder characterized by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis, calcium nephrolithiasis and the development of renal insufficiency after the middle age. so far, two genes responsible for the development of dent disease have been identified, i. e., clcn and ocrl . ocrl was originally identified as a causative gene for lowe syndrome. in japan, igarashi et al. described for the first time that idiopathic tubular proteinuria in japan is identical to dent disease by mutational analyses. most of japanese patients with dent disease are identified by annual urinary screening as chanced proteinuria and several clinical phenotypes, such as incidence of nephrocalcinosis and long term outcome of renal function remains to be elucidated. furthermore, identification of ocrl as a second causative gene for dent disease has made the understanding of dent disease more complex. here we report patients with dent disease phenotype with the results of genetic analyses and clinical features. out of patients in different families, mutations ( %) in clcn were identified. in the patients with no clcn mutations, genetic analysis in ocrl is ongoing, and at the moment different mutations in ocrl ((i stop, r c, r w and r h) were identified. the remaining patients are now beeing investigated. among the patients in whom clcn mutations were detected, hypercalciuria are not always present. in several elderly patients, mild renal function impairment is present. there are similar clinical phenotypes between patients with clcn or ocrl mutations, but serum levels of ldh and ck are likely to be higher in those with ocrl mutations. in summary, we will present genotype and phenotype heterogeneity in japanese dent disease, and will discuss the clinical spectrum of dent disease. a. gulati , s. sethi , j. lunardi , m. kabra , n. gupta , p. hari , a. bagga all india institute of medical sciences, st department of pediatrics, new delhi, india hôpital de la tronche, genetics, grenoble cedex. france, france objectives: to study the clinical features and genetic basis of patients with lowe syndrome and identify female carriers. methods. case records of patients with lowe syndrome presenting to this hospital, between - yr old, were reviewed. the clinical features were recorded and glomerular and tubular functions assessed. a detailed genetic analysis was performed on dna extracted from peripheral blood of patients and their mothers, which involved sequencing of all exons of the ocrl gene. results: all patients showed failure to thrive, bilateral congenital cataracts, refractory rickets, delayed motor and language milestones and proximal renal tubular acidosis with fanconi syndrome. the mean schwartz gfr was ml/min/ . sq. m. genetic analysis showed distinct mutations of ocrl gene in all patients studied. we report new mutations having identified the variants c. a>g and c. g>t in exon , the variant c. _ ins t in exon and c. - a>g in intron in independent patients. we also found previously described mutations involving the region c. _ del tg and c. c>t in exon . four of mothers were heterozygous carriers. all genotypically proven carriers showed characteristic lenticular opacities. conclusion: the identification of mutations in the ocrl gene provides confirmation of the diagnosis of lowe syndrome. the new mutations described in north indian children expand the range of mutations that give rise to this condition. these observations have important implications for molecular diagnosis and genetic counseling in families with lowe syndrome. juvenile nephronophthisis (nph), an autosomal recessive nephropathy, is the most common genetic cause of chronic renal failure in childhood. in - % of known cases, nph is associated with joubert syndrome (js), a neurological disorder described in patients with cerebellar ataxia, mental retardation, hypotonia and respiratory dysregulation. mutations in three genes, ahi , nphp and nphp have been identified in patients with nph and js. as nphp mutations usually cause isolated nephronophthisis, the factors which predispose to the development of neurological symptoms in some patients are poorly understood. to determine such genetic factors and to assess the mutation rate of ahi , nphp and nphp in nph and js, a cohort of families with nph and at least one js-related neurological symptom was screened for mutations in these genes. thirteen ( %) and ( %) unrelated patients were homozygous or compound heterozygous for nphp and nphp mutations, respectively. in patients ( %) without nphp , nphp or ahi mutations, mutations in a novel gene (nphp /cors ) encoding a ciliary protein have been identified. interestingly, of the patients with nphp mutations carried either a heterozygous truncating mutation in nphp ( patient), a heterozygous missense mutation in ahi ( ) or the ahi variant r w ( ) . the variant r w affects an amino acid conserved in vertebrates and predicted to be 'possibly damaging' by polyphen software. in conclusion, nphp , nphp or nphp mutations can be found in % of patients with nph and js in our cohort. our finding that half of all patients with nphp mutations carry a mutation or a damaging variant in nphp or in ahi strongly supports the notion that epistatic effects provided by these genes contribute to the appearance of neurological symptoms in patients with nphp mutations. molecular cytogenetic techniques such as array-based cgh have been instrumental in the identification of microimbalances associated with syndromic phenotypes. we investigated patients with unclear syndromic nephropathies (e. g. urinary tract malformations, focal segmental glomerulosclerosis, and persistent hematuria/proteinuria) and additional clinical features, such as mental retardation, heart defects or growth abnormalities. array-cgh analysis was performed with a whole-genome array with large insert clones providing an average resolution of < . mb. results: in one -year old female patient presenting with microhematuria, proteinuria, mental retardation including severe speech impairment, senso-neuronal hearing loss, and recalcitrant focal epilepsy, we detected a microdeletion in chromosomal bands xq . -q . this deletion was verified by fish, found to be uniallelic, . - . mb in size, and not to be inherited from the mother. electron microscopy of kidney biopsy showed splitting of the lamina densa and a thin basal membrane, which is diagnostic for alport syndrome. high-resolution cranial magnetic resonance imaging including white fibre tracking revealed a severe neuronal migration disorder with subcortical band heterotopia (double cortex syndrome), i. e. a second band of cortical neurons within the white matter below the true cortex. conclusions: in patients with unclear syndromic nephropathies, we identified a female with a contiguous gene syndrome at xq . -q . the microdeletion includes the x-linked alport syndrome gene col a and the lisx gene associated with subcortical heterotopia, mental retardation and epilepsy. thus, the phenotype observed in our female patient combines features of the amme-complex (alport syndrome, mental retardation, midface hypoplasia, elliptocytosis) with x-linked lissencephaly. ( f, m; . ± . yrs, hemoglobin . ± . gr/dl, ferritin ± mg/dl) were enrolled. lipid profile, acute phase proteins (apps) were measured. renal tubular functions, plasma vegf level, urinary nag/cre ratio were determined. abpm and imt measurements were performed. the results were compared with healthy controls. results: mean -hour, day and night systolic-blood pressure (sbp), diastolic-bp (dbp) and mean arterial pressure values were comparable to that of control group. dipping in dbp was less in tm ( . % vs . %; p< . ). the ratio of patients with less than % dipping in sbp (non-dippers) was higher in tm ( . % vs . %, p< . ). mean plasma vegf level was . ± . pg/ml [ . - . ] in tm, was within normal range (< pg/ml) in controls. apps were normal. imt of common carotid artery (cca) was . ± . mm in tm group and . ± . mm in controls, (p< . ); imt of internal carotid artery (ica) was . ± . mm in tm group and . ± . mm in controls (p< . ). positive correlations were found between vegf and microalbuminuria, b -microglobulin and homosistein; between nag/cre and microalbuminuria; between cca-imt and age, and a negative correlation between cca-imt and ferritin. conclusions: renal tubular damage, abnormalities in abpm, increase in vegf and increase in cca-imt and ica-imt occur when the patients are asymptomatic and routine laboratory test are normal. optimal hemoglobin levels and deferoxamine therapy do not prevent the development of renal and vascular damage. l. sylvestre , e. santos , p. granzotto , e. siqueira , l. moreira , l. rispoli , n. mendes , r. meneses hospital pequeno principe, pediatric nephrology, curitiba, brazil centro universitario positivo unicenp, curitiba, brazil introduction: hypertension is frequently underdiagnosed in children. early diagnosis and a planned follow-up is helpful in detecting and preventing the harmful long-term consequences of hypertension. therefore, we created a specific outpatient clinic to have a better follow-up of these patients. material and methods: we reviewed the files of patients from the outpatient clinic of hypertension, from the dept. of pediatric nephrology in hospital pequeno principe, curitiba, brazil, followed for more than months, from march to december . we analyzed demographic and anthropometric data, diagnosis, staging of hypertension, presence of target-organ damage and treatment. results: patients were eligible, boys, mean age at the first visit . years old, mean follow-up of months. mean bmi= . ( % overweight and obese). secondary hypertension was present in % of the cases, predominantly due to parenchymal renal disease; essential hypertension associated to overweight and obesity in patients ( %) and there was no established diagnosis yet in other patients. fifty-five patiens performed at least one abpm of hours, showed hypertension. twelve from patients showed left ventricular hypertrophy and from patients had abnormalities of the retinal vasculature associated to hypertension. the most frequent drugs used to treat hypertension were ace inhibitors ( ) and calcium channel blockers ( ). conclusion: our data are in accordance that secondary hypertension is frequent in children, mostly associated to renal disease. furthermore, we could detect a large number of obese hypertensive children and adolescents. target-organ abnormalities are not as frequent as in adults but need to be monitored. intrauterine growth retardation (iugr) is characterized by low nephron number with or without reduced kidney size. leptin, an important hormone in the regulation of body fat massand weight, is decreased in fetuses with iugr. in the present study, weexamined the effects of leptin in a metanephric mesenchymal cell line ms . ms is generated from the metanephroi of embryonic day . homozygous mouse transgenic for h- kb-tsa. incubation of ms withleptin , , , or ng/ml for h did not affect either [ h]-thymidine incorporation or cell number. on the other hand, [ h]-leucine incorporation was significantly increased by leptin in a dose dependent manner ( ± %, ± %, ± %, and ± % of control by , , , and ng/ml, respectively). protein/dna was also increased . -fold by leptin ng/ml. leptin ng/ml activated both erk and p . the levels of phosphorylated-erk (p-erk) and phosphorylated-p (p-p ) , as assessed by western blot analysis, started to increase at min, peaked at min ( . -and . -fold increase respectively) remaining elevated at , , and h, and began to decrease at h returning to the baseline level at h. the levels of p-erk and p-p at min were increased by leptin in a dose dependent manner ( . -, . -, . -, and . -fold increase by , , , and ng/ml respectively). the levels of total erk and p remained unchanged. increase in [ h]-leucine incorporation stimulated by leptin ng/ml was completely inhibited by coincubation with a mek inhibitor pd μm or a p inhibitor sb μm. these results demonstrate that leptin induces hypertrophy of metanephric mesenchymal cells via erk and p . the hypertrophic effect of leptin may play a role in normal renal development and may explain reduced kidney size in a hypoleptinemic state, iugr. objectives of study: to investigate the mechanism of nephron deficit in rat model of intrauterine growth retardation (iugr). methods: a rat model of iugr was built by maternal low-protein ( %) dietthroughout pregnancy. newborn male pups were chose as our studyobjects. the proliferation and apoptosis in kidney was showed by ki- detection and tunel method. expression of wt , bcl- , bax, and p mrnas in renal tissue were examined by real-time pcr, and expression of wt and bcl- gene products in renal tissue were examined by immunohistochemistry and western blot. the final number of glomeruli was determined at weeks of age when nephrogenesis has finished. results: at weeks postnatally, iugr offspring had fewer glomeruli per kidney than those in controls (p< . ). in iugr newborns, tunel positive cells were more numerous in the nephrogenic zone. renalwt and bcl- mrna levels were significantly reduced in newborn iugrpups, and the bcl- mrna/bax mrna ratio was also decreased, but therewas no change in the expression of p mrna. in iugr newborns, the wt and bcl- protein expressions were significantly decreased, and the irimmunostaining were also suppressed in the nephrogenic zone. conclusions: these results suggest that reduction of nephron number in iugr rat may be associated with enhanced apoptosis in kidneydevelopment. decreased wt and bcl- expressions and reduction of the bcl- /bax ratio may contribute to the molecular mechanisms behind these findings. objective of the study: the aim of this study was to identify risk factors for urinarytract infection (uti) during follow-up of children with isolatedantenatal hydronephrosis. methods: between and , patients were diagnosed with isolated fetal renal pelvicdilatation (rpd) and were prospectively followed. after initialclinical and imaging evaluation, us scans, clinical examination, andlaboratory reviews were scheduled at -month intervals. the event ofinterest was time until occurrence of first episode of uti. cox's regression model was applied to identify variables that wereindependently associated with the uti. results: a total of patients were included in the analysis ( boys and girls) themedian fetal rpd was mm (iq range, . ± ) and patients ( . %) presented bilateral rpd. seventyeight ( %) infants presented urinarytract anomaly. the most frequent detected uropathy was upjo ( ), followed by primary vur ( ), and megaureter ( ). median follow-up timewas months (iq range, - months). during follow-up, uti occurred in ( %) of the children. the incidencerate of uti was episodes per person-month. the incidence rate of uti has decreased from . episodes per person-month in the first year of life to . in the second year, and to . after the third year. by survival analysis, the risk of uti for the whole series was estimated in . % at months, % at months, and % at months of age. after adjustment, two variables were independent predictors of uti during follow-up: female gender (rr= . , % ci, . - . , p= . ) and presence of uropathy (rr= . , % ci, . - . , p= . ). conclusion: according to findings, in a cohort of antenatal hydronephrosis, girls with vur or urinary tract obstructionhad a higher risk of uti during follow-up. objective of the study: to identify predictive factors of resolution of fetal renalpelvic dilatation (rpd) in a cohort of medically managed children. methods: between and , patients were diagnosed with isolated rpd and were prospectively followed. of infants, ( %) were clinically managed. after initial clinical and imaging evaluation, us scans, clinical examination, and laboratory reviews were scheduled at -month intervals. the event of interest was rpd resolution, regardedas renal pelvis < mm on two consecutive renal sonograms. cox's regression model was applied to identify variables that were independently associated with the event. results: a total of patients were included in the analysis and uropathy was diagnosed in ( %) infants. median follow-up time was months (interquartile range, to months). during follow-up, ( %) patients presented rpd resolution. by survival analysis, the estimate of rpd resolution for the whole series was % at months, % at months, and % at months of age. the median time for rpd resolution was estimated at months ( % ci, - ). in the survival analysis, three variables were found to be significantly associated with resolution of rpd during follow-up: mild fetal rpd, grades - (sfu grading system), and presence of uropathy. after adjustment, only absence of uropathy remained as an independent predictor of rpd resolution (rr= . , % ci, . - . , p< . ). conclusion: according to these findings, it was estimated that rpd resolution occurs in about half of the patients without uropathy at years of age. objective: to study clinical and pathological characteristics of antineutrophil cytoplasmic autoantibody (anca)-positive glomerulonephritis(gn). methods: clinical data of thirteen patients during years, with anca-positive gn were analyzed. results: of patients with anca-positive gn with an average age of . ± . ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) years, patients were female and were male. the average course was . ± . months. cases onset between december and february. there was , , cases whose chief complaint on admission was anaemia, swollen and hematuria respectively. the main clinical symptoms were: anaemia ( %), hematuria/proteinuria ( %), renal functional lesion ( %), edema ( . %), oliguresis ( . %), hypertension ( . %), arthralgia ( . %), rash ( . %), abdominal pain ( . %), fever ( . %). laboratory tests: bun, scr and esr were high while hemoglobin was low in all patients. mpo-anca was positive in cases c was normal in cases and low in cases. pathology features: all glomeruli are affected and show different degree of segment and glomus sclerosis. there was different degree of capsula glomeruli thickening. glomerulus capillary loop was necrotic, nuclear leukocytes and cell debris could be seen. inflammatory cell interstitial infiltration with lymphocyte and plasmocyte. endotheliocyte of small vessels of interstitial was swelling and vessel wall was edema, necrosis and glassy degeneration. immunofluorescence showed no or small immune complex deposition and showed pauci-immune gn. conclusion: onset of patients with anca-positive gn was hiding and there were nonspecific clinicalsymptoms in the early stage that reduced late diagnoses until esrd. female patients was predominant. renal pathology showed segment necrotic nephritis interstitial inflammation and polyangitis. the disease had unfavourable prognosis. background: renal function maturation isn't achieved at birth. vlbw infants exposed to intensive care have an increased risk of developing renal function impairment. moreover, we showed that ibu was associated with a significant impairment in renal function at one week of life in vlbw infants. objective: to evaluate renal function development in infants treated with ibu for pda closure as compared to infants not exposed to ibu, during the first month of life. methods: multicentric prospective cohort study of to weeks gestation (ga) infants exposed or not exposed to ibu within the first days of life. infants presenting with renal impairment at birth, urinary tract malformation, or contraindication to ibu were excluded. infants exposed to ibu were paired to controls according to ga, centre and crib score. creatinine clearance (ml/min/ . m ) was measured for glomerular filtration rate evaluation. fractional excretion of sodium (fena%), micro-albuminuria (mg/l) and alpha -microglobinuria/creatininuria ( /ucr: mg/mmol) were also measured once a week up to month of life results: infants were studied, half exposed to ibu. birth weight was ± g (mean±sd), and ga ± wks. results are presented in the table: *p= . ;**= . ;***< . . j. rouillard lafond, mp. morin, c. girardin centre hospitalier universitaire de sherbrooke, département de pédiatrie, sherbrooke, canada objectives of study: many studies have focused on the negative effects of low birth weight, especially caused by intra-uterine growth restriction, on adult renal function. however, few have addressed the impact of extreme prematurity (< weeks) on renal function of these children during their later childhood and adolescence. the aim of the present study is to estimate the renal outcome of this population, by determining blood pressure, glomerular filtration rate, fractional excretion of sodium and microalbuminuria in children ( girls and boys) aged to years old (mean age ) born between - weeks of gestation (mean: weeks). methods: during one encounter, height, weight and blood pressure were measured for each subject. blood tests were conducted to quantify creatinine, electrolytes and cystatin c. microalbumine, creatinine and electrolytes were dosed in one micturition. pertinent risk factors of renal damage in their perinatal history were noted. results: renal insufficiency, defined by a clearance of less than ml/min/ , m , was present in subjects ( %) when estimated by schwartz formula ( , - , ml/min/ , m ) and in ( %) when estimated by cystatin c ( , ml/min/ , m ). furthermore, ( %) children presented an elevated fractional excretion of sodium ( , - , %) . finally, children ( %) presented microalbuminuria, with albumin/creatinine ratio greater than , mg/mol ( , - , mg/mol) . those children presented more episodes of hypotension during neonatal period (p= , ) and have a tendency to have had neonatal asphyxia more than the others (p= , ). conclusions: these results suggest that children born extremely preterm may present renal insufficiency and sign of tubulopathy as early as adolescence, with microalbuminuria possibly announcing upcoming glomerulopathy. organogenesis isregulated by epithelial-mesenchymal interactions that take place in theembryonic kidney between the metanephric mesenchyme (mm) and theepithelium of the ureteric bud (ub). the mm expresses signals thatregulate ureteric branching while the ub signaling leads to inductionof nephrogenesis. as a response to the ub signals the mm cellscondense, aggregate, epithelialize and undergo simple morphogenesis togenerate segmented nephrons during kidney organogenesis in connectionto ureteric bud branching. we reported earlier that mutagenesis of fgf function from the whole embryonic mesoderm leads to kidney failure. activation of wnt- gene expression encoding another essential signal for nephrogenesis also depends on fgf function (perantoni et al., ) . given the important role of fgf in kidney development we targeted fgf roles in urogenital system (ugs) development with an ugs specific cre line pax cre. pax credeletion was expected to recombine the floxed genome in the nephronprecursors, ureteric bud and the wolffian duct derivatives. in crossesbetween fgf c/c and fgf n/+ ; pax cre mouse lines fgf gene was deleted successfully. as a result the whole ugswas affected. the kidney was severely reduced in size. newborn nullmice were born alive but died within hours likely due to kidneyfailure. in the deficient kidney the organization of theproximal-intermediate segments of the developing nephron was disturbed. marker analysis with in situ hybridization was consistentwith serious defects in nephrogenesis. we conclude that fgf functionis involved in the control of wolffian duct development andsegmentation of the assembling nephron. the zellwegerspectrum disorders (zsds) are characterized by a generalized loss of peroxisomal functions caused by deficient peroxisomal assembly. clinical presentation and survival are heterogeneous. although most peroxisomal enzymes are unstable in the cytosol of peroxisomedeficient cells of zsd patients, a few enzymes remain stable among which alanine: glyoxylate aminotransferase (agt). its deficiency causes primary hyperoxaluria type (ph , mim ), aninborn error of glyoxylate metabolism characterized by hyperoxaluria, nephrocalcinosis, and renal insufficiency. despite the normal level of agtactivity in zsd patients, hyperoxaluria has been reported in several zsdpatients. we aimed to determine the prevalence of hyperoxaluria in zsds and tofind clinically relevant clues that correlate with the urinary oxalate load. methods: we reviewed medical charts of dutch zsd patients with prolonged survival (>one year). results: urinary oxalate excretion was assessed in and glycolate in patients. hyperoxaluriawas present in ( %), and hyperglycolic aciduria in ( %). renal involvement with urolithiasis and nephrocalcinosis was present in five of whichone developed end-stage renal disease. the presence of hyperoxaluria, potentially leading to severe renal involvement, was statistically significant correlated with the severity of neurological dysfunction. discussion: zsd patients should be screened by urinalysis for hyperoxaluria and renal ultrasound for nephrocalcinosis in order to take timely measures to preventrenal insufficiency. menkes disease is a very rare x-linked recessivedisorder of copper metabolism. the frequency is : . live births. mutations in the atp a gene are described, which encodes for aintracellular copper-binding membrane protein. pathogenetically a defect in copper absorption is responsible for inadequate synthesis of copper requiringenzymes and causes multisystemic manifestations. the clinical picture ischaracterized by early neurodegenerative symptoms like muscular hypotony andcerebral seizures. the patients also present with the so called kinky hair, hyperelastic skin, and anomalies of the kidneys and the urinary tract. wereport on a patient of non consanguineous parents of german origin. theprenatal ultrasound did not show any malformations. birth at weeks ofgestation. postnatally a softening of the cranial bones and a vesicoureteralreflux iv° with dilatation of the renal pelvis combined with a subpelvicureteral stenosis had been observed, which were operated at the nd month of life. at the age of months the patient presented with seizuresand abnormal hair structure. within the diagnostic course menkes diseasehas been suspected and the nonsense mutation parg x has been identified inthe atp a gene. the mother is not a conductor, a mutation in thegermline cannot be excluded. conclusion: the combination of urinary tract malformations and neurodegenerative symptoms should let you think of the very rare menkes disease. introduction: primary hyperoxaluria type (ph ) is an inborn error of glyoxylate metabolism due to the deficient activity of the hepatic peroxisomal enzyme agt (alanine: glyoxylate aminotransferase). it leads to excessive endogenous oxalate production. patients develop urolithiasis and renal insufficiency. the contribution of specific precursors in the pathway leading to endogenous oxalate synthesis is not known. this is warranted to design appropriate treatments. we aimed to test the contribution of different precursors to oxalate synthesis. methods: wild type mouse hepatocytes were incubated with different potential precursors of glyoxylate, either in the presence or absence of alanine. in the absence of alanine flux through agt is deficient thereby mimicking agt deficiency. similar experiments were also performed in hepatocytes from agtdeficient mice. results: oxalate production was found to be highest with glyoxylate as substrate in the absence of alanine, whereas oxalate production was lower with glycolate, hydroxypyruvate, glycine, fructose, and ethylene glycol. the results obtained in wild-type hepatocytes incubated in the absence of alanine were comparable to those obtained in hepatocytes from agt-deficient mice. upon addition of alanine to wild-type mouse hepatocytes, however, resulted in % lower rates of oxalate production, in contrast to hepatocytes from agt deficient mice. discussion: hepatocytes derived from agt deficient mice represent a good model to study the contribution of different precursors to oxalate production in ph . s. grisaru , c. geary-joo , f. snider , j. cross university of calgary, department of pediatrics, calgary, canada university of calgary, department of biochemistry and molecular biology, calgary, canada gcm (glial cell missing), is a transcription factor necessary for the formation of placental syncytiotrophoblast in mice. gcm mutant mice die before nephrogenesis at embryonic day (e) . during early murine development gcm expression is limited to the placenta. however, immediately after birth, gcm is increasingly expressed in the kidney in proximal tubular cells in the outer medulla. we recently reported successful rescue the gcm null phenotype using a tetraploid aggregation approach (jasn vol. , ) . since our previous report, further analysis of the aggregation products confirmed only homozygous mutants ( males and a female) obtained from six hundred and twenty five transferred aggregate embryos resulting in live pups. abnormal cortico-medullary patterning was demonstrated by histology analysis of adult gcm null mice kidneys. this abnormality was further defined by immunohystochemical detection of known nephron segment-specific markers (aquaporin- , aquaporin- and tamm-horsfall protein) in gcm null kidney sections. to define the expression of gcm in human kidneys, commercially available anti-human gcm polyclonal antibodies were used to detect gcm protein in tissue sections of newborn kidneys obtained from autopsies. gcm was detected by immunohystochemistry in the renal cortex in tubular structures with cells having a brush border suggestive of proximal tubules. gcm signal was not detected in the renal medulla. conclusion: in humans, gcm is expressed in renal proximal tubules at birth whereas in adult mice its mutation is associated with abnormal renal cortico-medullary ultrastructure. this effect may represent a primary role for gcm in late renal development and patterning, or structural changes occurring postnatally secondary to alterations of tubular physiology caused by gcm inactivation. objectives: lupus nephritis (ln) in singapore children treated with cyclophosphamide and/or azathioprine has a poor prognosis with a reported -year renal survival of %. this study examined the long-term outcome of children with lupus nephritis using a new protocol comprising pulse intravenous methylprednisolone, mmf ± cyclosporine. method: twenty-one children with ln (age range at start of treatment . - . years) who were treated between the years to were included in this retrospective study. mmf dose was mg/m /day. mean duration of follow-up was . ± . (range . - . ) years. treatment outcome was defined by systemic lupus erythematosus disease activity index (sledai), renal function, proteinuria and serologic markers. effect of steroids on growth was assessed by height standard deviation score (htsds). statistical analysis was performed using wilcoxon signed rank test. results: at presentation, % had nephritic-nephrotic syndrome, % had nephrotic syndrome, while % had renal failure requiring dialysis. renal biopsy classification (who) was ii in %, iii in %, iv in %, and v in %. comparing pre-mmf treatment and current follow-up parameters respectively, sledai ( . ± . objectives of study: to understand the effects of response gene to complement (rgc- ) in tgf-β induced epithelial-mesenchymal transition (emt) on human renal proximal tubular epithelial cells (hptecs). methods: constructed rgc- expression plasmids and rgc- sirna hairpin plasmids, transient transfected them into hptecs in vitro, and then treated hptecs with tgf-β ( ng/ml) or vehicle alone for indicated time ( , min, h, h, h) . rt-pcr and western blot were used to determine the expression of a-sma, ecm (col-i, fn ). the mrna expressions of e-cadherin and sm a were detected by rt-pcr. results: ( ) the promoting effects of rgc- on emt. instead of stimulation with tgf-β , the hptecs, those overexpressed rgc- gene, de novo obtain the ability to produce markers of myofibroblast phenotype (a-sma, col-i and fn) and sm a gene, as well as lost the capability of expressing e-cadherin gene. ( ) the eliminating effects of rgc- sirna on emt that induced by tgf-β . after stimulation of tgf-β for hours, the expression of a-sma, col-i, and fn as well as sm a gene in hptecs, those rgc- genes were interfered with rgc- sirna, were significantly decreased than that in controls. conclusions: rgc- was an important regulator for tgf-β and its downstream signalling smad proteins on emt. background: low birth weight is associated with a low nephron endowment. this may predispose to hyperfiltration and cascading proteinuria particularly if obesity develops. our report relates to an emerging population of children with proteinuric kidney disease in our multiethnic community. methods: forty-two obese children (mean age ± years) with proteinuric kidney disease (kd) were studied. twenty-four were of normal birth weight (nbw> grams) and were of low birth weight (lbw< grams). there was a female ( / = %) and an ethnic predominance ( african, hispanic). degree of proteinuria was determined by the random urine protein (pr) and albumin (alb) to creatinine (cr) ratios (upr/cr and ualb/cr). renal function (egfr) was estimated from the schwartz formula. body mass index was used as a measure of obesity (> % centile). insulin resistance was measured by the homeostatic model assessment (homa). kidney tissue was obtained in of the patients for pathology and histomorphometry. results: average bmi was ± % tile. fasting insulin and homa scores were not significantly different in the obese nbw versus obese lbw children. renal biopsy specimens revealed focal glomerulosclerosis (fsgs) in the majority of patients ( / = %). progression to end stage kidney disease was significantly greater in lbw compared to nbw children with a median renal survival of years, p< . . glomerulomegaly as measured by glomerular diameter was similar in obese patients and significantly greater than non-obese controls with fsgs. conclusions: obesity appears to be a confounding factor in the development of glomerulosclerosis and progression of kidney disease in children. low birth weight and concomitant low nephron endowment may contribute to disease progression, especially in those of african and hispanic descent. objective: to determine long term outcome and prognostic factors of iga nephropathy in a large single center cohort of pediatric patients. patients and methods: we have reviewed the medical charts of patients with biopsy proven igan that have been followed at our institution from to , with a minimal follow-up of years. follow-up data, including proteinuria > mg/ h or the need for ace-is therapy, chronic renal failure (crf) and hypertension were analysed after years and years of follow-up. data from patients with follow-up longer than years were also available (mean follow-up . years, range - years). % of patients received therapy (cyclophosphamide in patients and/or steroid±ace-is in the remaining). clinical features at the onset, histology class (lee and haas) and treatment during the first years were analysed by multivariate analysis against the above mentioned dependet variables. results: the average follow-up was . years (range - years). presentation symptoms included macroscopic hematuria in % of patients. at the end of follow-up, renal function was normal in % patients, patients have reached end-stage renal disease and had chronic renal failure. proteinuria or the need for aceis at years was significantly associated with the age of onset (or: . [ . - . ] ) and proteinuria at the onset (or: . [ . - . ] ). crf was significantly associated with familial igan (or> ). hypertension at onset was significantly associated with persistent hypertension during follow-up (or: . [ . - ] . conclusion: taken together, these data indicate that the overall prognosis of igan is good during childhood and that the worst prognostic factor for development of crf is familial igan. overall, histological classification had a poor correlation with the outcome of the disease. this study was designed to compare three urinary protein expert systems for profiling proteinuria (pu) in children with kidney diseases. freshly voided urine was collected from children with glomerular diseases, children with tubular diseases and healthy children aged - years. out of children with renal disease had a glomerular filtration rate (gfr) < ml/min/ . m . the urinary protein expert systems were . albumin/total protein ratio (apr), . alpha- microglobulin/alpha- -microglobulin + albumin algorithm (aaa), and . the complex upes algorhithm (using serum creatinine, urinary total protein, alpha- -microglobulin, albumin, igg, alpha- -macroglobulin and dipsticks). apr correctly identified glomerular pu in of ( %) children with glomerular diseases, tubular pu in of ( %) children with tubular diseases and normal pu in of ( %) healthy children. aaa correctly identified glomerular pu in all ( %) children, tubular pu in of ( %) children, and all healthy children were characterized as having no pathological pu. upes differentiated the type of pu in children with glomerular diseases into glomerular ( / patients) and mixed glomerulo-tubular ( / patients). tubular pu in children with partial or complete renal fanconi syndrome was identified in / patients and described as mixed glomerulo-tubular pu in / patients. mixed glomerulo-tubular pu was only found in children with ckd stages - of glomerular and tubular diseases. in conclusion, urinary protein expert systems may be used to distinguish between glomerular and tubular pu. the aaa algorithm had the highest reliability when compared with the two other expert systems and the accuracy was not negatively influenced by a decrease of gfr. however, upes provided additional information on mixed glomerulo-tubular pu in patients with a low gfr. background: the three lmw proteins cystatin c (cys), β -microglobulin (β -m) and β-trace protein (β-tp) are useful markers of gfr. cys is particularly well suited for the detection of incipient renal failure. however, corticosteroid medication has been shown to stimulate cys production. aim of the study: analysis of the effect of corticosteroid therapy on the correlation between gfr and the three lmw markers. patients: patients ( f, m; median age . years, range . to . ) with malignant (n= ) or nephrological (n= ) diseases underwent a single-shot inulin clearance. the respective lmw proteins were measured by particle-enhanced immuno-nephelometry. children received corticosteroids (prednisone or dexamethasone) in a mean dosage of mg/m /d of prednisone equivalent (pred/bsa). multiple linear regression analysis was performed between the lmw markers as dependent and both gfr and steroid-dose as independent variables. results: mean gfr was . ± ml/min/ . m , mean cys . ± . mg/l, β -m . ± . mg/l and β-tp . ± . mg/l. cys was highly correlated with the reciprocal of gfr (p< . ) but not with corticosteroid-dose (p= . ), whereas both β -m and β-tp were highly correlated (p< . ) with both the reciprocal of gfr and the reciprocal of pred/bsa. discussion: using gold-standard gfr measurements, we cannot confirm earlier reports indicating an increase in serum cys during corticosteroid medication. by contrast, steroids significantly lowered both β -m and β-tp serum concentrations. we conclude that at least in patients with mild renal insufficiency cys -unlike β -m and β-tp -appropriately reflects gfr also during steroid therapy. this further supports the concept of cys being a superior marker of incipient renal failure. objective: to repeatedly follow kidney function since onset of type diabetes and evaluate whether gfr can predict development of micro-or macroalbuminuria or end stage renal disease. design: observational cohort study. methods: since , all diabetic patients undergo renal function tests every nd to rd year from onset. children, boys, have done clearance studies. healthy children and young adults, - years of age, served as controls. gfr was evaluated by clearance of inulin during water diuresis and continuous infusion. results: gfr during the first years after onset of diabetes was significantly higher than that of controls (mean - vs. ml/min/ . m ). at onset, and years after, boys had significantly higher gfr than girls (mean , , vs. , , ml/min per . m ) but after years no differences were found between sexes. the occurrence of microalbuminuria, albuminuria during the first - years was analysed and mean of gfr of , and years, and years, , and years and all those gfrs separately were compared between patients still normoalbuminuric, microalbuminuric and macroalbuminuric after and years resp. no significant differences were found between the groups. moreover the change in gfr from to , to and to and to years were also compared between the groups and no significant differences were found. young adults reached end stage renal disease (esrd) after - (median ) years and comparing their gfrs during the first - years with those still normoalbuminuric after years, no significant difference was found. conclusions: hyperfiltration is found in children with type diabetes during the first - years from onset and hyperfiltration was equally seen during the first - years in those children who in the future developed normo-, micro-, albuminuria and/or esrd. background: hiv associated nephropathy (hivan) remains an important entity despite the use of highly active anti-retroviral therapy (haart). our objectives were to determine the prevalence and severity of renal manifestations in a cohort of hiv infected children during the haart era. methods: a retrospective analysis was conducted on children infected with hiv. renal assessments included quantitation of proteinuria, radiologic abnormalities, and renal function. persistent proteinuria (pp) was defined by urine protein to creatinine ratio (upr/cr) > . detected on at least two measurements month apart. renal sonography and mag renal scintigraphy were categorized according to the presence of bilateral increased echogenicity and/or nephromegaly, and cortical retention and/or diffuse parenchymal disease, respectively. hivan was considered in those children that had pp associated with any radiological abnormalities. results: of the children, . % were perinatally infected. eighty-five ( . %) had pp. of these, had pp alone, while ( . %) developed hivan. the mean age of onset of hivan was . ± . years. overall mortality at the time of analysis was . % and it was highest in those with hivan. viral load (vl) > , copies was significantly associated with hivan. creatinine clearance was significantly decreased in patients with hivan. conclusions: the prevalence of pp in our population of perinatally infected children remains high ( . %), with at least half of them showing evidence of hivan. persistently high vl (> , copies) was associated with the presence of hivan. a spectrum of renal related disorders is a frequent occurrence in hiv infected children and should be sought with periodic urinalysis, quantitation of proteinuria and renal function, and imaging and/or histopathological studies. mmf has shown to be effective in adult ln, whereas only anectodical data are reported in childhood. we evaluated mmf in children with ln, f/ m, mean age: . ± . yrs, proteinuria > g/day, decreased c and increased anti-dsdna serum levels, normal renal function. renal biopsies, before mmf, showed the following classes (weening) : iv in cases, iii in , ii in , vi in . before mmf: patients have received i. v. cyp; more received aza and csa but were in flare-up of disease; the remaining were newly diagnosed patients. each patient received three i. v. metilprednisolone pulses and thereafter mmf (plus oral prednisone(p): mg/kg/day) was administered (mean dose: ± . mg/kg/day; through level: . ± . μg/ml). outcome was monitored by sledai score, renal function, proteinuria. in children p was tapered and, after . ± . month mean time, stopped; children were receiving p ( . mg/kg/day). the mean followup is ± months. sustained clinical remission was observed: proteinuria was absent in all, in patients an increase of serum c and c and a decrease of anti-dsdna levels was seen. significant steroid sparing effect was obtained: hypercorticysm dramatically improved. of the patients achieved years of mmf treatment and in them, at this time, a serial second renal biopsy was performed: histopathological activity indices reduced ( . ± . vs. . ± . , p< . ), whereas chronicity indices did not change ( . ± . vs. . ± . ). no haematological and/or gastrointestinal side effects were observed. our pilot study suggests that mmf represents a good alternative to traditional therapy in the treatment of sle in children, and in controlling disease activity and as steroid sparing agent without significant side effects over the entire period of therapy. mmf has shown to be effective, during treatment, in mantaining remission of childhood sd and csad ns, but few data are available on the mmf long term effectiveness after drug stopping. we report the results of two years mmf treatment in children with sd and csad ns. the characteristics of sd and csad groups were, respectively: patients, boys, mean age . yrs vs. pts, boys, mean age: . yrs (p< . ); first episode ns mean age: . yrs vs. . yrs; ns mean duration: . yrs vs. . yrs (p< . ); mean steroid therapy duration: . yrs vs. mean csa therapy duration: . yrs; histologic features: fsgs , mc vs. fsgs , mc . in both groups mmf was started after remission was achieved with prednisone administered at the last relapse. mmf treatment: lenght: months; mean dose: . ± , mg/kg/day; plasma through level: . ± . mcg/ml; non responder: patient presenting a ns relapse during mmf. in sd group ( %) and in csad ( %) subjects were responders. in patients of sd group and patients of csad group p could be withdrawn over a mean period of . months, so that ns remission was sustained just by mmf; remaining patients were receiving p at a mean dose of . mg/kg/a. d. two years mmf treatment was accomplished in / ( %) patients. at . ± months mean followup since mmf withdrawal, ( %) patients ( of sd and of csad group) relapsed after . months ( . - . ) mean time no haematological or gastrointestinal side effects were observed. our results demonstrate that two years mmf treatment in sd and csad ns children is effective not only in maintaining remission during therapy, but also in achieving persistent remission after withdrawal of drug in a significant rate (> %) of patients; the side effects and the rate of mmf dependence are negligible with respect to those of steroids and csa. information on long-term renal function following treatment for wilms tumor (wt) are relatively scanty. previous studies reported a worrying late development of microalbuminuria (uma), hypertension (hpt) and even reduction in glomerular filtration rate (gfr). the aim of the present study was to evaluate the long-term renal outcome in a cohort of patients who underwent uninephrectomy for wt. glomerular function (as creatinine clearance by cockroft-gault formula) was calculated and uma (as uma/ucr ratio) as well as urinary b microglobulin excretion were detected. -hours ambulatory blood pressure monitoring was also recorded. fifteen patients ( f) with a median age at wt diagnosis of . yrs (range . - . ) were studied. the median follow-up was . yrs ( . ± . ). eight patients had been classified as wt stage and as wt stage ii. all patients had been treated with unilateral total nephrectomy and chemotherapy. two of the children had also been addressed to radiotherapy. the primary disease did not recur in any of the patients. the median age at time of investigation was , yrs (range: , - , ). none of them had a gfr below normal limit (mean gfr was . ± . ml/min/ . m ). urinary b microglobulin excretion was normal (mean ub /ucr: . ± . ) in all of the patients. the mean uma/ucr ratio, was . ± , with only patient exhibiting higher then normal values (uma/ucr ratio: , ). the hr blood pressure was normal in all patients with a mean systolic and diastolic blood pressure sds of - . ± . and - . ± . , respectively. we conclude that as far as renal function, unilateral total nephrectomy combined with chemotherapy for low-stages wt can be look at as a safe treatment although it might be wise to monitor renal function at -year interval. classicaly, patients are divided into monosymptmatic enuresis (mne) and non-monosymptomatic enuresis, however, there is upcoming evidence that this subtyping might be artificial. the aim was to register the characteristics of nocturnal diuresis-rate and bladder volume in both subtypes. methods: retrospective analysis of consecutive patient-files, age - , primary consulting for enuresis in a tertiary center. registration of incontinentia diurna (id) and maximal functional bladder volume (vmax), hours urine-collections in day and nighttime-collections with uosmol and diuresis-volume (dv) and-rate. patients are divided into a mne and nmne-group. results: ) vmax is significantly lower than bladder volume for age, ) nocturnal polyuria is only present in / patients, ) nocturnal diuresis is >vmax, ) there is a significant linear correlation between nd and the nocturnal/daytime-diuresis-ratio, indicating fluid intake dependency. ) there is a negative correlation between nd and urinary osmolality. ) but the positive correlation between total nocturnal osmotic excretion and nd is much stronger. this unexpected observation cannot be explained by the classical primary vasopressin-theory. conclusion: our data show (almost) no statistical difference between the mne and nme-groups, suggesting a continuum instead of separate identities. both groups have a significant low vmax and nocturnal polyuria. the observation of the extremely strong correlation of nocturnal polyuria with the high osmotic excretion and high h urine-production suggests that nocturnal diuresis-rate is highly fluid-and nutrition-dependent, and therefore more attention should be given to this part of the urotherapy. a. deguchtenaere, a. raes, j. dehoorne, r. mauel, e. vanlaecke, p. hoebeke, j. vande walle there is increasing evidence that a subgroup of patients with nocturnal polyuria may have an abnormal circadian rhythm of tubular sodium which may result in vasopressin resistance. the pathogenesis of this phenomenon remains to be elucidated. however if the increased sodiumexcretion overnight results in the ddavp-resistance, decrease of the sodium-excretion-overnight may respond in subsequent ddavp response. aim of the study: retrospective study on the circadian rhytm of diuresis-rate and osmotic excretion in basal condition and subsequent during introduction of ddavp, diet and furosemide. results + discussion: ) baseline-values show significant lower uosmol and higher diuresis-rate overnight compared to controls. striking is the > % part of electrolytes to explain the high osmotic excretion. ) introduction of ddavp results in a normalization of nocturnal uosmol, but despite a significant decrease of uosmol overnight, nocturnal polyuria persists. ) protein-and sodium-restriction results only in slight differences, but of course we do not have data on the compliance. ) furosemide in the morning results in a significant increase of daytime diuresis, osmotic and sodium-excretion, but as compensation decreased nighttime diuresis, osmotic and sodiumexcretion. ) in / cases the antidiuretic effect results in an anti-enuretic effect. conclusion: this pilot study clearly demonstrates that introduction of early morning furosemide results in significantly lower nocturnal diuresis. because the urinary osmolality remains high, this correlates with decreased nocturnal osmotic excretion associated with increased osmotic excretion (sodium) during daytime. background: the elasticity of the vessel walls decreases with age, this process is dramatically speeded up by uremia. as an early indicator of arteriosclerosis pulse wave velocity (pwv) increases along with arterial stiffness. aim: to establish normal values for pwv in healthy children; to compare it with children on dialysis. patients, methods: pwv was measured with a pulsepen device in healthy children and young adults (age range - years) as well as in uremic children ( , ± years) (crf) treated by hemodialysis (n= ) or peritoneal dialysis (n= ). two control groups of - childrens were formed using the database of healthy children: one matched for age (a-c) and one adjusted for height and weight (h/w-c). blood pressure, heart rate, serum calcium (ca), phosphate (p) , and parathyroid hormone levels were also determined. results: a significant linear correlation was found between pwv and age (r= , ), height (r= , ), weight (r= , ), (p< , ), systolic blood pressure (r= , ) and heart rate (r=- , ) (p< , ). crf patients were smaller by , cm than a-c (p< , ), and younger than h/w-c by , years (p< , ). pwv in crf ( , ± , m/s) did not differ significantly from a-c ( , ± , ), however it was elevated in comparison to h/w-c ( , ± , p< , ). serum p, caxp and pth was increased in crf (p< , ) conclusion pwv is higher in children with crf as a sign of increased arterial stiffness. controls matched for height and weight should be used in states of severe growth retardation. a number of established risk factors potentially responsible for arterial dysfunction are present in crf. ngal has been identified as an early marker of acute renal failure (arf). sepsis in very low birth weight (vlbw) infants is associated with arf more often than recognized. the aim of this study is to determine whether ngal represents a marker of renal impairment in vlbw infants affected by sepsis. samples of urine of vlbw infants were prospectively collected for weekly measurement of ngal. after evaluation of the clinical course, groups were identified: group sepsis includes infants affected with septic events associated with some degree of renal impairment and group normal includes uncomplicated vlbw infants. a mouse model of sepsis was created in neonatal mice by intra-peritoneal introduction of salmonella lipopolysaccharide. kidneys were harvested hours after the challenge, and ngal mrna was quantified by real time pcr. ngal values of the normal group did not differ with gestational age or post-natal age of the neonates. the upper bound of the th percentile confidence interval was ng/ml. the median value of ngal in the sepsis group at days before the septic event was ng/ml and during sepsis was ng/ml: these values were not significantly different, but both were significantly higher (p< . ) than the median of the normal group ( ng/ml). once sepsis had been treated, the median value of urinary ngal was similar to normal ( ng/ml p= . ). changes in urine ngal concentration paralleled changes in serum creatinine. sepsis induced animal models showed a dramatic increase of ngal mrna in kidney tubules that paralleled acute renal failure. these neonatal animal and human data suggest that ngal may be an early marker of renal impairment in septic vlbw babies. further investigation is necessary to more exactly define the temporal relationship between the onset of sepsis/arf and rise in urine ngal concentration. we report cases of acute renal failure (arf) associated with orellanus syndrome, a cortinarius mushroom poisoning. grand-father, mother, father and son presented with arf week after gastrointestinal symptoms and weeks after repetitive ingestion of wild mushrooms. critically arf was observed for the year-old boy: anuria, severe metabolic disorders (hyponatremia mmol/l, hyperkaliemia mmol/l, serum creatinine mmol/l, blood urea mmol/l). renal biopsy was performed for the grand-father, father and son (day , and respectively after presentation) and showed similar lesions: severe tubulointerstitial nephritis (tin) with tubular necrosis and interstitial fibrosis. renal replacement therapy was necessary for the father and the son. the mother recovered completely in two weeks without dialysis while renal function improved slowly for the two men. the boy is still hemodialyzed months later. his main problem is uncontrolled hypertension. the diagnosis was confirmed weeks later since fungal spores of cortinarius orellanoides were observed in the contaminated meal by light microscopy. the severity of the disease seems to be related to the toxin quantity: the kg boy ate mushrooms as much as his father and grand-father, the mother ate much less. cortinarius spp poisoning is an exceptional paediatric cause of arf. gastrointestinal disorders are the main symptoms of the initial phase of the poisoning appearing days after the mushrooms ingestion. the renal phase is delayed (median . days) characterized by arf secondary to tin. the toxin effects are dose-related, explaining the severity of the boy's symptoms. the prognosis is severe with % of end stage renal failure. currently no treatment is available. although rare, mushroom poisoning should be considered in the differential diagnoses of arf with tin. l. mendels, ah. bouts, j-c. davin, j. groothoff emma children's hospital/academic medical center, pediatric nephrology, amsterdam, the netherlands background: inchronic dialysis, tertiary hyperparathyroidism (th) is clinically revealed by persistent combined high parathyroid hormone (pth), normalor high total serum calcium (tca) and normal phosphate levels. sincethe introduction of bicarbonate containing dialysate in peritoneal dialysis (pd), we have observed combined high tca and pth level sunusually early after onset of dialysis therapy. in most of the secases, ionized calcium (ica) levels were low. we aimed to investigate the extent of this discrepancy and its association with the mode of therapy. methods: serum ica, tca, pth, bicarbonate and capillary ph were assessed over years in pediatric pd, hemodialysis (hd) and in transplanted (tx) patients. associations between tca, pth and ica were analyzed. results: comparedto tx patients, we found in pd and hd patients a lower mean ica/tcaratio (both p< . ), an increased mean tca-ica (p< . and p < . , respectively), and a higher number of combined normal/increased tca and decreased ica and increased pth values ( . % and . %, respectively for pd and hd, vs. % for tx). alow ica/tca was associated with a high capillary ph (r=- . ; p< . ), a high venous bicarbonate (r=- . , p= . ) and a lowage (r= . , p= . ). conclusions: ica levels are warranted for monitoring calcium phosphate homeostasis in dialysis patients, especially in young pd patients. the use of only tca levels might lead to an inadequate treatment with vitamin d, and henceinduce the development of autonomous hyperparathyroidism in these patients. preterminal renal failure (prf)and end-stage renal disease in children and adolescents are associatedwith an increased risk of atherosclerosis and cardiovascular disease. oxidative stress is one of the pathogenetic factors that could possiblybe influenced by therapeutic interventions. we investigated biomarkers of oxidative stress in children (median age . years) with prf (median gfr ml/min/ . m , range - ) andin children (median age . years) under peritoneal dialysis (pd)and healthy age-matched controls (c). plasma samples wereinvestigated for malondialdehyd (hplc) and carbonyl groups in proteins(elisa) as biomarkers for oxidative stress as well as the plasmaantioxidative substances vitamin c (photometric), vitamin e (hplc), ubichinols (hplc), sulfhydryl groups in proteins(photometric), erythrocyte resistance to radicals and the total radicaltrapping antioxidant capacity (trap). in both patient groups prf and pdwe found a depletion of sulfydryl groups and ubichinol- and a reducedresistance of erythrocytes to radicals. malondialydehyd (p< . ) andcarbonyl groups (p< . ) were elevated in the pd group compared tocontrols. conclusion: from these studies we concludethat in children under peritoneal dialysis biomarkers of oxidativestress are elevated. moreover antioxidative defenses in preterminalrenal failure as well as under peritoneal dialysis are impaired. significant acute renal failure due to non-steroidal anti-inflammatory drugs: inpatient setting in united states non-steroidal anti-inflammatory drugs (nsaid) are freely available over-the counter. many children routinely use them without medical supervision. fourteen inpatients mean age of . ± . years ( males, females), were referred to nephrology for acute renal failure. based on history, biochemistry, imaging and urinalysis the diagnosis of acute renal failure due to nsaid was made. all patients admitted to taking ibuprofen and six also consumed naproxen. the exact doses of either could not be scientifically determined as none were prescribed by a physician. none of the patients had underlying renal diseases at the time of admission. nine patients had proteinuria and had hematuria (including one with gross hematuria). one patient had nephrotic syndrome but resolved spontaneously without steroids and has remained in remission for years. two patients required dialysis. only one of the dialyzed patient required steroid therapy for recovery of renal function. all data are expressed as mean±sd. the mean duration of hospitalization was ± . days. the mean serum creatinine at the peak of renal failure was . ± . mg/dl (range . - . ). all patients recovered renal function with normalization of serum creatinine to . ± . mg/dl (range . - , p< . ). however, the duration from onset to normalization of serum creatinine was ± days; indicating many patients had abnormal renal function for aprolonged period. in conclusion, nsaids pose significant risk of renal failure forsignificant duration and as an entity may be under recognized. objectives: treatment with growth hormone (gh) improves growth retardation of chronic renal failure. cdna microarrays were used to investigate gh-induced modifications in gene expression in the growth plate of uremic young rats, the organ where longitudinal growth takes place. methods: rna was extracted from the tibial growth plate from two groups (n= ) of young rats: uremic (nx) and uremic treated with . mg/kg/day of intraperitoneal gh for one week (nxgh). after reverse transcription, agilent technology was used to analyze differential gene expression by microarrays containing , rat probes (four hibridizations were performed). most expressed genes were detected using linear models and bayesian methods. to confirm gene expression changes shown by the chips, some genes known to play a physiological role in growth plate metabolism were analyzed by real-time quantitative polimerase chain reaction (qpcr). the ribosomal protein l (rpl ) expression did not show changes in the array and was used as the housekeeping gene. results. gh modified the expression of genes, being upregulated and down-regulated. the assay was validated by the qpcr results, which confirmed the sense of expression modification found in the arrays for insulin like growth factor i (down), insulin like growth factor ii (up), collagen alpha (down) and proteoglican type (up) . conclusions: this study shows for the first time the profile of growth plate gene expression modifications caused by gh treatment in experimental uremia. the further analysis of selected individual genes, whose expression is differentially modified by gh will contribute to explain the mechanism of the stimulating effect of gh on growth in chronic renal failure. objectives of study: children with chronic renal failure have an increased risk of cardiovascular disease. this is associated with endothelial dysfunction, a key pathophysiological factor in atherosclerotic disease. circulating endothelial progenitor cells (epcs) have the potential to repair endothelial damage and promote angiogenesis. in adults, the number of epc in peripheral blood correlates with endothelial function and reduced epc levels are associated with a higher incidence of cardiovascular events. we aimed to investigate if children on long-term hemodialysis (hd) therapy have reduced epc levels. methods: we quantified circulating epc in pediatric hd patients before a midweek hd session and healthy age-matched controls. epc are a subfraction of the haematopoeietic stem cells (hsc) expressing both hsc-marker cd and the vegf-receptor- kdr. using flow cytometry, epcs were identified as cd +kdr+ cells and quantified relative to the number of granulocytes in the sample. results: the number of epcs in the peripheral blood was significantly reduced in hd patients ( . ± . vs . ± . / granulocytes, % reduction; p= . ). the total number of circulating hsc also tended to be lower in hd patients ( . ± . vs . ± . / granulocytes, % reduction; p= . ). conclusion: the number of circulating epcs is significantly reduced in children on long term hd. reduced epc levels may contribute to endothelial dysfunction and accelerated atherosclerosis in children on long term hd. future studies are needed to identify the cause of this deficiency and to evaluate if increasing epc levels provides therapeutic benefit. objectives: darbepoetin alfa (aranesp ® ) is a novel erythropoiesis stimulating protein that has been shown in adult trials to have safety and tolerability equivalent to recombinant human erythropoietin. however, to date there is only limited published data on the use of aranesp inpaediatric patients. the objective of this study was to determine the safety and efficacy of darbepoetin in children with chronic and endstage kidney disease. methods: from to , children with either chronic or end stage kidney disease were enrolled in a prospective observational study. the initialdose of darbepoetin was . mcg/kg weekly (either iv or sc) and subsequent dose was titrated to achieve haemoglobin (hb) between and g/dl. results: data analysis to date includes patients ( male : female) whose agesranged from month to years (mean years). hb improved significantly with darbepoetin treatment from mean g/dl (range - ) at start of treatment to g/dl (range - , p< . ) at completion. the mean starting dose was . mcg/kg/week (range . - . ) which was not significantly different to the dose atthe end of the study ( . mc/kg/week, range . - . ). however, there was a significant change in the frequency of administration, with % commencing on weekly treatment, but only % still on weekly treatment at the end of the study (p< . ). the most common treatment interval in stable patients was fortnightly ( %) but a significant number tolerated even longer intervals ( % dosed every weeks or longer). injection pain was common, but there were no other significant adverse events. conclusions: darbepoetin alfa is a safe and effective therapy for anaemia associated with kidney disease. the majority of children will maintain satisfactory haemoglobin at a dosing interval of every weeks orgreater. high prevalence ( %) of left ventricular hypertrophy (lvh) and impaired systolic myocardial function in children with mild-to-moderate chronic renal failure (crf) were observed in previous studies (jasn , jasn ). in adult patients with uncomplicated arterial hypertension, lv mass (lvm) exceeding compensatory value for body size and cardiac workload (inappropriate or ilvm) is associated with poor prognosis, independently of lvh. we tested in crf children if increased lvm compensates or exceeds the expected values for individual cardiac load and if ilvm is associated with impaired cardiac function. complete anthropometrics, biochemical profile and doppler echocardiograms were obtained in children (age . ± . yrs; gfr . ± . ml/min/ . m ). ilvm was defined above % of the value predicted for individual body size, gender, and stroke work and lvh was defined as lvm/m . > g/m . . patients showed ilvm. children with ilvm had higher mean age and lower heart rate as compared to patients with appropriate lvm (both p< . ), without differences in blood pressure, bmi and gfr. after controlling for differences in age, gender distribution and presence of lvh, patients with ilvm showed similar cardiac geometry and diastolic function parameters compared to children with compensatory lvm (p=ns). in contrast, presence of ilvm was associated with lower lv ejection fraction ( . ± . % vs . ± . %) and lower midwall fractional shortening ( . ± . % vs . ± . %)compared to children with compensatory lvm (both p< . ), indicating impaired lv chamber performance and reduced systolic myocardial function. in conclusion, in . % of children with mild-to-moderate crf, lvm is inappropriately increased for individual cardiac workload and body size. presence of ilvm is associated with reduced systolic function, independently of age, gender and presence of lvh. pediatric nephrology centers were enrolled. age groups of the patients were as follows: . % newborn, . % - months, . % months - years, . % - years. underlying diseases were prematurity ( . %), malignancy ( . ), congenital heart diseases (chd, . ), urologic disorders ( . %). low fluid intake was noticed in % of cases. . % of cases developed arf after they have been hospitalized. time to diagnose arf was longer in the surgery department ( . ± . days) compared to pediatrics ( . ± . days), p< . . thirty-nine percent of patients were on mechanical ventilation (mv) before the diagnosis of arf, an additional . % needed mvl after the diagnosis of arf. arf was prerenal, intrinsic and obstructive in %, % and % respectively. hemodialysis and peritoneal dialysis was performed in . % and . % of cases. mortality was . %; and it was secondary to non-arf related causes in . % of cases; presence of mv, intrinsic arf, prematurity, chd, malignancy and being in intensive care unit were poor prognostic factors. conclusion: our nationwide data suggest that nephrologist, intensivist and pediatrician should focus on risk groups to prevent and to diagnose arf earlier. appropriate fluid intake and earlier consultation to a nephrologist are simple but may be effective measures to prevent arf.. hemolytic uremic syndrome is characterized by the triad of hemolytic anemia, acute renal failure, and thrombocytopenia. recent studies have shown that shiga-toxins (st) may stimulate apoptotic cell death in renal tubular cells, but the underlying molecular mechanisms remain to be elucidated. in the present study, confluent llc-pk cells were exposed to st and cell death was studied with morphological and biological assay. in llc-pk cells st was found to induce apoptotic cell death in a dose-and time-dependent manner. the expression of calpain and bax were significantly up regulated by st, while the expression of bcl- was down regulated. cell death was completely inhibited by a specific calpain inhibitor, but not by a broad caspase inhibitor, zvad-fmk, implicating a caspase-independent pathway via calpain. moreover, we found that serum factors could trigger a survival signal against st-induced cell death through pi k/akt pathway. in conclusion, activation of calpain mediates st-induced renal proximal tubular cell death, and the expression of bcl- and bax were oppositely altered. stimulation of pi k/akt signalling protects cells against death. verocytotoxin (vt)-producing e. coli (vtec) infection represents the main cause of hemolytic uremic syndrome (hus) in children. a nationwide surveillance system of hus was introduced in italy in may to follow the trend of vtec infections. for each patient, epidemiological and clinical information was collected by a standardized questionnaire. laboratory diagnosis of vtec infection was based on the detection of vtec and free vt in stools and of antibodies to the lipopolysaccharide (lps) of serogroups, o , o , o , o , and o in the sera. the immuno-detection of vt on circulating neutrophils was also performed on some patients. as of december , cases have been notified, accounting for a mean annual incidence of . x , in the - age group with a significant difference among the regions (from . to . ); median age of patients: months, % males. most cases ( %) occured in summer from june to september. seventy-nine per cent of the cases had prodromal symptoms such as bloody diarrhea ( %) and non-bloody diarrhea ( %). five patients ( . %) died from the disease. stools and/or sera were collected from cases. evidence of vtec infection was observed in cases ( %). the vtec serogroups most commonly detected were o ( % of the vtec-positive patients), followed by o , o , o and o . the number of cases associated with non-o infections increased over time: from the o -associated cases are the most frequent. during the surveillance-period epidemic clusters have been registered: -lombardia, -veneto, and campania. the role of vesico-ureteral reflux (vur) as a predisposition for acquired renal scarring with urinary tract infections (uti) has been questioned in recent years. few studies have investigated baseline factors associated with chronic nephropathy in severe reflux. we aimed to evaluate dmsa scans in children having any degree of primary vur associated with uti in order to identify variables that are predictors of the presence and/or development of renal scar. data of patients with proven uti who have primary vur were evaluated retrospectively. patients and renal units were classified as scar (+) and scar (-) by dmsa results. the following parameters were assessed with respect to their relation to presence of renal scarring: sex, age at diagnosis, grade (g) of reflux, number of subsequent utis (on new renal scars). there were patients (m/f: / , median age months) and refluxing units. variables increasing the likelihood of scar detection were: male gender ( / vs. / , p= . ; or . ), > months of age (for girls only; / vs. / , p= . ; or . ), g iv-v reflux (or . vs. g i-iii reflux and . vs. no reflux). all boys having g iv-v reflux and girls over months of age having g iv-v reflux had very high rate of scarring compared to the rest ( / vs. / , p= . , or . and / vs. / , p= . , or . , respectively). however, variables increasing the likelihood of new/progressive scar development were only the presence of previous scar (or . ) and uti number > (or . ). neither uti number nor new/progressive scar development was affected by vur grade. in conclusion, the most predictive variables for the presence of renal scarring among children presenting with a uti were male gender, age (being > months; only for females) and grades iv-v reflux, while new/progressive scar development was associated with presence of previous scar and uti number. d. hothi , e. harvey , c. goia , d. geary hospital for sick children, department of pediatric nephrology, toronto, canada hospital for sick children, educational, toronto, canada introduction: adequate ultrafiltration (uf) is necessary for good health in dialysis dependent patients. however uf can be hindered by development of intradialytic symptoms and hypotension. objectives: to determine whether sodium ramping, uf profiles and mannitol could improve uf without increasing intradialytic morbidity in children. method: a standardized hd practice was instituted in our unit. we prospectively analysed dialysis treatments from chronic patients with routine scheduled hd, hrs x - /wk. results: uf volumes between . to . % of the dry weight were achieved. mannitol reduced the risk of developing intradialytic symptoms by % (p< . ) without altering the risk of hypotension, with a mean uf volume of . % of the dry weight. a linear sodium ramp ( - mmol/l) increased the odds of intradialytic symptoms (p= . ) and hypotension (p< . ), with no difference in the mean uf volume. all uf profiles increased the risk of intradialytic symptoms but the effect was not statistically significant except with profile (stepwise reduction of uf during procedure). achievement of dry weight was least likely with uf profile (p< . ); there was no statistical difference in the mean uf volume between them all. conclusion: uf volumes higher than the traditional recommendations of % of the dry weight can be achieved in children. the use of mannitol increased the uf volumes and reduced symptoms without increased hypotensive episodes. objective: innate immunity and urinary tract response play a central role int he development of urinary tract infection (uti), in which heat shock protein (hsp) and toll-like receptor have a key position. patients and methods: hspa b a( )g and tlr a( )g genotypes were determined using allele-specific polymerase chain reaction in patients treated with recurrent urinary infection. allelic prevalence was related to reference values of healthy controls. clinical data were also reviewed and statistically evaluated. results: hspa b ( )gg genotype and hspa b ( )g allele occurred more frequently in uti patients versus controls (p= . ) and both were associated with a higher risk of renal scarring (p= . and . , respectively). tlr ( )ag genotype and tlr ( ) g allele had also higher prevalence among uti patients than controls (p= . and . , respectively). the combination of carrying ag genotype at both sites meant the greatest risk for uti (p= . ). conclusion: our data indicate an association between the carrier status of hspa b ( )g and tlr ( ) one of the major goal of hemodialysis adequacy is to achieve the fixed endsession body weight, so called dry weight, in order to limit overhydration and thereby cardiovascular risks. the prescribedultrafiltration, can induce hypotensive episodes and thereby limit thedry weight achievement. on line equipments offer the assessment of theblood volume (bv) and its relative variation. the bv is derived fromdirect measurement of the hematocrite. weroutinely use such an equipment (fresenius a c) over all thesessions since february , conducting to a clinical experience of bvm curves. these registered curves could be related to thehemodialysis prescription parameters (uf, nad, td, kt/v) to the dryweight, the blood pressure and to the clinical dialytic symptoms. thisexperience conducts us to define the normal bv curve over a sessionand its variations. starting dialysis induces an acute initial ( to min) decrease of bv, to %, mostly asymptomatic: extra corporeal circuit filling; this initialdecrease is a sign of normality. there after the normal bv curve should be flat; uf rate/amount being compensated by the plasma refilling rate: iso osmotic dialysis, no symptoms, no cramps, no hypotension, no vomiting. incase of no bv decrease over the dialysis session, the patient isoverloaded: reduce his dry weight. in case of a decrease of the bvhigher than %, there is a hypotensive risk: uf rate/amount, dryweight, sodium dialysate, sodium temperature and kt/v urea (cellular water shift) should be individually adapted conducting to arefilling curve. the effectiveness on the bv of these individual changein dialysis prescription can be directly, on line attested by the bvmcurve: plasma refilling capacity test. the bv changes reactivity is rapid, to min. renalscarring following acute pyelonephritis (apn) in children is a frequentcomplication which may impair renal growth. its pathophysiology includes host response, bacterial virulence, associated malformationand/or renal dysplasia. we prospectively studied virulence factors of e. coli isolates from children with a first episode of apn (fever > . c°, crp > mg/l, monomicrobial e. coli positive culture > * cfu/ml). we excluded patients with anyconcomitant infection, renal dysplasia or obstructive uropathy (us examination, renal length < sd) or grade - vur. renal scarring was evaluated by dmsa scan performed to months after apn. patients were included in a multicentre prospective randomized study comparing short vs long i. v. treatment with ceftriaxone as a first line antibiotic treatment [in press]; out of them fulfilled criteria for virulencestudy. six virulence genes were investigated by multiplex pcr (pap, sfa, afa adhesine genes; cnf , hly toxin genes, aeraerobactin gene) and the k capsular antigen was researched by latextest. we identified distinctive virulence profiles; % of e. coli strains had one or more virulence factors; % expressed the aer genewith at least one adhesin or one cytotoxic factor. renal scars occurredin % of cases and low grade ( - - ) vur was detected in %. statistical analysis did not show any correlation between the presenceof scars and e. coli virulence pattern. in addition, scarring was not correlated with the antibiotoc regimen but was correlated with grade vur (p . ). most e. colistrains associated with apn in children show several virulence factors, mainly adhesins and cytotoxins, but their profile was not correlated with renal scarring. background: acute lobar nephronia (aln), a severe renal parenchymal inflammatory disease, ranging between acute pyelonephritis (apn) and frank abscess formation, has been diagnosed with increasing frequency due to the advancement of non-invasive diagnostic modalities and the development of systematic diagnostic schemes. e. coli is the most common bacterialpathogen isolated from the urine samples of aln patients and the associated percentage is significantly higher than those among the patients with first time urinary tract infections. this prospective study was conducted to elucidate and differentiate the bacterialvirulence factors associated with aln and apn in pediatric patients. methods: patients included in the present study were those suspected of anupper uti and underwent a systematic scheme of ultrasonographic, ct and tc m-dmsa evaluation for the differential diagnosis of aln andapn. exclusion criteria were any evidence of underlying diseases orurinary anatomical anomalies except vur. the e. coli isolates from the urine samples of patients were screened with pcr analysis for various urovirulence genes. pulsed-field gelelectrophoresis was used to analyze the genetic association of theisolates. results: a total of patients were enroled. forty-six patients were diagnosed as aln, while the other cases were apn. diverse genotypes were found among the e. coli isolates in either group. among the pathogenetic determinants examined, multivariate logistic regress analysis indicating that a papg ii allele was the only significant urovirulence factor associated with aln (p< . ; odds ratio, . ). conclusions: while no specific genetic lineage was identified among the e. coli isolates studied, a papgii gene was found strongly associated with the cause of aln among pediatric patients without underlying disease other than vur. -< yr during - were sent to leading paediatric nephrologists of asian countries/regions. those having national renal registry were to use the registry data. results: data from countries/regions were returned (incl. national registries), namely china, hong kong sar, india, indonesia, japan, malaysia, pakistan, philippines, singapore, south korea & thailand. a total of esrd patients were reported: on peritoneal dialysis (pd), on haemodialysis (hd), & transplant (tx) of %, % & % respectively. chronic pd: capd and automated pd (apd) were the main modes of pd at ratio of . to . only countries had apd morethan capd. peritonitis rate ranged from episode in to patient-months, and seemed less common in those having more apd. chronic hd: hd comprised of % chronic dialysis, mostly adolescents. a-v fistula wasused in %, and permanent catheter % for vascular access. background: current data suggest the role of chronic inflammation and lipid disorders in atherogenesis. the aim of the study was to evaluate established and new markers of atherosclerosis in apd and hd pediatric patients and to assess whether the method of dialysis has an impact on those factors. methods: soluble(s) e-selectin, il- and il- concentrations were evaluated by elisa in sera of apd patients on, hd patients and controls. hscrp levels were assessed by nephelometry. the lipid profile (total cholesterol (chol), hdl-chol, ldl-chol, triglycerides (tgl)) was also estimated. results: se-selectin concentrations in dialyzed patients were higher than in controls (apd p< . ; hd p< . ) and in apd were increased vs. hd (p< . ). there were no differences in median values of il- , il- and hscrp between examined groups. chol levels were increased only in apd vs. controls (p< . ). hdl-chol concentrations were decreased in all dialyzed patients when compared to controls (apd p< . ; hd p< . ), without difference between apd and hd. ldl-chol in apd and hd were higher than in controls (apd p< . ; hd p< . ), but failed to differentiate between two dialysis modalities. tgl levels behaved in the same way. conclusions: the elevated se-selectin concentrations in all patients show the role of endothelium in atherogenesis in ckd children. thus, the se-selectin augmentation may serve as an early marker of endothelial activation, appearing prior to inflammation (unchanged hscrp, il- ). increased seselectin and cholesterol levels in apd patients prove that children on peritoneal dialysis are more prone to atherosclerosis than those on hemodialysis. background: end-stage renal disease (esrd) is associated with an increased risk of cardiovascular morbidity and mortality. according to recent data, arterial stiffness measured by aortic pulse wave velocity (pwv) and augmentation index (aix) is a strong independent predictor of cardiovascular mortality in adult esrd patients. few studies have been reported regarding arterial stiffness in the paediatric renal population. methods: aortic pwv and aix (difference between the first and the second systolic peaks on the aortic pressure waveform divided by the pulse pressure) were determined in haemodialysis children ( boys; age ± years) by applanation tonometry using a sphygmocor device. seven of the hd patients ( boys; age ± . years) received a renal transplant (tx) and were restudied ( ± months post tx). the immunosuppressive regimen included basiliximab induction, cyclosporine, mycophenolate mofetil, and steroids. results: in the hd population, aortic pwv ( . ± . m/s) was correlated with age (p= . ), weight (p= . ), height (p= . ) and systolic blood pressure (p= . ). in the transplanted cohort aix decreased in six children out of seven after transplantation ( . ± . % on hd versus - . ± . % after tx). no significant change was observed for aortic pwv ( . ± . m/s on hd versus . ± . m/s after tx). objective: to study the pathogenic role of host and escherichia coli virulence factors in the development of e. coli febrile urinary tract infection (uti) in children with acute cystitis (ac), acute pyelonephritis (apn) and renal scar. materials and methods: isolates recovered from children consecutively admitted to the hospital with e. coli febrile uti that diagnosed as ac (n= ) or apn (n= ) were retrospectively enrolled into this study. virulence genes of e. coli, that included papg genes (classes i-iii), aer, cnf , fimh, hlya, afa, sfa/foc, iha, usp, irone and ompt, were detected by polymerase chain reaction analysis. results: young age (=< months), male sex were more frequently associated host factors for patients with apn, but old age (> months) and female sex were more frequently associated with renal scar formation. after multilogistic regression analysis, with regard to e. coli virulence factors, the papg class ii gene might play a more important role in the development of e. coli apn. however, iha was significantly higher in young children with acute pyelonephritis. afterwards, age, gender, duration of fever before admission, and crp level were considered as potential confounders for the further multivariate analyses, specifically estimating the relative risks of e. coli genotypes to the incidence of acute pyelonephritis and renal scar by age group and the existence of vesicoureteral reflux. odds ratios with % confidence intervals for each variable were utilized to estimate the relative risk of acute pyelonephritis and renal scar. in addition, there were no differences between young children and old children, if we excluded the factor of vesicoureteral reflux (vur). conclusion: both host and e. coli virulence factors contribute to the development of febrile uti, apn and renal scar. since / we have started an acute peritoneal dialysis (duration - days) in infants (age days to months) with the use of the baxter acute set for children under constant warming of the complete dialysate inflow tract to °c (barkey system). as dialysate solutions we chose a glucose/bicarbonate/lactate solution (physioneal ) in all patients and in patients a mixture of this solution with a . % amino acid solution (nutrineal) in a : ratio. the body weight before the renal insufficiency was . to . kg. in patients the renal failure followed cardiothoracic surgery. the handling of the system was easy. because of obstruction by omentum and fibinous layers, respectively, the dialysis catheter had to be cleared surgically in patients. body temperature could be kept constant and in the normal range, even with low body weight and intensive dialysis (as measured by dialysate volume per kg body weight and day). in the infants dialyzed with the glucose/amino acid-mixture a decreased loss of albumin through the dialysate (as measured by the necessary intravenous albumin substitution), a better glucose homeostasis (less episodes of hyperglycemia and less need for insulin infusions) as well as a better acid-base control (less episodes of metabolic alkalosis) could be found. the detected tendency to a better homeostasis (concerning body temperature, serum albumin, blood glucose and acid-base) with this dialysis system and the used dialysate solutions could help to increase the survival chances of infants with renal failure. this will be evaluated prospectively. objectives: varicella-zoster-virus (vzv) infection can cause significant morbidity and mortality in the immunocompromised patient. since there is no clear correlation between antibody titers and protection monitoring after vzv vaccination is unclear. patients and methods: serum samples of nineteen pediatric transplant recipients were investigated for vzv igg antibody titers and avidity (elisa test). a relative avidity index (rai) < % showed evidence for low-avidity antibodies, an rai > % high-avidity antibodies, borderline avidity inbetween. the control group consisted of healthy children. had suffered from varicella infection after wild-virus contact, had undergone varicella vaccination. as there was no difference between diseased and vaccinated controls both subsets were treated as one group. results: median vzv igg antibody titers were u/ml (range - ) for transplanted children and u/ml (range - ) for control subjects (n. s.). median rai was % for transplant patients and % for controls (p= , ). there was no correlation between rai and antibody titers in either group. rai increased significantly with time after vaccination or infection in both groups. despite protective antibody titers after vaccination and an rai of % one transplant recipient showed a moderate vzv infection that required antiviral treatment. postinfectious course showed an increase of rai up to nearly %. conclusion: vzv igg antibody avidity might be a pathbreaking parameter regarding decision making for a second vaccination before transplantation or preemptive treatment in a transplanted patient in case of exposure. in japan, almost half of children with esrd received renal transplantation and more than % of those were living kidney transplants from their parents. burden of esrd during childhood frequently causes psychosocial problems in their families, including parental relationship problems. we investigated how parental divorce or death affected the choice of renal transplantation in children. patients and methods: in children younger than years old who started renal replacement therapy in our hospital, percentages of the children losing a parent or parents by divorce or death were investigated. we compared renal transplantation rates and percentages of fathers as kidney donors between those living with both parents and those without. results: in observation periods ( . ± . years), ( %) received renal transplants from living and deceased donors. nineteen children ( %) lost a parent or parents by divorce (n= ) or death (n= ). in all divorced families, mothers got parental authority. ten parents divorced during ckd period, after start of dialysis, and after transplant. of children living with both parents, ( %) transplanted with kidneys from fathers, mothers, and deceased donors. of children whose parents divorced, ( %) transplanted from fathers ( just before and after their divorce), mothers and other family members. however, in children at least one parent died, only ( %) transplanted from a deceased donor. conclusion: a high parental divorce rate from ckd period was observed in children with esrd, suggesting burden of the disease on their families. renal transplantation was preferred even in divorced families and divorced fathers still were willing to donate kidneys to their children. objective of study: to determine the importance of gastrointestinal evaluation in pre-transplantation phase in pediatrics with end stage renal disease (esrd). methods: twenty four children with esrd ( female, male) mean age . (± . ) years on maintenance hemodialysis were included in this study. upper gastrointestinal endoscopies were performed and four gastric antral and duodenal biopsy specimens were obtained for urease test and histological study for all patients. serum gastrin levels were measured in all patients, too. a control group was chosen to compare the rate of h. pylori infection using student's t. test. results: gastrointestinal symptoms were present in ( %) of patients. seventeen ( %) patients had abnormal upper gastrointestinal endoscopic findings. h. pylori was detected in % of patients and % in control group (p< . ). in symptomatic patients % had abnormal endoscopic findings and % had positive urease test for h. pylori infection. while, in asymptomatic cases these rates were % and %, respectively. seventy one percent of patients with gastrointestinal lesions and % of patients with normal endoscopic examination were infected. high serum gastrin levels in infected and non-infected patients were detected in % and . %, respectively (p< . ). conclusion: we demonstrated a significant number of patients with peptic ulcer diseases and h. pylori infection and secondary hypergastrinemia. this study showed that, clinical symptoms are not a reliable predictor of gastrointestinal problems. our results emphasize the importance of periodic, and also pre-transplant gastrointestinal evaluation in these patients to find out their problem and manage appropriately. key words: renal failure, hemodialysis, peptic ulcer disease, helicobacter pylori, hypergastrinemia. background: preservation of a stable allograft function in children following renal transplantation (rtx) depends on various factors including genetic variability. the gene of the angiotensin i converting enzyme (ace) has been shown to influence allograft function. we therefore analysed various polymorphisms of the renin-angiotensin system in children following rtx and kidney donors and associated genotypes with loss of renal function. patients and methods: children and adolescents ( male, female, mean age at transplantation . ± . years) with stable renal function and observation period exceeding months were included. mean follow-up time was . years ( . to years). dna was extracted from all recipients and donors and genotyped using rflp. the following polymorphisms were studied: renin g/a; ace i/d; angiotensinogen (agt) met/thr and angiotensin ii receptor type- (at r) a/c. the slope of glomerular filtration rate (gfr) was determined by linear regression analysis and correlated with the genotype. results: allelic frequencies were not different from healthy controls. genotypes of renin, agt and at r showed no significant association with the slope of gfr but patients homozygous for the ace-d-allele had a significantly steeper decline of gfr when compared to homozygous carriers of the ace-i-allele (slope dd: - . ± . vs. ii: - . ± . ; p= . ). the dd-genotype was also present in out of donors and in four cases a dd-recipient received a kidney from a dd-donor. those four patients showed a more pronounced decline of gfr (- . ± . ; p= . ). in addition, dd-recipients had a significantly increased systolic and diastolic blood pressure before rtx. conclusions: the dd-genotype is associated with a faster, non-immunological loss of graft function which has to be evaluated in prospective studies. year large single-center review b. warshaw, l. hymes, l. greenbaum, s. amaral from - , children received renal transplants at emory university/children's healthcare of atlanta of whom ( %) had nephroticsyndrome (ns) as their primary diagnosis ( fsgs, minimal change). all children received calcineurin-based immunosuppression. thirteen children ( %) developed recurrent ns within the first week post-transplant and received plasmapheresis (pp) - times weekly. nine ( %) had complete resolution of proteinuria. two who responded to pp suffered graft loss fromlate recurrences of ns at years. ns did not resolve with pp in children who suffered either delayed function ( ) or early cessationof function ( ); each of the latter lost their grafts within the first months. patients did not have recurrences of ns. comparison of these groups showed significantly increased riskfor recurrence with younger patient age (p< . ), interval < years from onset of ns to esrd (p< . ), and living donor source ( / = % ld vs / = % dd; p< . ). no differences were seenfor hla match, donor age, gender, or african american race. actuarial graft survival for children with recurrence was % at year and % at years vs. % & % for patients without recurrence. conclusions: ns recurred in % of children with ns as their primary cause of esrd. risk factors for recurrence included younger age, interval < years from onset of ns to esrd, and living donors. most recurrences responded to pp ( %); failure to respond was associated with delayed or early cessation ofrenal function & early graft loss. the incidence of recurrence was strikingly high ( %) among living donor recipients, suggesting a need to explore prophylactic strategies such as preemptive pp in this group. methods: a single-centre retrospective case-controlled study including children < yr (g ) and matched kidney tx recipients older than yr ofage (g ). patients were matched for donor type and tx period. kaplan-meier method was used for patient and graft survival. results: tx were performed using deceased donors in both groups. median recipient age, weight and height at tx in g were . [ . - . ] yr, . [ . - . ] kg and . [ . - . ] cm, respectively, while median age in g was . [ . - . ] yr. hypoplasia-dysplasia wasmore frequent in g ( vs %). median hla-dr mismatch, time ondialysis and number of blood transfusion before tx were not different. in g , kidneys were placed intraperitoneally and most of vascular anastomoses were done on distal aorta ( %) and inferior vena cava ( %). median follow-up was . [ . - . ] yr and . [ . - . ] yr ing and g , respectively. patient survival was % at yr and % at yr in g ; patients died in g ( ptld, recurrence of primary disease), none in g . fiveyear graft survival was % in g and % in g . acuterejection episodes occurred in % in g and in % in g (p . ). chronic rejection led to late graft losses in g ( . to . yrafter tx) vs in g . renal function did not differ between the groups during the first yr post tx. the average height gain was better in g at yr post tx (+ . sds vs. - . ). primary disease recurrence was observed in cases ( in g ) causing graft lossin cases. two arterial thromboses were observed in g causing earlygraft-loss. conclusion: the outcome after cadaveric kidney transplantation is as good in children under yr of age at transplantation as in older recipients in our experience. c. garcia, v. bittencourt, d. malheiros, a. tumelero, j. antonello, a. oliveira, v. garcia cancer is an increasingly recognized problem associated with immunosuppression. recent reports, however, suggest that sirolimus (srl) has anti-cancer properties that could address this problem. aim: to report a retrospective analysis of preliminary results of patients who received srl because of post-transplant de novo malignancies in a consecutive cohort of pediatric kidney recipients. patient and methods: we retrospectively evaluated the efficacy and safety of srl in pediatric renal transplantation recipients, who were ± years when converted to srl. the post-transplant de novo malignancies were: gall bladder and hepatic leiomyoma (n= ), wilms tumor in the native kidney (n= ), ptld (n= ) and hpv-associated neoplasia. the immunossupressive regimen at the malignancy diagnosis was tacrolimus/cyclosporin, mmf/azathioprin and prednisone. all were converted to double immunossupression with sirolimus at a standard dose of mg/day (tl - ng/ml) and prednisone. patients with ptld were also treated with rituximab, and the patients with wilms tumor received chemotherapy. mean follow-up after srl conversion is ± months. results: all patients were maintained with srl and pred without rejection, with good renal function and no cancer recurrence (follow-up to months). the patients with wilms tumor are still on chemotherapy. follow-up control after srl conversion in the patients: conclusion: although the intraperitoneal group had characteristics associated with increased surgical risk (they tended to be younger and smaller, with a higher incidence of aortic anastomoses and a higher incidence of multiple vessels), surgical complications were significantly lower than expected in the extraperitoneal group % v. %. objective of study: proteinuria is a frequent complication in adult patients after renal transplantation (r-tx) and is associated with poor graft survival. in children, there are no studies focusing primarily on proteinuria after r-tx. the aim of this study was to investigate the prevalence of proteinuria in children after r-tx and to evaluate changes of proteinuria during a -yr study on intensified antihypertensive therapy. methods: protein excretion was measured in -hr urine and proteinuria defined as > mg/m /day. proteinuria was investigated at baseline, and years after intensifying of the antihypertensive therapy in children with uncontrolled hypertension at baseline (i. e. additional antihypertensive drugs given to children with blood pressure > . pc). children ( . ± . yrs) out of from our center fulfilled inclusion criterias (> months after r-tx, no acute rejection (ar) in the last months, no recurrent fsgs). results: the prevalence of proteinuria was % at baseline, % after year (ns) and it decreased to % after years (p< . ). the mean protein excretion was ± mg/m /day at baseline, ± after year (ns) and it decreased to ± after years (p< . ). mean number of antihypertensive drugs increased from . ± . drugs/patient to . ± . after years (p< . ). mean nighttime bp decreased significantly after years. the number of patients on ace-inhibitors increased from % at baseline to % after years (p< . ). conclusions: this is the first study on proteinuria in children after r-tx. it showed that proteinuria is a frequent finding in transplanted children and that intensified long-term antihypertensive treatment using ace-inhibitors can decrease not only bp but also proteinuria in these patients. allograftrejection involves t cell activation and proliferation and multipleinflammatory components. monocyte chemotactic peptide- (mcp- ) is achemoattractant and activating factor for monocytes. interleukin- (il- ) may contribute to monocyte recruitment, results intubulointerstitial damage. cytotoxic lymphocytes induce target cell death by ligation of the fas-fasligand. allelic polymorphisms in recipient genes coding for them reported to beassociated with variations of outcome in renal transplantation. the aim was to investigate impact of mcp- - a/g and il - g/c, fas- a/g polymorphisms on acute allograft rejection (ar). there were males and females, ± . years meanly; of the graftscame from living-related donors, were from cadavers. the controlgroup consisted of unrelated, healthy individuals with similar ageand sex. ar group was composed by patients experienced at least one ar episode within the first months of transplantation. the non ar group was comprised by kidney transplant patients without ar. there was no significant difference between renal transplant patients and healthy controls in genotype distribution of allelic frequencies of il- , fas and mcp- polymorphisms. while il- and fas gene polymorphisms had no effect on the incidence of ar episodes, there was significant association with mcp- . the distribution of the genotypes for mcp- - a/g in ar group were aa/ag/gg , %, , %, , % respectively. the distribution of the genotypes for mcp- - a/g was aa/ag/gg %, %, % in nonar group respectively. the carriage of g allele at - position of mcp- gene has a significant association with ar (or: , , %, ci: , - , ). the il- and fas gene polymorphisms had no effect on the incidence of ar. mcp- - g allele carriage increases the ar risk in turkish renal transplant patients. the high recurrence rate of focal segmental glomerulosclerosis (fsgs) in transplanted kidney recipients suggests the hypothesis that such patients have a circulating factor that changes glomerular capillary permeability. serum from patients with fsgs increases glomerular permeability to albumin, and this permeability factor was partially identified as a protein. the removal of this protein by plasmapheresis (pp) decreases proteinuria. object: the aim of this paper is to provide data about the therapeutic effect of pp in fsgs children with recurrence in the transplanted kidney. methods and results: twenty eight pediatric kidney transplant recipients had fsgs as cause of renal failure from to in our center, confirmed by biopsy pre-transplant. seventeen of these ( . %) had a recurrence (proteinuria > g/m per day associated with hypoalbuminemia). the mean age was ± . years, , % were caucasians and , % were performed with living donor. since , patients who presented fsgs recurrence were treated with cycles of pp ( cycles/weekly), initiated immediately post-recurrence (n= ). immunosuppression comprised of cyclosporin in high doses (c levels of - ng/ml) or tacrolimus (tl= mg/dl), mycophenolate sodium or mofetil (until azathioprine was used) and prednisone. among patients who received pp (n= ), ( . %) achieved a complete remission. there were no cases of remission among those six patients who were not treated with pp. those who achieved remission after pp had no recurrence. the patients treated with pp had infectious complications: one patient had cytomegalovirus disease and two patients had varicella. conclusion: pp appears to be effective in treating recurrent fsgs following kidney transplantation. it should be started as soon as possible. because the calcineurin inhibitors (cni) cyclosporin a (csa) and tacrolimus (tac) are drugs with a narrow therapeutic index, individualization of cni dosage by therapeutic drug monitoring is indisputable. however, the optimal strategy for monitoring cni therapy is currently under debate. dosing of cnis according to the molecular effect of the drug on its target cells could optimize immunosuppressive therapy with cnis. for this purpose, we developed a reliable, precise, and robust whole blood assay based on the measurement of the expression of three nfat-regulated genes (il- , ifng and gm-csf) in pma/ionomycin-stimulated lymphocytes before and . (tac, c . ) or hrs (csa, c ) after oral drug intake. the inhibition of genes in this assay is independent from other commonly used immunosuppressive drugs and reflects calcineurin inhibition expressed as residual nfat activity. in a pilot study, patients (mean age yrs, mean time period posttransplant mo.) were analyzed. in csa-treated patients (n= ), a mean c concentration of ng/ml (range, - ng/ml) corresponded to a mean residual nfat-activity of % (range, - %) ; the correlation between individual residual nfat-activity and c was moderate (r= , , p< . ). at a csa-c of ng/ml, the residual nfat-activity varied between % and %. in tactreated patients (n= ), a mean c . concentration of ng/ml (range, - ng/ml) corresponded to a mean residual nfat-activity of % (range, - %); the correlation between individual residual nfat-activity and c . was also only moderate (r= , , p< . ). conclusion: these data indicate that there is a considerable inter-patient variability of residual nfat-activity at a given maximal cni blood concentration. ongoing studies are validating this assay regarding clinical outcome criteria of immunosuppression such as acute rejection and infections. hus due to antibodies against factor h (husafhab) is a very rare disease for which a limited experience in its management is available. we present a case of husafhab who was transplanted but lost her graft after only mos. in aug a -mos old child was admitted for a d-hus which did not go into remission and required chronic peritoneal dialysis. no fh and mcp gene mutation were detected nor adamst- activity was decreased. afhab were not searched at that time. in apr. the child underwent cadaver renal transplant (rtx). the immunosuppressive regimen was basiliximab-prednisone-cyclosporine-mycophenolate mofetil. fifteen days after rtx, following surgery for urinoma, the child exhibited an hus relapse with thrombocytopenia, haemolytic anemia and increased serum creatinine (scr). high afhab were detected ( au/ml). four plasma exchanges (pe) were performed over wks with a drop of afhab to control level ( au/ml) and a remission of hus. until the end of aug, afhab remained low (< au/ml) and the child was well (scr range: . - . mg/dl). in early aug, the patient was shifted to tacrolimus for severe hypertrichosis with a fluctuation of its plasma level (lower recorded value: . ng/ml) signs of acute rejection developed and metilprednisolone (mtp) pulses brought scr to baseline level. in oct. , following an urti, the child presented with severe proteinuria (upr/ucr: , ) without other clear signs of hus recurrence. since afhab were increased ( au/ml), pe was restarted but an acute hemorrhagic complication (hemotorax) occurred and pe had to be interrupted. septicemia followed and the child became anuric. the renal biopsy performed days later showed signs of glomerular and vascular thrombotic microangiopathy. renal function did not recover despite mtp pulses and pe. in nov the child was back to pd and in dec the graft was removed. background & aims: recently, the role of nitric oxide (no) in the pathogenesis of idiopathic nephrotic syndrome (ins) has been intensively investigated. however, its rapid turnover has made us impossible to investigate the quantity and the source. as we have developed a novel method for quantitative analysis for no by a new fluorescent indicator, , -diaminofluorescein (daf- ), its amount produced by both t and b lymphocytes in ins was studied. methods: five children with steroid-sensitive ins (mean age: . y) were included in this study, together with children with other renal diseases (mean age: . y) such as chronic glumerulonephritis and alport syndrome with significant amount of proteinuria, and healthy adults (mean age: . y) for the control. no production from cd + cell and cd + cell was investigated by a flow cytometry using daf- . results were expressed as mean fluorescence intensity and were compared among the groups. results: the amount of no produced by cd + cell and cd + cell in children with ins was significantly greater than those in children with other renal diseases and healthy adults (cd + cell: . ± . [mean±sd], . ± . , and . ± . , respectively; cd + cell: . ± . , . ± . , and . ± . , respectively, p< . ). additionally, both cd + cell and cd + cell during nephrotic relapse produced more no than in nephrotic remission (p< . ). discussion: patients with relapsing ins showed increased production of no by both t and b lymphocyte. these findings indicate that no plays some role in the pathogenesis of ins and suggest that an abnormal immune system may exist not only in t but also in b lymphocytes. a. bagga, a. sinha, s. menon, p. hari aim: the treatment of patients with srns is challenging. based on suggestions that b-lymphocytes are crucial in the pathogenesis of nephrotic syndrome, we examined the efficacy of rituximab (rtx) in patients with srns refractory to standard therapies. methods: six patients ( with initial, late resistance), - yr old, were included; biopsy showed minimal change & focal segmental glomerulosclerosis in each. all had previously received iv high-dose steroids, alkylating agents & calcineurin inhibitors (cni) for - yr with periods of partial (pr; urine - +) or complete remission (cr; urine trace/negative). all now had srns refractory to -months treatment with cni. rtx ( mg/sq. m) was infused iv every week for weeks. therapy with cni and/or alternate-day prednisolone, & cotrimoxazole prophylaxis was continued. patients were monitored for proteinuria and renal functions. results: at a median interval of wk following the last rtx dose, cr was seen in & pr in patients. remission was sustained in patients, despite tapering doses of steroids & cni. one case had relapse of nephrotic syndrome -months later, which responded to steroid treatment. at median follow-up of wk, cr, pr and recurrence of nephrotic proteinuria ( - +) were seen in , and patients respectively. mean urine albumin-to-creatinine ratio was . at baseline and . at followup; respective blood levels of albumin were . and . g/dl & cholesterol and mg/dl (all p< . , anova); difference in leukocyte counts and levels of igg were not significant and none had serious infections. conclusions: this is the first report on the efficiacy of rtx in sustaining remission in patients with srns. therapy with this agent appears promising for difficult srns, with a better risk/benefit profile than other medications. quantitative or functional deficiency of factor h results in uncontrolled complement activation and is an important cause of familial hemolytic uremic syndrome (ahus). factor h-related proteins (fhr) constitute a protein family which share structural and most likely functional similarities to factor h. we here describe complete deficiency of fhr- /- as novel cause of ahus. factor h and fhr- /- were quantified by elisa and were further analyzed by western blot using specific antibodies. complement activation was determined by measuring c and c . serial hgb (g/dl), platelet, creatinine (mg/dl), and ldh (u/l) were measured. a year old girl presented with a day history of lethargy, pallor, vomiting and hypertension. hgb was g/dl, platelets x /l and creatinine was . mg/dl. initial therapy consisted of packed red cell and platelet transfusion, followed by steroid therapy. representation occurred weeks later with hypertension, edema, persistent anemia thrombocytopenia and renal dysfunction (creatinine . mg/dl). renal biopsy demonstrated features of chronic thrombotic microangiopathy. low c levels indicated activation of the complement system. while western blot analysis showed normal factor h level, fhr- /- was absent. by repetitive plasma infusion and plasmapheresis, the cycle of hemolysis and thrombocytopenia could be disrupted. chronic periodical plasma infusion q days resulted in regression of renal impairment to a degree (current baseline creatinine . mg/dl). in conclusion, fhr- /- are thought to have co-factor activity and play a role in complement activation in ahus. deficiency of fhr- /- may lead to a subclinical form of ahus such that patients may initially present with features of chronic renal failure. however, factor replacement therapy may lead to regression of renal impairment. s. choudhry objectives of the study: the aim of the study is to investigate the long term prognosis ofsevere childhood iga nephropathy after years combined therapy. patients: we examined patients who had entered thejapanese pediatric iga nephropathy treatment study group between and , had been treated with years combined therapy (combinationof prednisolone, azathioprine, dipyridamole and heparin/warfarin) andhad been followed for more than years after the therapy. significantproteinuria is defined as more than . g/m /day. results: mean age at onset was . years ( - years), proteinuria at diagnosis was . ± . g/m /day, proteinuria after the combined therapy was . ± . g/m /day and mean follow-up period after the combined therapy was . years ( . - . years). proteinuria improved in all patients during thecombined therapy (p< . ). the final prognoses were as follows: patients ( %) showed no proteinuria, ( %) showed proteinuria withnormal renal function and ( %) proteinuria with decreased renalfunction. we compared the clinical and pathological parameters betweenpatients with proteinuria (n= ) and those without proteinuria (n= ) at the last observation. period between disease onset and start of treatment, glomeruli showing crescents before the combined therapy (%) and glomeruli showing pathological changes after the combined therapy (%) were the significant risk factors for the proteinuria at the last observation. logistic multivariable analysis revealed that glomeruli showing pathological changes after the combined therapy (%) was theonly independent risk factor for the proteinuria at the last observation. conclusions: pathological activity of nephritis at the end of the combined therapy might correlate well with the final proteinuria and the long term prognosis. s. arun, a. bagga, s. bhatnagar, p. hari, s. menon, s. saini aim: relapses in ssns of ten follow minor infections and are associated with perturbed t-cell function. based on data that zn supplements modulate t-cell function and reduce risk of infections, we examined its efficacy in reducing relapses in patients with ssns. methods: in this double blind rct, consecutive patients with ssns - yr old, stratified into frequent (fr= ) and infrequent (ifr= ) relapsers, were randomized to -months therapy with zn ( mg daily) or placebo. patients with fr also received long-term, alternate day prednisone. relapse and infection rates were monitored monthly. blood levels of zn, sil r, il and interferon (ifn) were measured at baseline, relapse andend of study. results: patientsin the zn (n= ) and placebo (n= ) groups had similar baseline clinical & laboratory features. the former showed % lower frequency of relapses (difference in means - . ; % ci - . , . ) with trend towards reduction from -months onward. a higher proportion ( . %) of patients in the zn group had sustained remission compared toplacebo ( . %). reduction in relapse rates was higher in fr receiving zn vs. placebo (- . ; ci - . , . ); respective sustained remission was seen in % and % patients (relative risk . ; ci . , . ; p . ). no differences were found in infection rates, and levels of zn, sil r & il ; levels of ifn were higher in those receiving zn compared to placebo (p= . ). conclusions: zn supplementation for -yr was effective in maintaining remission and reducing relapse rates. the effect was mediated not by reducing infections but perhaps through effect on th cytokines. while zn therapy appears promising, these results need confirmation in patients with frequent relapses and perhaps at a higher dose. background: n-glycosylation process in the endoplasmic reticulum (er) is tightly regulated and orchestrated by many factors such as chaperones and energy systems. we showed that adequate nglycosylation is crucial for nephrin to assemble to the plasma membrane (jasn, ) . additionally we recently demonstrated that the er stress evoked by glucose starvation induces hypoglycosylated nephrin retained in the er, which is rescued by dexamethasone (dex) (ki, ) and immunosuppresant: mizoribine (mzr) (submitting). in the present study, we tested whether other er stress inducer, hypoxia, could also interfere the alteration of nephrin n-glycosylation system and whether dex and immunosuppressants rescue its defective process. methods: nephrin-expressing cell line was cultured either in % o or % o for hours in the presence or absence of dex, mzr and cyclosporin a (csa), followed by western blot analysis with nephrin, cytochrome c. intracellular atp concentrations were measured by the highperformance liquid chromatography. protein expression of cyclophilin d (cyp-d), a component of mitochondrial permeability transition pore (mptp), was tested in the samples from human glomeruli and cultured podocyte. results: hypoxia induced hypoglycosylated nephrin. csa, but not dex and mzr, inhibited the formation of this hypoglycosylated nephrin and rescued mature form. csa inhibited the increase of cytochrome c in the cytoplasm caused by hypoxia. in addition, csa partially rescued the decrease of intracellular atp. cyp-d was distinctly observed in human glomeruli and located in podocytes. conclusion: csa inhibit the formation of hypoxia-induced hypoglycosylated nephrin through protecting the mptp opening via selectively binding to cyp-d in the mitochondria, resulting in a recovery of atp. csa may exert direct action on the alteration of nephrin biogenesis induced by the er stress. background and objectives: in two previous randomized controlled trials (rcts) we showed that treatment of severe childhood iga nephropathy (iga-n) with diffuse mesangial proliferation using prednisolone, azathioprine, heparin-warfarin, and dipyridamole reduced immunologic renal injury and prevented any increase of sclerosed glomeruli. in one of the two rcts we also showed that treatment with prednisolone alone did not prevent a further increase of sclerosed glomeruli. accordingly, the immunosuppressant is considered to play an important role in the combination therapy. often however, we were unable to complete the azathioprine regimen due to its severe side effects. therefore we considered that a different, but effective immunosuppressant would be worth trying. mizoribine, like azathioprine, is an antimetabolite that exerts its immunosuppressant effect by inhibiting lymphocyte proliferation. design, setting, participants, and measurements: in this pilot study, we administered mizoribine instead of azathioprine as part of the combination therapy for treatment of children with severe iga-n and evaluated the efficacy and safety of the regimen. results: eighteen patients reached the primary endpoint (urinary protein/creatinine ratio < . ) during the two-year treatment period. the cumulative disappearance rate of proteinuria determined by the kaplan-meier method was . %. mean urinary protein excretion was reduced from . g/m /day to . g/m /day (p< . ). after treatment, the mean percentage of glomeruli showing sclerosis was unchanged in comparison with that before treatment. no patients required a change of treatment due to side effects. the efficacy and safety of the mizoribine combination seems to be acceptable for treatment of children with severe iga-n. objectives of study: alport syndrome is a hereditary renal disease which is normally diagnosed by either histopathological studies or a genetical analysis. we attempted to diagnose alport syndrome by means of immunofluorescence staining of cultured cells with collagen type alpha chains obtained from voided human urine specimens. methods: the cells were cultured from the voided human urine of patient with x-linked alport syndrome, patient with sporadic alport syndrome, and patient with autosomal-dominant alport syndrome. for comparison purposes, controls cells were cultured from the voided human urine of patient with iga nephropathy, patient with fsgs, and patient with purpura nephritis. the cultured cells were stained by immunofluorescence techniques with collagen type alpha , , , , and chains. results: in the cultured cells of the controls staining for collagen type alpha and chains were observed both in the extracellular matrix and in the cytoplasm while for the staining of collagen type alpha , , and chains were observed in the cytoplasm. in cultured cells of xlinked and sporadic alport syndrome staining of collagen type alpha chain was lost or attenuated. in the cultured cells of autosomal-dominant alport syndrome the staining patterns of collagen type alpha , , and chains were observed. the staining patterns of the collagen type alpha chain in cultured cells of alport syndrome correlated with that observed in renal biopsies obtained from alport syndrome patients as reported previously. hence, the staining of cultured cells with the collagen type alpha chain obtained from voided human urine may therefore be a potentially useful means of diagnosing alport syndrome in a non-invasive manner. the aim of our study: was to examine zeta chain expression in cd +, cd + t cells and nk cells from ins children in active phase of the disease and in remission and to assess the effect of h and h anti-cd + ril- stimulation on zeta chain expression. we enrolled ins children in relapse before initiating the therapy, ins children in complete remission of proteinuria on prednisone for - weeks ( mg/kgbw/d) and age-matched controls. zeta expression was determined by flow cytometry as mean fluorescence intensity (mfi). results: cd +cells: mfi in relapse was higher than in remission and in controls. anti-cd + ril- stimulation had no impact on zeta expression in acute phase and in cotrols, but increased mfi values after h in pts with remission. cd +cells: zeta expression stayed unchanged irrespective of the examined group or antibody stimulation. nk cells: there were no differences between mfi values before stimulation and in relapse after stimulation. in remission and in controls antibody stimulation decreased zeta expression. in controls, mfi values for nk cells were higher than those for cd + and cd + populations, but this preponderance disappeared after h stimulation. in remission, that nk cell predominance vanished after h stimulation. in relapse, mfi values in all cells were comparable and stimulation had no impact on lymphocyte proportions. urinary protein, creatinine, and scd were measured. scd was measured using a elisa kit. scd was expressed as ng/g of urine creatinine. data were analyzed using anova and spearman rank correlation (src) tests. ) scd urinary concentrations in patients with mlns in relapse were higher than patients in remission, healthy controls and other patients with proteinuria (anova p . ) but similar to those seen in sle. ) in patients with mlns relapse, scd concentration did not correlate with urine protein/creatinine ratio (src, r: . , p: . ) ) in patients with mlns, serial urine scd concentrations were measured over a period a time. scd was increased at the time of relapse and decreased toward normal range weeks before patients went into remission. conclusion: urinary scd is elevated in mlns patients in relapse. this increased urinary concentration is not due to the proteinuria, since scd was not elevated in other patients with glomerulopathies and proteinuria. upregulation of podocyte scd during relapse may play a role in the pathogenesis of proteinuria in mlns. aim: patients with mpgn type ii/dense deposit disease (ddd) and atypical haemolytic uremic syndrome (ahus) secondary to defective complement control are found to have a high prevalence of y h polymorphism of factor h gene (cfh), which is linked to age-related macular degeneration (amd). however, no studies have looked into an ocular phenotype of children with complement based renal diseases, yet. methods: in two pediatric nephrology centres all patients with mpgn ii/ddd and ahus were identified and screened prospectively for the presence of y h polymorphism and drusen maculopathy. all patients have been on immunomodulatory therapy at the time of screening. results: four children were identified (male:female= : ) with mpgn ii/ddd and ahus. there were two children in either group. the median (range) age at examination was . years ( . to . years). of the four patients, all were found to have the y h polymorphism. none of the patients had evidence of drusen at the time of examination. two patients with mpgn ii/ddd and one patient with ahus had additional factor h mutations, which were thought to be responsible for the renal disease. conclusion: in our study of children with mpgn ii/ddd and ahus we found a % prevalence of the y h polymorphism of factor h gene, which puts these patients at higher risk for drusen maculopathy. therefore, all children with either mpgn ii/ddd or ahus should be screened for y h polymorphism; and if found positive have regular follow-up ophthalmologic examination. in the future, should y h be proven to be of functional significance with respect to complement control, there would be a role for plasma infusion or replacement of purified factor h for the treatment of both the renal and the ocular phenotype. we previously demonstrated that angiotensin-( - ) is an endogenous ligand for the g-protein coupled receptor mas. the aim of this study was to evaluate the role of angiotensin-( - ) mas receptor in kidney structure and function by using transgenic mice with genetic deletion of the receptor mas. mas -/-(knockout) mice were compared to mas +/+ (wild type) mice regarding renal function parameters and kidney histology. the animals were housed in metabolic cages to obtain -hour urine samples for measuring urinary volume, osmolality and microalbuminuria. at the end of the experiment, mas -/-and mas +/+ mice were sacrificed by decapitation to harvest the kidneys for histological analysis and immunofluorescence of collagen types iii and iv. the quantification of collagen expression was determined by confocal microscopy (zeiss lsm ). urinary volume was significantly reduced in mas -/-mice as compared to mas +/+ animals ( . ± . vs. . ± . ml/ hs in mas +/+ mice, p< . ). this change was associated with an increase in urinary osmolality ( ± vs. ± mosm/kg in mas +/+ mice, p< . ) and albumin excretion ( . ± . vs. . ± . mg/ hs in mas +/+ mice, p< . ). the histological analysis showed a significant reduction in the glomerular diameter in mas -/-mice as compared to mas +/+ animals ( . ± . vs. . ± . μm in mas +/+ mice, p< . ), where as any significant change was observed in tubular diameter. the immunofluorescence of mas -/-kidneys revealed a marked increase of the expression of collagen types iii and iv in periglomerular region as well as in external and internal medulla. collagen iv was also augmented in mesangial area of mas -/-mice. these results suggest that the receptor mas is critical for the regulation of renal structure and function. a circadian rhythm in calciuria is evident with a peak after : h, a lower excretion overnight and a nadir in the early morning. during the peak period both ca/creat ratio (figure) and calcium output frequently surpass the reference values of . mg/mg and mg/kg/day respectively. conclusion: a significant circadian variation in calciuria is evident in normal school age children, with peaks surpassing commonly used reference values for hypercalciuria. this peak excretion is independent from urine output, glomerular filtration and intake. the average h excretion of mg/kg is rarely surpassed despite this peaks. the management of children with secondary hyperparathyroidism is complicated and should start early in the course of renal insufficiency. in spite of an optimal management hyperparathyroidism is sometimes uncontrolled and calcimimetics like cinacalcet hydrochloride which directly stimulates calcium sensing receptors and potently suppress pth secretion are an alternative to parathyroidectomy. they are very promising agents, but paediatric experience is lacking. a years old girl with a bardet biedl syndrome without medical care came last year with end stage renal failure. thanks to daily hemodialysis, serum phosphate level was kept within normal limits and phospho-calcic product remains below . as recommended. in spite of this treatment, serum pth level increased to ng/l. this toxic hyperparathyroidism with optimal monitoring of serum calcium, phosphate, vitamin d levels led us to start calcimimetics. a , mg/kg cinacalcet dose was administrated and induced a decline of pth level to ng/l one month later. a years old boy with recessive polycystosis and chronic renal failure was treated with calciumbased phosphate binders and sevelamer hydrochloride but with a poor compliance and a free diet which led him to hyperparathyroidism (pth to ng/l). in addition, a parathyroid gland hyperplasia with two adenoma was individualized. start of calcimimetics treatment (less than mg/kg) led to a rapid decline in pth level from ng/l to ng/l. the two adenoma decreased in size. in case of hyperparathyroidism, with close monitoring of serum calcium, phosphate, alkaline phosphatase and vitamin d levels, calcimimetics are an excellent alternative to surgery, with safe use and low dose in these cases. preliminary favourable experience has been reported in children but paediatric experience is lacking. side effects result from chronic administration of steroids. the aims of this study are to analyze graft function and metabolic effects of low dose and withdrawal of steroid therapy. this is a single center pilot, one arm and prospective study. methylprednisone (mp) was decreased to . ± . mg/kg/day (low dose) after months. we studied changes in graft function, height velocity, lipid profile, body composition and bone mass after year of low dose mp and after a nd year following mp withdrawal. patients received daclizumab induction; tacrolimus and mycophenolate mofetil. the inclusion criteria was st living related graft and pra < %; patients were enrolled and total follow-up was . years. age at transplantation was . - years, females, prepubertal, postpubertal patients. patients and graft survival were %, acute rejection (ar) occurred after months of mp withdrawal in / ( %) prepubertal patients (banff , b). in prepubertal patients, at the moment of steroid withdrawal and year later creatinine clearance was . ± . and . ± . ml/min/ . m , p< . ; height velocity . ± . and . ± . cm/year, p: ns, with a height increment of . ± . sds, p< . during the last year of follow-up. graft function did not change in postpubertal patients. in all patients at the moment of steroid withdrawal and year later lipid profile was normal; fat body mass . ± . and . ± . kg, p: ns; lean body mass . ± . and . ± . kg, p< . ; total skeleton bmd - . ± . and - . ± . sds, p: ns and lumbar spine bmd - . ± . and - . ± . sds, p< . . this study demonstrates that low dose and steroid withdrawal allow catch up growth, normal lipid profile with no fat accumulation. steroid withdrawal prevents bone loss with increment of lean body mass, but with a concerning rate of ar and graft function deterioration in prepubertal patients. children with x-linked hypophosphatemic rickets (xlh) usually present with progressive disproportionate stunting. we therefore conducted a year randomized controlled trial on theeffect of rhgh therapy on body anthropometry ( parameter) in prepubertal children with xlh (each patients in rhghandcontrol-group). age at baseline was . ± . yrs (mean±sd), height was - . ± . sd, calcitriol dosage was ng/kg x day, and phosphate dosagewas mg/kg x day (each p> . rhgh-vs. control-group). results: within the whole study population longitudinal bodydimensions were more affected than transversal body dimensions aswell as circumferences (extremities/trunk). leg length (- . ± . sd; p< . ) was the most impaired longitudinal parameterexplaining % of the overall variability of total body height, whereassitting height (- . ± . sd) was the best preserved longitudinalparameter. longitudinal body dimensions were significantly increased after months rhgh-treatment (height + . ± . sd; sitting height + . ± . sd, leg length + . ± . sd; arm length + . ± . sd; each p< . ). in contrast, progressive stunting was noted in control patients (height - . ± . sd; sitting height - . ± . sd; leg length - . ± . sd; arm length - . ± . sd; each p< . vs. rhgh-group). rhgh treated patients showed a significant increase in all transversal body dimensions (each p< . ), as well as a decrease in skin folds (range - . up-to - . sd; each p< . ). one year rhgh treatment in severely growth retardedprepubertal children with xlh leads to improvement of longitudinal bodydimensions, harmonization of body (i. e. transversal body dimensions & body proportions), and decrease of body fat. thalassemia is an hemolytic anemia characterized by decreased production of β globin. the chronic hemolysis requires frequent bloodtransfusions that caused hemosiderosis, including iron deposition in the kidney. removal of excess iron via iron chelators, the most commonof which is desferal produce iron excretion in urine and stool. few studies have been published, the studied patients, mostly adults, exhibited proteinuria, aminoaciduria, low urine osmolarity and excess secretion of the proximal tubular function markers, n-acetyl-d-glucoseaminidase (nag) and β microglobulin. the iron accumulation may causes lipid oxidative peroxidation and this oxidative process cause's tissue damage. in this study we examined thalassemia major patients treated with desferal. the degree of hemosiderosis was determined by measuring serumiron and ferritin. children without iron metabolism disorders orrenal disease serve as controls. the renal and tubular function was analyzed. no differences in creatinine clearance, blood hco , na and k fe, tmp/gfr was found. serum uric acid was equal in the two groups but itsurine excretion was significantly higher in the thalassemic group probably due to persistent hemolysis. the nag level and its ratio to creatinine were significantly higher compared to the control group. the results of our work showed that most of the thalassemic patients have sub clinical disturbances in tubular function and high nag in theurine. these results raise the question of treating thalassemic patients with oral chelators which removes iron from cells preventing the oxidative process; moreover, and add antioxidants which may prevent the deposition of iron in tissues. in light of these findings, it would be advisable to routinely check glomerular and tubular function as part ofthe follow-up in these patients. objectives of study and methods: little information is available on the long-term follow-up in patients with biallelic mutations in the two genes slc a and kcnj , encoding the bumetamidesensitive na-k- cl cotransporter and the in wardly rectifying renal potassium channel, respectively. we evaluated the long-term follow-up (> years) in patients with these two forms of bartter syndrome. the slc a and kcnj genes were screened by dhplc and sequencing techniques. results: the long-term follow-up period was to years, median , after diagnosis, in patients with mutations in slc a ( homozygotes, compound heterozygotes) and patients with mutations in kcnj ( homozygotes, compound heterozygotes) genes. medical treatment with indo methacin at last follow-up control including supplementation with potassium in patients and medical treatment with indomethacin in patients (meandose . mg/kg/day). in two patients (one with slc a and another one with kcnj mutations) growth hormone (gh) deficiency was detected with specific tests. both patients were treated with recombinant human gh. at the end of follow-up, body height was < ° percentile for agein of the patients, of whom with gh deficiency and body weightwas < ° percentile for age in patients (none of them with gh decifiency conclusions: these data demonstrate that some patients with biallelic mutations inthe slc a and kcnj genes tend to present slight impaired glomerular kidney function after a median follow-up of years and that growth retardation and gh deficiency are often present in these patients. the cytosolic c-terminus of nhe does not mediate its apical localization or baseline activity -implications for blood pressure and ph homeostasis the epithelial sodium proton exchanger, nhe , is expressed in the apical membrane and subapical endosomes of the proximal tubule. apical localization is fundamental to proximal tubular na+, water and hco -absorption, a process necessary for the maintenance of plasma ph and blood pressure. moreover the redistribution of nhe between these compartments alters its activity. for example, acute hypertension leads to an increased endomembrane accumulation of nhe and pressure natriuresis. nhe is composed of a n-terminus with transmembrane helices and a cytosolic c-terminus. the former is necessary for sodium-proton exchange while the latter regulates activity. the goal of our studies was to evaluate the contribution of the cytosolic c-terminus to apical localization and therefore to nhe function. to this end we generated a series of nhe constructs with sequential deletions in the cytosolic c-terminus. all constructs contained an extracellular epitope tag to facilitate the delineation between cell surface and endomembrane nhe . stable renal epithelial cell lines were generated expressing each construct. surprisingly, even when the entire c-terminus was deleted nhe was still detectable at the apical membrane. we proceeded to evaluate the activity of the truncated exchangers and found they retained activity. finally, we assayed the attachment of nhe to the actin cytoskeleton (a process thought to be mediated by the c-terminus), by measuring their solubility in the weak detergent triton x- and by measuring their mobility in the plane of the plasma membrane. both assays confirmed that exchangers lacking the c-terminus retained their association with the plasma membrane. in conclusion, the cytosolic c-terminus of nhe is not necessary for apical localization nor baseline nhe activity. further studies will be needed to confirm its role in specific regulatory processes. background: ibu is used as a safer alternative to indomethacine for pda treatment. however, safety/efficacy balance has not been extensively studied. animal and a few clinical studies suggested that ibu might also have significant side effects. objective: to evaluate renal function at one week of life in infants treated with ibu as compared to infants not exposed to ibu, within the first days of life. methods: multicentric prospective cohort study of to weeks gestation (ga) infants exposed or not exposed to ibu. infants presenting with renal impairment at birth, urinary tract malformation, or contraindication to ibu treatment were excluded. infants exposed to ibu were paired to controls according to ga, centre and crib score. creatinine clearance (ml/min/ . m ) was measured for glomerular function evaluation; fractional excretion of sodium (fena) and microglobinuria/creatininuria ( /ucr) for tubular function evaluation. results: infants were studied: exposed to ibu for pda closure with . % efficiency and controls. birth weight was ± g (mean+sd), and ga . ± . wks. glomerular filtration rate (gfr) significantly decreased on day in ibu exposed infants. noteworthy, diuresis remained in the normal range, but was significantly lower after ibu treatment (given on day ) as compared to controls. antiresorptives, particularly bisphosphonates (bp), offer a promising treatment inpediatric bone disease. bp have been successfully used to treat childrenwith osteogenesis imperfecta (oi), secondary osteoporosis, fibrousdysplasia, hypercalcemia. concerns exist regarding bone mineralizationand bone growth and transient adverse reactions. according to available literature, bp were successfully used in ~ children, intravenous pamidronate (pm) being the most frequently used one (> children, mostly with oi), followed by alendronate (al) (~ patients with oi, secondary osteoporosis, hypercalcemia), risedronate, etidronate, zoledronate, clodronate, olpadronate. oi treatment with bp resulted in an increase in bmd, improved growth, relief from pain, mobility improvement, improved quality of life and a drop in fracture rate there are sparse data comparing oral and i. v. bp. oral and i. v. bp seem to have a similar effect in children with oi. daily al therapy seems to be safe and effective in children with oi, and daily or weekly administration of al led to increase in bmd in patients with secondary osteoporosis. there is scarcity of randomized, double blind, placebo-controlled or active comparator trials with bp in children. currently, double-blind, placebo-controlled study with risedronate andactive comparator trial with intravenous zoledronate in children with oi are planned. bp therapy should be used in context of a well-runclinical program with specialist knowledge in the management of pediatric metabolic bone disorders. other emerging antiresorptive agents include denosumab, glucacon-likepeptide- and calcitonin tablets. these drugs are tested in phase iii trials in adults. their applicability to children is likely to be discussed in the coming years. the current kdigo recommendations on classification or renal osteodystrophy recommend assessment of three areas of bone histology: turnover, mineralization, and volume. while lesions of bone turnover are prevalent in children treated with dialysis, little is know about the prevalence of mineralization defects and their response to therapy with vitamin d sterols and phosphate binders. we evaluated the skeletal mineralization (osteoid thickness (o. th.) and osteoid maturation time (omt)) in patients ages ± years treated with maintenance dialysis who were not receiving vitamin d sterol therapy. serum biochemical markers were: ca: . ± . mg/dl, p: . ± . mg/dl, pth: ± pg/ml, alk p'tase: ± iu/dl. % of patients with high turnover bone disease ( % ci: - %) and % ( - %) of patients with normal or adynamic bone had abnormal skeletal mineralization as reflected by both a prolonged omt and widened o. th. subsequently, a subset of patients underwent treatment with calcitriol and calcium carbonate. while serum pth levels decreased by % (p< . ) and bone formation rate decreased by % (p< . ) with therapy, there was no change in o. th or omt from baseline. indeed, % ( - %) of patients had abnormal mineralization after therapy. we conclude that mineralization defects are prevalent in children treated with dialysis and are not affected by current therapeutic options. further studies are needed to determine the pathophysiology and optimal treatment of these defects. introduction: clara cell secretory protein (cc ) is a protein synthesized primarily by non-ciliated bronchiolar epithelial cells, the clara cells. like other low-molecular size proteins, plasma cc is rapidly eliminated by glomerular filtration and reabsorbed by proximal tubular cells. this protein has been rarely studied in the paediatric age. the sensitivity of cc in urine was compared to that of b -microglobulin (b m) and n-acetyl-b-d-glucosaminidase (nag conclusions: cc is a good marker of the proximal tubular function. cc is related better with the urinary b m elimination, since both are low-molecular size proteins that are reabsorbed by the proximal tubule. sd. kim, bs. cho kyunghee university hospital, pediatrics, seoul, south korea background: many studies have demonstrated that arb prevents renal progression in patients with glomerular nephritis or diabetic nephropathy by inhibition of hmc proliferation and reduce of extracellular matrix expansion and glomerulosclerotic changes. however, the molecular effects of arb in cultured hmc have not been completely defined. we investigated differential gene expression by arb treatment on cultured hmc according to time sequence using cdna chip (affymetrix). methods: mc was grown in dmem with % fbs and then arb was treated on cultured mc. rnas of hmc at different time points ( , , and h after arb treatment and no treatment) were compared using affymetrix cdna chip. to validate the patterns of gene expression analyzed by the microarrays, some genes were selected and semi-quantitative rt-pcr was performed. results: among genes, humoral immune response, cytokine activity, il- receptor binding, chemotaxis, cell cycle arrest, and morphogenesis associated genes were down-regulated for , , and h after arb treatment. they also showed different clustering according to their changing patterns. conclusion: the present study demonstrates profile of gene expression as time goes by after arb treatment on proliferation of human mc. gene expression by arb treatment on cultured hmc showed sequential changes. our results showed that chemotaxis and immune response associated genes were suppressed by arb treatment on hmc. further evaluation of individual genes will be conducted to elucidate molecular mechanism. podocin is the major component of the slit diaphragm, the site responsible for size and charge selectivity of filtration. mutations in the nphs gene, which encodes podocin can lead to steroidresistant nephrotic syndrome (srns). in this work we studied whether genetic changes of podocin might predispose to the development of sporadic non-familial srns in childhood. we screened for podocin mutations children ( m/ f; mean age . ± . years) with sporadic srns and healthy controls. renal biopsy in srns patients revealed mesangial proliferative glomerulonephritis (n= ), focal segmental glomerulosclerosis (fsgs; n= ), membranoproliferative glomerulonephritis (n= ) and membranous nephropathy (n= ). the mean age of onset of srns was . ± . years. all exons of podocin gene of patients with srns and controls were amplified and direct dna sequencing was performed. there is one novel nonsense heterozygous mutation of c. g>t p. glu>stop was identified in the st exon of nphs gene in srns child with fsgs who has renal transplantation at the age of years without recurrence of fsgs in her graft. we found one kind of single nucleotide polymorphism c. + a>g in the th exon of nphs gene in % ( / ) srns patients ( with fsgs; with membranoproliferative glomerulonephritis) and % ( / ) children in controls. allele frequency of this polymorphism of the nphs gene in srns patients and controls was not different significantly. our results indicate that mutation-detected rate in the nphs gene in russian children with sporadic srns was %. the low mutation-detected rate and identified polymorphism c. + a>g in nphs gene unlikely predispose to the development of sporadic srns in russian children. further determining the slit diaphragm genetic profile of children with sporadic srns is warranted in order to improve disease classification and tailoring of treatment. for diagnose of essential hypertension is necessary except all causes of secondary hypertension (sh). case: family history of -year-old female patient was unremarkable for hypertension, incl. renal diseases. during last months she had often headaches with intermittent vertigo. she was not anywhere examined. at admission on intensive care unit patient had headache, her pulse rate was /min, respiratory rate /min, bp (right arm) was / mmhg and the lower extremity bp / mmhg. other physical examination was normal, incl neurological exam. fundoscopy of the eyes did not show any evidence of hypertensive retinopathy. cardiac ultrasound showed mild left ventricular hypertrophy. abnormal laboratory parameters (without medication) were: hypokalemia ( . mmol/l), metabolic alkalosis (ph . , hco . mmol/l), low urinary output of sodium ( mmol) and chloride (< mmol), high urinary output of potassium ( mmol). renal function tests were normal and no abnormalities were detected by renal ultrasonography, incl. doppler exam of renal blood flow. by large hormonal analyse were detected high plasma renin activity (pra; . ng/ml/hod; n.r. . - . ) and very mild increased serum aldosterone (ald; . nmol/l; n.r. - . ). during the ct renal angiography was found solid mass in the upper part of the left kidney. a partial left nephrectomy was performed and histological exam revealed juxtaglomerular cell tumor (so-called reninoma, re). after the resection we stopped subsequently patients antihypertensive therapy. in a -month follow-up our girl was normotens. re is a very rare cause of sh. re typically present during adolescence or young adulthood. this cause of severe sh should be considered along renal artery stenosis in adolescents presenting with secondary hyperaldosteronism or in causes with renin-secreting tumor of non-renal origin. we report our preliminary molecular findings in twelve turkish cystinosis patients. the patients were to years; male/female ratio was : . all presented initially with severe failure to thrive, polyuria and polydipsia. cystinosis was diagnosed at age month to years. six of the patients reached end stage renal failure at ages ranging from . to years necessitating renal replacement therapy; are currently on hemodialysis, one is on capd, and two were transplanted. while three of remaining have renal fanconi syndrome with proteinuria, had kidney failure in varying degrees. molecular analyses involve an initial multiplex pcr, checking for the presence or absence of kb founder deletion, and subsequent sequencing of the coding exons of ctns. interestingly, none of the nephropathic cystinosis patients carried the kb deletion. instead, one patient had a new homozygous kb deletion of exons to of ctns. one patient was homozygous for a known bp deletion in exon , i.e., c. del gact. two patients were homozygous for new missense mutations in exons and , i.e., c. g>a (r g) and c. a>g (y c), respectively. the most common mutation in our turkish patients was a new exonic splice site mutation in exon , i.e., c. g>a (e e). of alleles studied, carried this mutation, which is expected to disrupt proper splicing. two patients were compound heterozygous for one of the above-mentioned mutations and a known missense mutation in exon , i.e., c. g>a (g r). in two patients, we could not find any disease-causing mutation; in two patients, we could find only one disease-causing mutation. in summary, cystinosis patients of turkish ancestry show ctns mutations different from those of western european patients. these findings will be of relevance for molecular-based screening and diagnostic methods for cystinosis. introduction: the association of hypertension with bell's palsy in adults has been reported from - %, but there is few data in children. the presence of bell's palsy in children requires a complete evaluation for hypertension, solid tumors, leukemia, neurofibroma, and trauma. hypertensive children usually present with clinical manifestations of underlying disease, but with substantial elevation, symptoms of hypertension develop. although headache, dizziness, blurred vision and seizure are common neurologic symptoms of hypertension, but facial paralysis is not a wellrecognized presenting feature of hypertension in children. case report: this paper describes two severely hypertensive children who referred to children's hospital of tabriz with periferal hemifacial nerve paresis and initial diagnosis of bell's palsy. case : a years old girl who admitted with blood pressure of / mmhg on admission. renal ultrasound study revealed left small size kidney and renal scintigraphy followed by angiography confirmed renovascular hypertension. case : a years old boy with blood pressure of / mmhg on admission. sonography of kidneys was normal except for a small size ( mm) stone in left kidney. renal scintigraphy and angiography were normal. all other evaluations for etiology of hypertension including cardiac and endocrine investigations were negative. treatment of hypertension with antihypertensive drugs resulted in complete recovery of facial paresis in both cases within - months. conclusion: unilateral peripheral facial nerve paresis is a rare presentation of hypertension in children. unawareness of this presentation may result in delay in diagnosis of hypertension which may increase further with steroid therapy for bell's palsy. to uncover the frequency and the spectrum of nphs mutations in egyptian children with non familial steroid-resistant nephrotic syndrome (srns), patients were screened by pcr-singlestrand confirmation polymorphism analysis of nphs gene followed by direct sequencing. nphs mutations were evident in patients ( . %) who were bearing five novel mutations including two frame shift mutations ( - insg and - insg), two missense mutations ( a>c and t>a) and a silent mutation ( a>t). there were no phenotypic or histological characteristics of patients bearing nphs mutations, apart from the earlier onset of the disease, compared to those who were not bearing mutations. in conclusion, nphs mutations are prevalent in egyptian children with non-familial srns and this may in part explain the less favorable prognosis reported in these patients. , which is an inherited systemic disease of connective tissue primarily affecting the skin, retina, and cardiovascular system, also leads to rvh. these symptoms of pxe are usually apparent in adulthood and rarely observed in children. here, we describe a very rare pediatric case of rvh caused by pxe. case report: a -year-old boy was noticed to have severe hypertension ( / mmhg) when he was admitted to our hospital for an operation for exotropia. he had no previous or family history of pxe or hypertension. laboratory examination showed that plasma renin ( . pg/ml) and aldosterone ( . ng/dl) concentrations were markedly elevated. his systolic and diastolic blood pressure (bp) decreased . % and . % from baseline after administration of captopril, respectively. a computerized tomographic scan of his abdomen showed multiple calcified vessels in kidneys and spleen. yellowish papules on the bilateral axillary regions and inguinal area were detected. characteristic histological changes of pxe such as elastic fiber mineralization and calcification were noticed in the biopsy of affected skin lesions. conclusion: pxe is characterized clinically by high heterogeneity in the age of onset and extent and severity of organ system involvement. although its symptoms usually appear in the second or third decade of life, gastrointestinal bleeding and acute myocardial infarction have been reported in childhood. we should also consider pxe as one of the causes of rvh in children, because its prognosis depends largely on the extent of extracutaneous organ involvement. the clcnkb gene is rarely reported as having a large deletion mutation, but all cases reported previously were large homozygous deletions and a large heterozygous deletion is impossible to detect by direct sequencing. patients and methods: this report concerns a genetic analysis of japanese patients with type iii bs. to identify the mutations in the clcnkb gene, we used polymerase chain reaction (pcr) and direct sequencing to investigate all exons and exon-intron boundaries in the patients and their family members. to detect large heterozygous deletion mutations of the clcnkb gene, we conducted semi-quantitative pcr amplification using capillary electrophoresis. results: four mutations were identified, comprising novel bp deletion mutation (c. _ delct), an entire heterozygous deletion and a heterozygous deletion mutation of exon and of the clcnkb gene. the nonsense mutation w x in the clcnkb gene was detected in all patients ( of them were homozygous and were heterozygous) and this finding indicates that this nonsense mutation is likely to constitute a founder effect in japan. two patients had large heterozygous deletion of the clcnkb gene, which was proved by semi-quantitative pcr amplification. conclusions: capillary electrophoresis is a new method and extremely useful for detecting large heterozygous deletions, and should be employed to examine type iii bs cases in whom only a heterozygous mutation has been detected by direct sequencing. obesity defined as body mass index (bmi) above th percentile for age and gender is regarded as a risk factor for cardiovascular (cv) target organ damage (tod) in children and adults with ph. however, when using percentile-based definition of obesity one may miss children at risk of cv complications. the aim of the study was to compare sensitivity of traditional definition of obesity (bmi> th pc) and bmi thresholds (tbmi) for cv complications described by katzmarzyk et al. ( ) majority of children with idiopathic nephrotic syndrome (frequent relapsers, steroid dependent and steroid resistant) require adjunctive therapy. the response to cyclophosphamide (cp) in these children is variable and difficult to predict. there may be an effect of polymorphic expression of gst on the remission with cp. in this study, we have tried to evaluate the correlation of gst polymorphism and response to cp therapy in these children we studied gst polymorphism in consecutive children ( males, females) with steroid sensitive (n= ) and steroid resistant (n= ) nephrotic syndrome, receiving cp therapy. we evaluated the inter-relationships between gstm , gstt , and gstp genotypes and correlated it with the response to cp therapy in these children. the mean age of onset was . ± . years. out of children, % children responded to cyclophosphamide therapy. the null genotype of gstm and gstt was observed in . % and . % respectively while val genotype of gstp was seen in % children. there was no significant correlation among the various individual genotypic combinations. however, a trend was seen towards remission in children with a combination of gstp polymorphism with gstt null genotype (p= . ) or combination of gstp polymorphism with gstm wild type genotype (p= . ) another important finding in our study was that there was a significantly higher frequency of val allele of gstp in responders to cyclophosphamide as compared to nonresponders (p= . ). the results indicate that the presence of the val allele correlates with the response to cyclophosphamide in these children. gst gene polymorphism may be a significant therapeutic tool in the management of children with idiopathic nephrotic syndrome receiving therapy. objectives of study: primary vesicoureteral reflux (vur) is a common pediatric disease that may lead to reflux nephropathy and end-stage renal disease. the renin-angiotensin system (ras) was proposed to be associated with primary vur. the objective of this study was to investigate whether the gene polymorphisms of the ras are involved in primary vur and correlation with the severity of vur in taiwanese children. methods: we studied the angiotensin ii type receptor (at r) c a gene polymorphism for association with susceptibility to primary vur and disease severity in vur children and healthy controls. fifty four of the vur patients had low-grade vur (grade i-iii) and had high-grade vur (grade iv and v). to analyze the polymorphisms in the c a of at r gene, the snp genotyping assay were performed. the genotypic frequency and allele frequency for four ras genes were analyzed to detect the correlation between the patients with mild, severe vur, and healthy control. results: we found that the c a of at r gene was associated with the development and severity of vur. significantly higher c and lower a allele frequencies were presented in vur patients (c allele . and a allele . ) compared with controls (c allele . and a allele . , p< . ). the similar results were observed in both mild (c allele . and a allele . ) and severe (c allele . and a allele . ) vur compared with controls (p< . ). the cc genotype was higher in vur patients compared with controls (p< . ). conclusions: at r c a gene polymorphism was associated with the development and the severity of vur in taiwanese children. it raises the possibility to utilize the genotype of at r as a risk factor to evaluate the development and severity of primary vur. results: stone analysis led to diagnosis of cystinuria in patients ( % of all), but only were children ( . % of the paediatric stone patients). age at diagnosis in three patients was - years and in four - years. time from first manifestation (pain x, gross haematuria x, urinary retention x, uti x) until diagnosis was - years in seven, - in three and even and years in two. renal function was impaired in patient (ckd stage ii). the urinary cystine test was positive in all patients with cystine stones examined, but was negative in family members thus excluding cystinuria in them. family history of urinary stones was positive in two; the brother of one had died of renal failure due to bilateral urolithiasis. conclusions: delays in diagnosis of cystinuria in armenia are unacceptable. production of tablets containing nickel/dithionite which is non-toxic in contrast to brand test (cyanide/nitroprusside) is planned and could allow screening of all patients with stones of unknown origin. background: classically, childhood hypertension has always been recognized as secondary and frequently demanded an exhaustive etiological investigation. however, in the last two decades, many studies have been shown that pediatric patients also present primary hypertension and, sometimes, the adult disease probably begins during childhood. the aim of this study was to analyze a cohort of patients followed-up at a single tertiary unit (belo horizonte, brazil). methods: in this retrospective cohort study, the records of diagnosed with arterial and followed at our unit between and were analized. a data base was used for statistical analysis. results: of patients, . % were male and . % female. the distribution of patients according to the age at diagnosis was: - . years, ( . %), yr- . yr, ( . %), yr- . yr, ( %), and yr, ( . %). the causes for hypertension were: renal diseases in ( %), primary hypertension in ( %), renovascular disease in ( %) and ohers in patients ( %). the comparison between primary hypertensive subjects and patients with renal diseases showed that, although blood pressure was similar at admission, a better control was achieved in the first group (p< . ). the frequency of overweight and/or obesity was higher in primary than in secondary hypertension ( nephrnophthisis (nphp) is a very rare cause of crf in korea. identification of five genes mutated in nphp subtypes - has linked the pathogenesis of nphp. ten percent of affected individuals have retinitis pigmentosa, constituting the senior-löken syndrome. we experienced juvenile-onset crf with leber's amaurosis in two sibilings. case : a -year-old boy presented with pale appearance. he had severe renal impairment and visual disturbance, but no symptom of polyuria and polydipsia. his past annual school screening urinalysis was normal. his growth and development were normal except opthalmological findings and pallor. case : his -years-old sister also had a visual disturbance and was found to have crf. there was no specific problem during perinatal period. opthalmologic findings were similar to her brother's. nphp and on chromosome q was analyzed by direct sequencing. sequencing of mitochondrial dna-mbol digestion for mutation was analyzed by pcr-sequencing and rflp. electroretinogram revealed a decreased in amplitude of a and b waves. on the kidney biopsy, some of glomeruli were globally sclerotic. remaining showed no cellular proliferation or capillary wall thickening. interstitium was diffusely fibrotic and in which were scattered lymphocytes. most tubules were preserved well but a few dilated tubules were intermingled. no positive reaction for immunoglobulines or complements in if. by em, tubular membranes showed thickening, splitting and disintegration. nphp and genes were not identified. there was no transition mutation at mitochondrial dna nt. , , , . late-onset senior-löken syndrome were diagnosed in these cases even though there were no polyuria and polydipsia of initial symptoms of nphp and nphp and were not identified. we need to identify other known or novel mutation genes. nail-patella syndrome (nps) is an autosomal dominant disease characterized by classic tetrad of dysplastic nails, absent or hypoplastic patellae, elbow dysplasia, and iliac horns. some patients manifest nephropathy and adult-onset glaucoma. nps is associated with mutations in the lmxib gene. there is marked inter-and intrafamilial variability in the phenotypes. in this study, phenotype-genotype correlation was analyzed in unrelated korean children with nps. the probands were boys and girls. they manifested dysplastic nails ( / , %), absent or hypoplastic patellae ( / , %), elbow dysplasia ( / , %), iliac horns ( / , %) and nephropathy ( / , %) . four missense mutations/ in the lim-b domain (h q and l p) and in the homeodomain (r q and a p)/and frame-shifting deletion (c, dela) were identified in the lmxib gene.r q and a p are known to be common mutations, and r q was detected in patients in this study. autosomal dominant inheritance was identified in patients by phenotype and genotype analysis of the family members and in patients by phenotype analysis only. remaining patient had de novo r q mutation. one patient and her mother with r q mutation developed nephrotic syndrome, which progressed to end-stage renal disease (esrd). another patient with h q mutation had asymptomatic proteinuria with microscopic hematuria, and her father had esrd. galucoma was not detected in any patients or family members affected. there were inter-and intrafamilial variability of the phenotypes, but no genotype-phenotype correlation was identified. this is the first study to characterize mutations in the lmx b gene in korean patients with nps. r q is a common mutation in korean, also. the mechanism underlying the phenotypic variations and predisposing factors to the development nephropathy remain unknown. the pathological mechanism which would be responsible for higher production of digitalis similar compounds in essential arterial hypertension (ah), would be a genetically defect kidney, which causes difficulty in na + excretion. higher intake of salts can be an etiological factor inessential ah only patients with inherited abnormalities of thetransport mechanisms in the cell membrane.the objective of the studywas to establish the incidence and type of ah and frequency of genetic factor in the investigated population of school children (age - years). in children with essential and borderline ah we evaluated the activity of erythrocyte membrane na+, k+-atpase in the presence ofvarying atp concentrations. atp, adp and amp levels and lipid peroxides (as tbars) in the erythrocytes and tbars in plasma were measured. our data have shown that the prevalence of ah is lowest in - years oldchildren, while it is the highest in - years oldchildren. essential ah was established in ( . %) and borderline in ( . %) children. genetic factor were found in . % of children with essential ah and in . % of children with borderline ah. but, statistical analyses of the first and second degree relatives of children with essential and borderline ah suggested normal prevalence of hypertension. atp, adp and amp levels, as well as, lipid peroxides were not significantly altered compared to healthy children. kinetic profileof erythrocyte plasma membrane na+, k+-atpase activity revealed the presence of noncompetitive (allosteric) inhibition of enzyme activityin the children with essential and borderline ah. the differences in the kinetic properties of na+, k+-atpase between two investigated groups of children suggested that this dynamic model could be used as potential biological marker for early diagnosis and differentiation of these two type of ah. majority of these patients were obese and with increasing body weight nighttime hypertension became prominent in these patients. objectives: it has been shown that weight gain is directly related to increase inblood pressure. the objective of this study was to analyze the frequency of overweight/obesity in children/adolescents with primary hypertension (ph) and the relationship between the overweight/obesityand the stage of hypertension (h). methods: we analyzed the data of patients aged - . years (m ; f ) diagnosed with primary hypertension. overweight/obesity was defined asperc. of bmi - / c. the stage of hypertension was determined according to the th report on the diagnosis, evaluation,and treatment of high blood pressure in children and adolescents of the nhlbi working group. results: out of pts, prehypertension was found in pts ( . %), stage i h in ( . %) and stage ii h in pts ( . %). stage ii h was more frequentin boys ( % vs. % in girls). combined systolic/diastolic h was found most frequently, in pts ( . %), isolated elevation in systolic blood pressure (bp) was found in pts ( . %), while only pts ( . %) had isolated elevation in diastolic bp. sixty-one pts ( . %) were found overweight/obese; of which ( . %) above c bmi. theobese children were predominantly found to have stage ii h: . % ofthe obese children. none of the obese children had prehypertension. contrary to the general perception, boys were found more frequently overweight/obese ( . % boys vs. . % girls). conclusion: our data shows that stage ii ph is not rare also in theteen-age group. frequently it is accompanied with overweight/obesity, especially in boys. we can conclude that the roots of ph in the adultage are already set from the childhood. our efforts should focus onearly diagnosis of ph and include prevention of obesity as the possible contributing factor for the development of ph. objectives of study: alport syndrome (as) is a progressive renal disease characterized by hematuria, progressive renal failure, high-tone sensorineural hearingloss and ocular lesions. xlinked dominant alport syndrome (xlas) isthe major inheritance form, accounting for almost % of the cases, caused by mutations in col a genes. there are no good cures available for as at present, but there are some patients who requestfor prenatal diagnosis and genetic counciling. this study performed thefirst prenatal diagnosis in chinese as family. methods: the entire coding sequence of col a mrna of peripheral blood lymphocytes was amplified using nest pcr to screen mutations in a chinesexlas family. mutation analysis of the fetus was performed on both cdna-based level and dna-based level of amniocytes. fetus sex was determined by pcr amplification of sry as well as karyotypes analysis. maternal cells contamination was excluded by linkage analysis. results: mutation screen showed that there was a g to a substitution at position in exon of col a gene (c.g a), it was subsequently confirmed at genomic dna level by pcr amplification of exon of col a gene. the mutation was identified in the index case, family members aswell as the pregnant lady. the prenatal diagnosis showed that fetus didnot carry the same mutation as the mother detected by both cdna-basedand dna-based mutation analysis. pcr amplification product of sryas well as karyotypes analysis revealed a male fetus. linkage analysis of the three x chromosome markers showed that there was no contamination of maternal cells in amniocytes. conclusion: after mutation identification of col a gene in a large chinese as family, a successfully prenatal diagnosis was performed in one of the female members in this family based on both cdna as well as genomic dna level of amniocytes. objectives of study: alport syndrome (as) is a clinical and genetic heterogenousdisease. autosomal recessive as (aras) is caused by mutations in col a and col a genes, accounting for % of the cases. thin glomerular basement membrane nephropathy (tbmn), is also caused by mutations in col a and col a genes, inherited as an autosomal dominant trait. differentiation between early stages of aras and tbmn may be difficult in clinic, itdepends on gene mutation analysis of col a or col a . methods: the whole entire coding regions of col a and col a mrna of peripheral blood lymphocytes were analyzed using reverse transcription polymerase chain reaction (rt-pcr) and direct sequencing to screen mutations in three chinese aras families, the corresponding exon with flanking intronic sequence was further amplified to confirm the abnormality. results: both the entire coding regions of col a and col a mrna were successfully amplified and completely sequenced by seven overlapping pcr products, respectively. results showed that there were variations of col a and variations of col a , respectively. among the variations of col a ,three were snp reported previously, four were new snp, one nonsense mutation, one small insertions and one splicing mutation, the latter three were the pathogenic mutations for the three families, respectively. all the four variations of col a were snp reported previously. we concluded that rt-pcr and direct sequencing using peripheral blood lymphocytes rna is a practical, sensitive and feasible approach for analysis col a and col a gene variants in autosomal recessive alport syndrome patients, which offers a useful, inexpensive and timesaving approach for systematic gene analysis in patients with aras. objectives of study: gitelman syndrome (gs) is an autosomal recessive tubular disorder characterized by metabolic alkalosis, hypokalemia, hypomagnesemia and hypocalciuria. the majority of gs patients carry inactivating mutations of the slc a gene encoding the sodiumchloride cotransporter located in the distal convoluted tubule. this study aimed to detect mutations in a chinese family with gs. methods: two brothers presenting muscle weakness, hypokalemic metabolic alkalosis, hypomagnesemia and hypocalciuria were clinically diagnosed as gitelman syndrome. the two brothers, as well as their healthy brother and parents, were detected for mutations in slc a gene by direct pcr for each exon and then sequencing on genomic dna extracted from peripheral blood cells. results: the two patients were found to have the same compound heterozygous mutations (c. c>t and ivs - t>c) in the slc a gene. the two mutations were also detected in paternal and maternal genomic dna, respectively. the unaffected brother had one mutation (c. c>t) only. conclusion: a novel compound heterozygous mutation on the slc a gene was revealed in a chinese family with gs. the objective: to determine the clinical value of ambulatory blood pressure monitoring (abpm) in pediatric kidney disease. methods: patients with common kidney diseases aged from - yrs were enrolled. -hour abp were performed by welch allyn abpm . the number of cases whose ccr> mmol/l/ . m , ccr - mmol/l/ . m , ccr - mmol/l/ . m , ccr - mmol/l/ . m and ccr< mmol/l/ . m is , , , and , respectively. seven patients only took fosinoprilto control blood pressure did abpm again more than one weeks after therapy. healthy children performed in german in was used asthe normal data. casual bp was measured by sphygmomanometer. children took echocardiography to calculate left ventricular mass index (lvmi). results: the incidence of nocturnal hypertension was significantly higher than that of diurnal hypertension (p< . ).theincidence of non-dipper in children with kidney disease was . %. nocturnal dipping rate in the patients was significantly lower than that in the healthy children (p< . ). the incidence of masked hypertension and white coat hypertension inchildren with kidney disease were . % and . % respectively. nocturnal systolic and diastolic dipping rate of the children with lupus nephritis and acute glomerulonephritis were lower than those of the children with henoch-schönlein purpura nephritis (p< . ). lvmi hadpositive correlation with -hour diastolic blood pressure load (r= . , p= . ), but it had no correlation with casual bp. after taking fosipril, -h, diurnal and nocturnal average abp decreased significantly (p< . ). nocturnal dipping rate increased, but did not reach statistical difference (p> . ). conclusions: abpm was an effective tool for diagnosis and management of hypertension in childhood with kidney disease. identification of novel mutations in the col a gene of japanese patients with x-linked alport syndrome background: alport syndrome consists of nephritis, often progressing to renalfailure, and sensorineural hearing loss. x-linked phenotype (omim# ) is the result of mutation in the gene for the alpha- chain of collagen iv (col a ). objectives of study: to find mutations causing x-linked alport syndrome in japanese patients. patients and methods: diagnosis criteria of alport syndrome were proteinuria, familial history of renal failure andchanges of gbm in electron microscopy. to identify the mutations in the col a gene. results: for the time being we finished genetic analysis of patients with suspected x-linked alport syndrome, males and females. we identified mutations in of patients; of them were novel mutations. they comprise: nonsense mutations, missense mutations and mutations of splicing acceptor site resulting in exon skipping or truncation, and establishing of premature stop codon. in previous reports of x-linked alport syndrome, mutation detection rate was around %. the present study provides a detection rate of . %, although our number of examined cases is limited. conclusions: direct sequencing of rt-pcr and pcr products is efficient method of finding mutations in col a gene. we found mutations in high percentage of investigated patients. objectives of study: to make a genetic diagnosis of juvenile nephronophthisis for a chinese boy. methods: analyze the presentation, family history, laboratory investigations, and histological features of a patient suspected of juvenile nephronophthisis, make a clinical diagnosis. to confirm the diagnosis on genetic level by pcr amplification of satellite markers located within the known homologous deletion of nphp ,including del- , del- , del- , del- -( ) , del- and markers outside the deletions (ranbp / and d s )as control. results: the boy was nine years old, he was admitted becauseof renal failure for months. this case manifested by school age, negligible onset, anemia, polyuria, renal failure at years old,without hypertension and abnormal urine analysis. his sister presented with anemia at year old, and died of uremia at years old.laboratory investigations showed no proteinuria and hematuria. thekidney size is normal, and the cortical medullary boundary is obscure.the histological features consist of the disintegration of tubularbasement membrane, the atrophy and dilation of renal tubules, theinterstitial cell infiltration and fibrosis. he was suspected asjuvenile nephronophthisis. by pcr amplification, we found the missingof the satellite markers of del- , del- , del- -( ) and del- , which indicate that there is the common large homologous deletion ( kb) in the child's nphp . conclusions: nephronophthisis is the major hereditary cause ofchronic renal failure. the boy was suspected of nephronophthisis because of chronic renal failure, family history, normal kidney sizeand hitological features. according to the age of renal failure, he was suspected as juvenile nephronophthisis. the diagnosis was confirmed by gene analysis. it is the first juvenile nephronophthisis case for chinese confirmed by gene analysis. cutaneous small-vessel vasculitis is a rare condition in children and is commonly associated with a wide spectrum of systemic inflammatory conditions, malignancies, infections or drug hypersensitivities. enalapril is anangiotensin-converting enzyme inhibitor, commonly used for the treatment of hypertension. cutaneous vasculitis due to enalapril has very rarely been reported and only with adults. we report a case of an -yea-old boy presented with a pruritic eruptionover his lower legs that started hours after he had initiated treatment with enalapril at a dose of . mg/kg/daily. he had a history of hypertension due to a shrieked right kidney since infancy and he wason treatment with nifedipine and propranolol for the last three years. this medication was discontinued because it was ineffective, the day before initiation of enalapril. clinical examination revealed palpable purpuric lesions involving lower legs and ankles. he was otherwise well. a skin biopsy of the lesions showed leucocytoclastic vasculitis of small vessels. abnormal investigations were elevated c-reactive protein, esr and leucocytosis. further laboratory tests including creatinine, liver function tests, urineanalysis, antinuclear antibody, cryoglobulins, viral serology, complement levels, were normal or negative. enalapril was discontinued and he was started oral prednizolone and ceterizine over the next ten days. the skin eruption regressed rapidly. cutaneous vasculitis induced by enalapril is a rare adverse effect and it is essential a prompt recognition and withdraw of the suspicious drug. objectives of study: barttin, the gene product of the bsnd gene involved in bartter's syndrome with sensorineural deafness, is an essential b-subunit for clc-ka and clc-kb chloride channels, and it is expressed in the kidney as well as in the inner ear. one patient affected by deafness and renal bartter phenotype without bsnd mutations has been previously reported with simultaneous mutations in both clcnkb (responsible for classic bartter syndrome) and clcnka genes. we report here on a new case of a -months-old boy presenting such a disease. a severe polyhydramnios was detected during the pregnancy. he presented also polyuria, growth retardation, nephrocalcinosis and sensorineural deafness. laboratory studies revealed metabolic alkalosis (plasma hco , mmol/l), hypokalemia ( , mmol/l), hypercalcuria (cau/cru , mg/mg) and elevated plasma renin ( pg/ml). the aim of the study was to identify the cause of the severe renal salt wasting and sensorineural deafness in this patient. methods: dna sequencing analysis was performed on the bsnd, clcnkb, and clcnka genes. results: no mutation was detected in the bsnd gene. we identified a reciprocal partial homozygous deletion of exons - for the clcnkb gene and theloss of exons - for the clcnka gene. conclusions: the disruption of both clc-ka and clc-kb chloride channels leads to a syndrome clinically not distinguishable from bsnd, characterized by severe salt wasting and deafness. this digenic disorder is due to simultaneous mutations on the two genes clcnka and clcnkb respectively. the tight topology of the highly homologous clcnka genemight predispose to an unequal crossing over leading to partial orcomplete deletions of the clcnkb gene. we hypothesize that thischimaeric resulting gene interferes with the correct function of both the channels clc-ka and clc-kb, and leads to a bsnd-like phenotype. familiary hypomagnesemia with hypercalciuria and nephrocalcinosis (fhhnc) is a nautosomal recessive tubular disorder that is frequently associated with progressive renal failure. mutations in cldn which encodes the renal tight junction protein paracellin- were identified as the underlying genetic defect. in this work we present a gipsy family with fhhnc in which the mother and daughter both showed homozygous mutations in the cldn gene. a three-year-old girl was investigated after acute pyelonephritis and was found to have medullary nephrocalcinosis, hypomagnesemia ( , mmol/l), hypercalciuria ( , mg/kg/d), hypermagnesuria (femg %) and incomplete distal renal tubular acidosis. her renal function was normal. her mother demonstrated also bilateral medullary nephrocalcinosis, hypomagnesemia ( . mmol/l) with high femg ( %), moderate renal failure (creatinine umol/l) and high ipth levels ( pg/ml). as a child she had afebrile seizures, but serum mg levelwas not measured. index patient's uncle had history of recurrent passage of calculi in childhood, bilateral medullary nephrocalcinosis, normocalcemic hypercalciuria but his serum mg was not determined. he developed obstructive uropathy due to impaction of the calculus in urethra and eventually progressed to terminal uremia and later was transplanted. mutational analysis confirmed that the index case, motherand uncle were homozygous for the common mutation in the cldn gene (leu phe), while the father was heterozygous. we present a new family from macedonia with fhhnc with unusual presentation over two generation. mutational analysis confirmed also the diagnosis of fhhnc in the uncle although as a child he was considered to have idiopathic hypercalciuria. thus, serum mg should be routinely checked in children with nephrolithiasis/nephrocalcinosis. m. pan ' czyk-tomaszewska, j. s ' ladowska, j. so l /tyski, m. roszkowska-blaim arterial hypertension is one of the complications of reflux nephropathy. the aim of the study was to assess the risk factors of arterial hypertension in children with primary vesicoureteric reflux (vur). we studied children aged from to years mean ± . , with unilateral and with bilateral vur. in all children ambulatory blood pressure monitoring (abpm) and m tc dmsa renal scanning (dmsa) were performed and z score body mass index (z-score bmi) were calculated. the following criteria were examined as predictive risk factors: age, gender, age at diagnosis andat resolution of vur, period between diagnosis and resolution of vur,grade of vur, type of vur (unilateral or bilateral), treatment modality (medical, surgical), z-score bmi, grade of dmsa and birth weight. results: i grade of dmsa scan was diagnosed in children, iigrade in , iii grade in and iv in patients. hypertension (hp) was diagnosed in children ( %). the mean value of z-score bmi in children with hypertension was significantly higher in comparison withchildren with normal blood pressure ( . ± . and . ± . ). the multivariate discriminate analysis showed that zscore bmi and grades of dmsa scars were significant risk factors for developing arterial hypertension in children with vur. both parameters had the same influence on development of hypertension (standardized coefficient of discriminate analysis , and , respectively). conclusion: the development of hypertension in children with vur is associated with higher bmi and higher grades of renal scars in dmsa scan. grange syndrome comprises arterial stenoses with hypertension, brachy syndactyly, bone fragility, learning disability, and cardiac defects and it has been reported in the members of two families up to now. we report here a -year-old boy with hypertension, multiple arterial stenoses, microcephaly and brachysyndactyly. severe hypertension ( / mmhg) was detected on his routine control for acute rheumatic carditis and he was hospitalised for investigation. he had no complaints. his parents were first degree relatives. his physical examination revealed microcephaly, bilateral brachysyndactyly between the forth and the fifth fingers of hands and the second and the third fingers of feet. complete blood count, electrolytes, renal, thyroid, and hepatic functions and acute phase reactants were all in normal limits. echocardiography showed aortic and mitral insufficiency and left ventricular hypertrophy. renal and cerebral magnetic resonance angiographies demonstrated stenoses at bilateral renal, internal carotid, superior cerebral and posterior cerebellar arteries. association of hypertension with microcephaly and finger abnormalities and multiple arterial stenosis suggested grange syndrome. chromosomal analysis showed xy karyotype. hypertension persisted despite triple antihypertensive agents and percutaneous renal angioplasty was performed leading to a reduction of antihypertensive medication. with this case report we wanted to remind the recognition of this extremely rare syndrome in a hypertensive child with multiple morphological abnormalities and percutaneous angioplasty as a treatment modality in cases with persistent severe hypertension. hypertension is usually indicative of an underlying disease process in children. the combination of severe hypertension with hyponatremia is called hyponatremic hypertensive syndrome (hhs). in this report we present a case of hhs. the boy was referred to our hospital at the age of years old with generalized tonic clonic convulsion. his past history was insignificant and positive findins of the patients were as follows: hypertension ( / mm/hg), agressive behaviors after convulsive period, metabolic alkalozis (blood gases, ph: , , hco : , , pco : , ), hypocloremia ( meq/l), hypokalemia ( meq/l), hyponatremia ( meq/l), low urine density, polyuria and high serum aldosterone levels ( pg/ml, range: - ). the serum renin, cortisol, tyroid and antidiuretic hormones were within normal range. abdominal color doppler ultrasound were revealed double renal arteries in both kindneys. cranial and abdominal tomography examinations and cebrospinal-fluid examination were normal. the diagnosis of hhs was suggested based on these clinical and laboratory findins and therapy of nifedipine was started. the arterial pressure improved with this therapy. in hss due to renal ischemia, activation of renin angiotensin system which induce pressure natriuresis and thus, thence hyponatremia. we think that presence of renal arterial anomaly might be a cause of an ischemic condition and activation of renin-angiotensin-aldosterone system in our patient. also, activation of aldosterone could enhance with hyponatremia and it could be suppressed of renin secretion in our patient. [hadtstein et al. hypertension ] . the aim of this study was to analyze whether children with renal scars have altered rhythms of mean arterial pressure (map) and heart rate (hr). study design: ambulatory -hour blood pressure profiles of untreated patients with renal scars associated with recurrent urinary tract infections and vur were investigated and compared to healthy controls. results: pre-pubertal, but not pubertal patients with renal scars displayed a number of significant differences to controls. before puberty, the mesors of map and hr were significantly elevated, and the peak-trough difference of the h curve was blunted by . mm hg for map and . bpm for hr. the amplitudes of h and h map rhythms were blunted by . and . mmhg, and those of h and h hr rhythms by . and . bpm (all p< . ). pubertal patients did not display any abnormalities of bp or hr rhythms. we did not find any correlations of the degree of renal scarring, bmi or gfr with the abnormalities in cardiovascular rhythms. conclusion: in summary, pre-pubertal children with renal scarring due to vur show blunted circadian and ultradian rhythms of bp and hr. this phenomenon may reflect subtle alterations of autonomous nervous signaling in children with damaged kidneys; it remains to be addressed whether such abnormalities constitute an independent cardiovascular risk factor. mutations in the eya gene are associated with bor/bo syndrome and rarely with an isolated renal phenotype. we present a family from macedonia displaying a novel eya gene mutation. a six-year-old female was found to have bilateral grade iii vesicoureteral reflux (vur) after an episode of acute pyelonephritis. mutational analysis detected a novel eya gene mutation [an inframe bp deletion (c. _ delttg), resulting in l del of eya a]. she had no clinical stigmata for bor/bo syndrome. the paternal grandmother died due to end stage renal failure. all first grade relatives underwent detailed physical and ophtalmological examination, audiometry, ultrasound screening of the urinary tract and mutational analysis of the eya gene. the father and older sister were mutation carriers and both had normal ultrasound findings. the physical examination did not reveal abnormalities suggestive for bor/bo syndrome, except the sister had esotropia/ hypermetropia and horizontal nystagmus. the male sibling was found to have mild hydronephrosis on the left side. he was not a mutation carrier and cystographic study was not performed at that time. on repeat ultrasound examination he demonstrated dilatation of the right prevesical ureter. the cystography revealed presence of right sided vur grade iii. in conclusion: we present two siblings with vur; although eya gene mutation was found in one of them, it can not be incriminated for the renal phenotype in this family, as co-segregation of the mutation with the vur does not occur in all affected members of the family. decision to perform cystographic study should be still based on clinical grounds. associations asymmetric dimethylarginine (adma) is a novel predictor of cardiovascular (cv) outcomes in adults. aim: to evaluate adma in children with hypertension. subjects: children ( girls/ boys; median age: yrs) with primary (n= ) and secondary (n= ) hypertension. methods: adma levels were analyzed by elisa method. in study subjects antropometrical data, ambulatory blood pressure monitoring (abpm), left ventricular mass index (lvmi), carotid artery intimamedia thickness (cimt), -hour urinary albumin excretion (uae) and serum biochemical markers (lipids, uric acid) were also evaluated. results: adma concentration was positively correlated to serum uric acid (r= . , p< . ) and uae (r= . , p< . ). when analyzed in boys separately, more apparent correlation was found for uae (r= . ) and a tendency for adma to be associated with lvmi r= . , p= . ). interestingly, when analysis restricted to older children (above the median age), adma correlated to lvmi more significantly (r= . , p< . ). no relation was found of adma to cimt, lipids, and abpm parameters. moreover, patients with left ventricular hypertrophy ( %) and microalbuminuria ( %) had a tendency for higher adma values compared to those without these abnormalities ( . ± . vs . ± . μmol/l, p= . and . ± . vs . ± . μmol/l, p= . , respectively). when data analyzed on the basis of adma values, patients in the top quartile showed the worst profile. when compared to the lowest quartile, they had higher lvmi (p< . ), higher uae (p< . ; inter-quartile comparison p= . ), and higher uric acid concentration (p= . ). conclusions: the associations of adma with known factors of cv damage found in this study provide evidence that adma is closely linked to the early cv dysfunction in hypertensive children. nephrogenic diabetes insipidus (ndi) is a disease characterized by unresponsiveness of distal tubule and collecting duct to vasopressin. although ndi usually presents with polydipsia and polyuria, most infants do not have any of these symptoms and presentation is with features of dehydration like fever, constipation, vomiting, failure to thrive and developmental delay. so, the diagnosis is usually delayed until hypernatremia is noted. almost all infants go through a period of hypogammaglobulinemia at approximately the th- th months of age. at this time, the serum ig g level reaches its lowest point, and many normal infants begin to experience recurrent respiratory tract infections. the clinical findings of ndi and transient hypogammaglobulinemi of infancy (thi) may be seen at the same period. here, we report a five-month old boy with ndi. on his history, he was admitted because of recurrent fever attacks and was diagnosed as thi when he was three-months-old. on his follow-up, hypernatremic dehydration was detected and he was diagnosed as ndi. at the time of diagnosis, he had intracranial calcification secondary to delayed diagnosis of ndi. in infants with ndi, recurrent fever attacks due to dehydration may occur and incorrectly lead to think as an infectious disease. we think that this report can be an important warning for clinicians. we analyzed nphs , nphs and neph gene in japanese cns patients independent of the patients in previous report (k.i. ) from different japanese group which suggested that the mutation of nphs was not a major cause of cns in japanese patients. we extracted genomic dna from leukocytes and analyzed all exons and exon-intron boundaries for nphs , nphs and neph using polymerase chain reaction and direct sequencing after informed consent had been obtained. the study was approved by the ethics committees of okayama university medical school. results: we found compound heterozygous mutations of nphs in patients and homozygous mutations in patients. one of these homozygous mutations was already reported in paper from europe and was not found in more than healthy japanese. another one cause defection of trafficking to the membrane as we reported before (k.i. (k.i. , ajkd . the other patients have only heterozygous mutation in nphs that healthy parent also has. we could find any mutations in neither nphs nor neph in the patients with heterozygous mutation. one of these patients has mild form of cns. another one has neither expression of nephrin nor podocin protein on kidney tissue by immunohistochemistry. interestingly, patients out of have the same mutation in nphs as nt (delc). parents who have this mutation heterozygously were from neighboring prefectures. all mutations including this mutation but one have never been reported out of japan which was isolated from continent. all amino acids substituted by missense mutations which seem to be causative were preserved among mouse, rat and human. conclusions: our studies clearly demonstrated that nphs is a major cause of cns even in japanese patients. moreover, nt (delc) is a common mutation in japanese cns patients like fin major or minor. long-term survival of childhoodonset ckd is mainly limited by the manifestation of cardiovasculardisease (cvd). the development of early stages of cvd can be assessedby non invasive methods, e.g. flow mediated vasodilation (fmd) ofperipherial arteries and measurement of intima media thickness (imt) of the common carotid artery. wetherefore performed fmd and imt investigations in children and adolescents (mean age . ± . years) suffering from ckd (mean gfr ± ml/min/ . m ) on conservative treatment (n= ), dialysis treatment ( hd, pd) and after renal transplantation (n= ), and in sex-and age-matched healthy controls. ckdpatients showed significantly decreased fmd ( . ± . % vs . ± . %, p< . ), where as imt did not significantly differ between patients and controls ( . ± . mm vs . ± . mm, p= . ). within the ckd group the presence of arterial hypertension tended to be associated with increased imt ( . ± . vs . ± . mm, p= . ). in contrast, duration of ckd, mode of renal replacement therapy and degreeof renal dysfunction was not significantly associated with fmd and imt findings. conclusion: children and adolescents suffering from ckd show decreased arterial elasticity irrespective of the mode of renal replacement therapy, the rebycontributing to increased long-term cardiovascular morbidity and mortality. the genetic researches have shown the connection between the essential hypertension and angiotensinogen gene. the researches of preeclampsia also showed the connection with angiotensinogen gene. according to established connection of angiotensinogen gene with essential hypertension and also preeclampsia the aim of our research was to determine by the help of m t, g- a anda- c polymorphisms of angiotensinogen gene whether there is a genetic disposition for essential hypertension in those children whose mothers had preeclampsia. at the same time we wanted to establish whether the polymorphisms of angiotensinogen gene can be connected with preeclampsia in women in our population. two groups of children were studied: children of mothers who had preeclampsia and children of mothers without hypertensive disease in the pregnancy. we also studied two groups of mothers: mothers who had preeclampsia and mothers without hypertensive disease in the pregnancy. m t, g- a and a- c polymorphisms of angiotensinogen gene were performed using the pcr method. in investigating the differences between the two groups of children no statistically significant differences were found in m t,g- a and a- c polymorphisms of angiotensinogen gene. in investigating the differences between two groups of mothers no statistically significant differences were found in genotype distribution. the results of our study failed to confirm that with help of m t, g- aand a- c polymorphisms of angiotensinogen gene we might establish genetic disposition for essential hypertension in those children whose mothers had preeclampsia. we did not confirm the association between m t, g- a and a- c polymorphism of angiotensinogen gene and preeclampsia either. ( ) previously treated also with cyclosporine. before start of fosinopril treatment all had proteinuria . - . g/ h and gfr > ml/ . m /min. all active steroid and immunosuppressive treatment were discontinued. eleven children also were treated with calcium channel blockers to control hypertension. after twelve months of fosinopril ( . - . mg/kg) treatment a dna analysis for ace-gene polymorphism was performed. three patients carried ii, -id and -dd gene polymorphism of ace gene. no significant differencein proteinuria at start of fosinopril treatment between all polymorphism types was observed. all patients with ii polymorphism had a good antiproteinuric effect of fosinopril with more than -fold decrease in proteinuria in comparison with just , fold decrease in id polymorphism and no response in dd. renal function remained stable in all children except of with id and with dd gene polymorphism who demonstrated decrease in gfr. we suggest that ii polymorphism of ace gene may be associated with better antiproteinuric effect of acei while dd predicts poor response. wider study is required to confirm genetic predisposition for ace blockade efficacy in proteinuric diseases. introduction: dent disease is x-linked recessive proximal tubulopathy, due to mutations in the clcn gene. it is characterized by low molecular weight proteinuria, hypercalciuria, nephrocalcinosis and progresive renal failure. aim: case report of patient with short stature and proximal tubulopathy where dent disease is determined by gene analysis. method: seven-year-old boy is refered after endocrinological exemination where abdominal ultrasound showed nephrocalcinosis. there are anamnestic data neither of oedema, macrohaematuria, nor poliuria or hypertension. there are also no data of chronic renal failure in the family. we describe detailed diagnostic procedures performed in the boy and his family. results: we determined: proteinuria ( , g/day), elevated urinary excretion of beta- microglobuline, microscopic hemathuria, hypercalciuria ( - mg/kg/day), nephrocalcinosis, decreased tubular reabsorption phosphate ( - %). values of grow hormone, parathormone on thyroid hormone are normal. except hypercalciuria, which is registered in patient's mother, all other analysis performedin family members are betwen referent values. diagnosis is finalized by mutation analysis, which has showed s l substitution on cncl . mutation carrier is mother with normal fenotype. conclusion: dent disease is rare x-linked nephrocalcinosis. definitive diagnosis ofthis proximal tubulopathy which leads to progressive renal demage, is not possible without evidence of gene mutation in renal chlor channel. introduction: the segmental renal infarction is a rare disease, allthough it is more frequent in children than in adults and can be clinically veryrelevant. objective: we describe the clinical course of two children with idiopaticsegmental renal infarction who suffered severe arterial hypertension. cases description: the typical clinical picture of this disease, as seen in our twopatients, is characterized by metabolic alkalosis, hyponatremia, hypokaliemia, hyper-reninemia, hyperaldosteronism and renal salt lossfrom the contralateral enlarged kidney. hypertension was diagnosedduring the study of haematuria in the first case and due to ahypertensive emergency in the second case. the ethiology was found tobe renovascular in both patients, involving the occlusion of small renal arteries causing segmental renal infarction. our first patient was treated with partial nephrectomy, and the second patient wastreated with antihypertensive medication given the impossibility ofremoving the renal infarcted area. conclusions: in the clinical picture, the sodium depletion with increased urinary volume of the contralateral healthy kidney can be explained by the goldblatt model. the gold standard test for the diagnosis is theselective renal arteriography, which is the most sensible and specifictest for diagnosing renovascular hypertension secondary to a segmental renal infarction because it helps identifiing the segmentary artery ofthe infarcted area, this being the source of increased focal renin production. the definitive treatment is the surgical segmentectomy. if segmentectomy is not feasible because of the localization of the infracted area as inour second patient, a medical treatment is needed. conclusion: although an inverse association between birth weight/blood pressure has been suggested in several large studies, interpretation is still controversial. in our study, we have found only a weak inverse correlation between birth weight and pad (abpm): no statistical significance has been found among other variables, although graphs show a trend of low birth weight children towards hypertension. probably a long term follow-up is necessary. he took longer to have improvement, but his calcemia, phosphatemia and alkalinephosphatase are normal. the coding region of the vdr was amplified by pcr and directly sequenced. results: three mutations (two novels) were identified. two patients had anovel mutation in exon , changing the amino acid glutamine to glutamicacid at position (q e). one patient had a novel mutation in exon changing glycine to valine at position (g v). those mutations are in the ligand binding domain and belong to the patients with better control of the disease. one had mutation in exon , in the dna binding domain, changing arginine to a stop codon at position (r x) and it was from the patient with worse response to the treatment. conclusions: two novel mutations are presented in the vitamin d receptor and it could be possible to do a correlation between the clinical evolution and the localization of the mutations. we aimed to evalute the effects of intrauterine growth retardation (iugr) on blood pressure (bp) in small for gestational age (sga) children. sga children ( f, m) aged . ± . y ( preterm and term) and ( f, m) agematched control with appropriate for ga (aga) were included in the study. -hr ambulatory blood pressure monitoring (abpm)was performed using an oscillometric device (mobilograph). th centile limit was set according to published data sets, nocturnal threshold was % less than awake limits. bp was classified as normal if the mean sbp is < th percentile and sbp load is > %. nocturnal bp dip for sbp and dbp were evaluated. in sga and in aga case, office sbp were above th%, all dbp values were normal in both groups. according to the mean of abpm records, systolic, diastolic ht were determined in sga group, and systolic, no diastolic ht were in aga group. there were sga and aga children whose sbp load over %, and only of them remarked as hypertensive according to mean sbp values. children considered as hypertensive had significantly higher sbp loads than those that were not hypertensive( % vs %, p< . ). abpm records were not different between preterm and term sgas. sga group had lower nocturnal bpdip for sbp and dbp in comparison to aga group( . % vs . % for sbp, . %vs . %for dbp, p: . ). although it was not statistically significant, the frequency of non-dipper children was higher in sga group ( . %) than those in aga group ( . %). except the lower nocturnal bp dip and higher sbp loads in sga group which may be a marker for further hypertension, no clear association between being sga and hypertension could be found in our study population. pres is a rare clinico-radiological entity associated with acute hypertension, renal insufficiency and immunosuppressive therapy. it is typically reversible but cases with irreversibility had rarely been reported. we report contrasting cases of pres associated with renal disease, one with full recovery and the other subsequently had epilepsy. first patient had steroid sensitive nephrotic syndrome with acute hypertension, fluid overload and acute renal failure while the second patient had severe flare of lupus nephritis with malignant hypertension, renal failure and thrombotic thrombocytopenia. both had acute onset of drowsiness, blindness and seizures and mri findings of subcortical oedema in the parietal-occipital-temporal regions. while the second patient had full recovery, the first patient developed temporal epilepsy and repeat mri showed mesial temporal sclerosis. pres is attributed to capillary leak from functional cerebral vascular changes of hypertension, rather than infarction. prolonged vascular disruption may lead to ischemia resulting in neurological sequelae and chronic epilepsy. using mri, pres can be readily diagnosed and normalisation of blood pressure is imperative in patients at high risk of pres. efforts have been done to describe the significance of various genetic polymorphisms (snps) in acute renal failure (arf). available reports do not investigate the predictive value of snps in disease forecasting, because so many interacting factors influence arf that classical statistical methods become unstable. high-dimensional nonparametric methods such as random forest technique overcome this problem and help to identify each clinical and genetic factor that possibly contributes to disease. we tested the classification value of basic clinical data available at birth and snps in arf of preterm infants. we determined the relative importance score (ri) of each parameter in classification. low birth weight and gestational age had the highest ri; just few snps had medium ri, while the majority of snps had small ri. then we created variable-patterns and searched for pattern with the highest accuracy of classification. for each complication, the accuracy was . solely basic clinical data were considered. if snps were incorporated, the accuracy of classification for arf was not improved. in contrast with previous observations these findings suggest that the snps do not provide additional information about arf-risk of the general preterm population. conclusions: srbd in children with elevated blood pressure is higher than that of the general pediatric population. the prevalence appears highest in patients with pre-hypertension and may be higher in patients with essential and secondary hypertension than in patients with white-coat hypertension. the renal phenotype in lowe syndrome is similar to dent's disease a -month-old girl presented with heart failure due to severe hypertension ( / ). doppler ultrasonography (us) revealed a right renal artery stenosis. biological findings showed normal serum creatinine (scr) ( mmol/l), hyponatremia ( mmol/l) and hypokalemia ( mmol/l). aldosterone plasma level was increased as were epinephrine ( pg/ml n< ) and norepinephrine ( pg/ml n< ) plasma levels measured times. renal arteriography confirmed the presence of a nearly obstructive right renal artery stenosis with a normal left kidney. pta failed to improve signifcantly the renal artery flow. in the following hours after pta, her scr level increased, up to mmol/l. doppler us showed an unchanged right kidney but hypoperfused area in the left kidney confirmed by the tc -dmsa scan. both aspects were strongly in favor of focal ischemic events. secondarly, her renal function improved but hypertension remained difficult to control autotransplantation of the right kidney was then done, but unfortunately, thrombosis of the right renal artery occured in the following hours. six months later, her plasma creatinine level is of mmol/l. her cardiac function is normal but she has to remain on antihypertensive drugs. what exactly happened during arteriography in her left kidney, in order to provoke such ischemic injury, knowing that the left renal artery was not catheterized during arteriography and pta? one hypothesis is that arterial vasospasms occured, explained by a high vasospastic predisposition due to enhaced cathecolamines secretion. such increased has already been drescribed in patients with renal artery stenosis. this case raised the question of preparing patients in this condition with efficient antispasm therapy agents before radiological vascular investigations are done. rtd is a cause of oligohydramnios leading to potter's sequence and neonatal anuria. it is characterized by absent or hypoplasic proximal tubules. these lesions can be secondary to non genetic conditions involving renal hypoperfusion. genetic forms of rtd have autosomal recessive transmission. mutations of genes encoding for the renin-angiotensin system have been reported. evolution is most often severe with in utero or neonatal death. case report: this boy was born at weeks of gestation with oligohydramnios, arthrogryposis, large fontanels with poor calvarian ossification. he was referred to intensive care unit for respiratory distress, low blood pressure (bp) unresponsive to vasopressors and anuria (plasma creatinine μmol/l at day ). renal ultrasound (us) showed enlarged kidneys with bilateral cortical hyperechogenicity. weaning from ventilation and vasoactive drugs was possible at day . glomerular filtration recovered (plasma creatinine μmol/l at day ). at age , the child is well with normal growth and a mild chronic renal insufficiency (creatinine clearance ml/min/ , m ). bp is in the low normal ranges with plasma renin x over the upper range of normal values and normal plasma aldosterone. on renal us, kidney volume normalized with persistent cortical hyperechogenicity. genetic study revealed compound heterozygous mutation in the gene encoding angiotensin converting enzyme. one is a nonsense mutation (r p), the other is a truncating mutation (k fsx ). it is possible that the first mutation is less deleterious than the other and this could partly explain the unusually favourable evolution of this rtd. in conclusion, this is a rare report of a child with autosomal recessive rtd surviving after neonatal period. further functional studies are needed to explain this unusual phenotype. data on hbp in children are very limited, and it is unclear how much it is specific in pediatric patients. the objective of our study was to determine the reproducibility of hbp in children and adolescents. automatic omron -cp devices, which have been validated for use in children and adolescents, were provided to all families. hypertensive children measured blood pressure (bp) every minutes, three times consecutively in the morning or early afternoon, and three times in the evening during days. the reproducibility of hbp was quantified using repeated measures analysis of variance test and the sd of differences between average hbp values of consecutive days. confidence interval (ci) was calculated. we studied patients ( girls, boys); mean age was , year, range - years. there were measurements of systolic blood pressure (sbp) and diastolic blood pressure (dbp). in the morning or early afternoon the mean sbp and dbp were , mmhg (sd , ) ( % ci , - , mmhg) and , mmhg (sd , ) ( % ci , - , mmhg), respectively. in the evening the mean sbp and dbp was , mmhg (sd , ) ( % ci , - , mmhg) and , mmhg (sd , ) ( % ci , - , mmhg). the mean average difference between the daily measurements of sbp and dbp were analyzed with each period and were not statistically significant (p> . ). on the basis of these results, we conclude that self-monitoring of blood pressure at home in children has good reproducibility and is not influenced by white coat effect. case report: a -year-old caucasian girl presented with history of severe polyuria and polydipsia of few months duration. past history was significant for head injury and possible seizure activity at age yr. there was no history of headaches, vomiting, or visual problems. family history negative for di. physical examination was essentially normal. basal plasma and urine osmolality, and plasma vasopressin were and mosm/kg, and < . pg/ml, respectively. at the conclusion of water deprivation test these readings were and mosm/kg, and . pg/ml, respectively. however, urine osmolality increased to mosm/kg after desmopressin injection, confirming the diagnosis of cdi. mri scan revealed absence of the bright spot on t weighted images. genetic analysis detected avp gene mutation a t, where the normal alanine at amino acid position is changed to threonine. elevated levels of plasma vasopressin after water deprivation were misleading and intriguing. we believe that elevated plasma vasopressin, although immunoreactive was devoid of biological activity. conclusion: molecular genetic evaluation should be performed in all children with cdi without an identifiable cause, even in the absence of a positive family history of cdi. mutations of the nphs gene encoding podocin lead to autosomal recessive corticoresistant nephrotic syndrome, focal and segmental glomerulosclerosis (fsgs), and early end-stage renal disease (esrd). in mice, podocin inactivation by homologous recombination results in diffuse mesangial and glomerular sclerosis, esrd and death within the first weeks of life. this early demise precludes extensive study and elucidation of the molecular pathways engaged by podocin in the mature kidney. we have, therefore, generated a novel mouse model in which a tamoxifeninducible creer-loxp system allows for conditional inactivation in a temporal fashion in podocytes. following tamoxifen administration in nphs flox/-, cre+ mice, cre expression was noted in % of glomeruli and in - % of podocytes. two weeks after cre induction, podocin expression is decreased in podocytes correlating with the appearance of selective albuminuria at - days. this progresses to massive, nonselective proteinuria by weeks, along with high blood pressure and impaired renal function. optical microscopy of kidneys showed no lesion at week and fsgs progressively developed by weeks along with tubular lesions. however electron microscopy revealed a partial foot process effacement at week with no significant albuminuria that extends by weeks along with abnormalities of the basement membrane and development of albuminuria. no mesangial or vascular lesion has been noted, differentiating it from our previous podocin null model in which renal development may be affected by podocin loss or nephrotic syndrome. this model will allow a better understanding of the mechanisms underlying the development of nephrotic syndrome and the role of podocin in the mature kidney, and will be crucial to test new therapeutic approaches. glomerulonephritis is a group of diseases with complex etiology, pathogenesis, morphological features and clinical course. the renin-angiotensin and coagulation systems genes are important group of candidate genes involved in pathogenesis of chronic renal diseases. the purpose of our study was to analyze the association of genetic polymorphisms of these genes with glomerular kidney diseases. the study population consisted of patients with immunological glomerular kidney diseases and patients with renal failure with glomerulonephritis as primary disease. the control group consisted of healthy subjects. by means of the polymerase chain reaction (pcr) the following polymorphisms were evaluated: insertion/deletion (i/d) polymorphism in intron of the angiotensin-converting enzyme gene (ace), g/ g polymorphism of the plasminogen activator inhibitor- (pai- ). no significant association was found between the ace and pai- allele and genotype frequencies and the disease. more progressing of glomerulonephritis current was marked at patients with simultaneous has dd genotype of ace gene and g/ g gene pai- (c = , ; p= , ). our results suggest that ace i/d and pai- g/ g polymorphism is an important modifying gene in the progression of glomerulonephritis. captopril objectives: secondary causes of hypertension such as renovascular hypertension are more abundant in children unlike adult population. the objective of this retrospective study is to assess the use of captopril renography (cr), which provides a non-invasive approach in the differential diagnosis of hypertension. patients and methods: clinical, radiological and scintigraphic data of a total of patients were analyzed. there were girls and boys (mean age: ± years). none of the patients had parenchymal renal disease or reduced renal function. all patients were orally hydrated before scintigraphic study. cr was performed hour after orally captopril administration and iv furosemide injection was done simultaneously with - mci tc m-mag . when post-captopril study was normal, baseline scintigraphy was not performed. computed tomography angiography (cta) was performed in and gadolinium-enhanced magnetic resonance angiography (mra) was performed in children in addition to routine renal doppler ultrasonography (dus). results: nineteen out of patients had other comorbid diseases as follows: obesity n= , previosly-diagnosed fibomuscular dysplasia n= , n= neurofibromatosis, n= demyelinating diseases, n= bartter and n= turner syndrome. cr was normal in patients. in children abnormal cr findings in correlation with radiological methods were reported. correlation with radiological methods could not be done due to suboptimal technique in patients, of whom dus in obese children could not be interpreted. in the other patient, although cr was abnormal, radiological methods could not confirm scintigraphy. conclusions: captopril renography is a useful and simple-to-perform imaging modality in children suspected of having renovascular hypertension. takayasu's arteritis (ta) is a chronic, inflammatory, large-vessel vasculitis affecting the aorta and its main branches, which causes stenosis, occlusion, rarely aneurysm and distal ischemia. the disease is most common in young women, it is rare in inviduals before the age of years. clinical presentation may be heterogeneous. in this report, we present a pediatric patient with ta who had hypertension as the sole manifestation of multipl critical arterial involvement but no other symptoms. a -year-old boy was admitted with hypertension. the acute-phase reactants were moderately elevated with an erythrocyte sedimentation rate mm/h, and a c-reactive protein value of mg/l. serologic tests including ana, anti-ds dna, c and panca, complement c , and c were negative and other laboratory data were normal. mr angiography showed multiple severe stenosis or occlusions of the thoracic and abdominal aorta together with bilateral renal arteries, and saccular aneurysm in the abdominal aorta. immunosuppressive treatment including pulse steroid and methotrexate was prescribed. the patient underwent angioplasty of bilateral renal arteries and suprarenal aorta, and a stent was placed in the right renal artery. ta should be kept in mind in the differential diagnosis of hypertension in children, even if they do not have other associated symptoms of the disease. human urotensin ii is the most potent vasoconstrictor which circulates in the plasma of healthy individuals. it was suggested that it has an endocrine role in sodium handling and even in metabolic syndrome. the aim of this study was to investigate the role of u-ii in obese adolescents with hypertension. fourteen obese adolescents with essential hypertension (group ) were compared with thirteen age-and sex-matched obese adolescents with white-coat hypertension (group ). they underwent twenty-four hour abpm and echocardiographic investigation, complete physical examination, including adiposity indexes. plasma and urinary levels of u-ii were measured by ria. obese adolescents in group have significantly higher blood pressure measurements than those in group confirmed by abpm. there was no significant difference in left ventricular mass index between two groups. no significant difference was found in plasma u-ii concentrations (pg/ml) between group and group ( . ± . and . ± . , respectively), whereas mean urinary u-ii level (pg/mg urinary creatinine) was significantly higher in group than that of group ( . ± . , . ± . , respectively). considering the renal synthesis and vasoactive role of u-ii, these results suggest that u-ii may have a role in adolescents with white-coat hypertension. distal renal tubular acidosis (drta) and deafness is a rare autosomal recessive disease characterized by severe metabolic acidosis in childhood and inappropriately high urinary ph along with sensorineural hearing loss. the disease is caused by defects in the atp v b gene. the aim of the present study was to determine the molecular basis for drta with deafness in eight patients from four families (a-d) in israel. molecular testing was done by sequencing the coding exons of the atp v b gene in one affected child from each family. a population screen was performed for mutations found in family a. the results yielded a different mutation in the atp v b gene, as follows: families a and d: missense mutation, c>g (p r), in addition to a single nucleotide polymorphism ( t>c) in the first codon; family b: insertion mutation, - insc (i fs); family c: a novel nonsense mutation, c>t (r x). in conclusion, the phenotype of drta and deafness concurs with mutations in the atp v b gene. in the present study, four families of different origins with the same phenotype had three different genotypes, indicating that there is no single common mutation in israel. these findings have implications for genetic counseling during pregnancy and testing of families. the fact that all the patients that were examined have harbor mutations in the atp v b gene, pointed for the specific clinical phenotype. making correct and early clinical diagnosis is a fundamental step in finding the molecular basis of this rare disorder. delta f is the most common cystic fibrosis (cf) mutation worldwide. the prevalence is approximately % in caucasian and - % in asian while f l is demonstrated in only . %. homogenous delta f mutation is recognized as the most common genotype however there are small numbers of cf patients having delta f /f l. in the present study we report a year-old thai boy, originated from north india, presented with recurrent episodes of febrile illness, hyponatremia, hypokalemia and metabolic alkalosis since months of age. he was transferred to our hospital for further investigation. blood chemistry revealed serum electrolytes: sodium , potassium . , chloride . , bicarbonate . meq/l, and urine electrolytes: sodium< , potassium . , chloride< meq/l. after intravenous fluid administration, hyponatremia and metabolic alkalosis improved. dna sequencing analysis of his blood demonstrates compound heterogenous mutation for delta f and f l in cftr gene. t to g transversion at nucleotide and g to a transversion at nucleotide are found without altering amino acid encoding gene. in conclusion, we report a rare case of cf with delta f /f l genotype presented with recurrent hyponatremia and metabolic alkalosis. awareness of electrolyte abnormalities during febrile illness, proper genetic counseling and long-term follow-up are necessary in this patient. objectives of study: about % of families with congenital nephrogenic diabetes insipidus (ndi) have mutations in the aquaporin gene (aqp ), which codes for the vasopressin-sensitive water channel. only seven aqp mutations are known to cause a dominant form of the disease. in this study we performed genetic and clinical studies in a generation family with autosomal dominant inheritance of a partial di phenotype. methods and results: the proband (man, yrs old) was initially diagnosed with partial central diabetes insipidus due to antidiuretic effect of ddavp. his daughter ( . yrs old) also showed polyuria and polydipsia which was responsive to high doses of intranasal ddavp. the pedigree was consistent with an autosomal dominant inheritance pattern. sequence analysis of the entire coding region of the avp gene and aqp gene was performed in the proband and his affected daughter and in unaffected family members. the avp gene was normal in all subjects. in the two affected patients but not in the healthy subjects we identified a novel missense mutation in one allele of exon of the aqp gene (c. c>t) which predicts a substitution in the c-terminal part of the aqp protein (p.r w). conclusion: partial ndi can be caused by heterozygosity for a p.r w substitution of the aqp water channel. the substitution is likely to significantly alter the c-terminal tail of aquaporin which is important for proper trafficking to the apical plasma membrane. the preservation of some residual antidiuretic function indicates that some aqp tetramers are processed correctly. the study further illustrates the importance of molecular diagnostic tools in establishing a correct differential diagnosis in familial cases of di. a background and aim: dent's disease is a renal tubulopathy characterized by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis and nephrolithiasis. mutations in the clcn gene encoding the chloride/proton exchange transporter clc- cause this disease. we have described an alu insertion in clcn that leads to exon skipping in the patient's mrna. in this study, we investigated the consequence of this mutation on the function of two putative exonic splicing enhancers (eses) in exon and the role of alu '-end sequences on splicing inhibition. methods: minigenes were constructed by inserting exon and exon -alu with their intronic flanking sequences into the exon trap vector. artificial mutations were introduced by site-directed mutagenesis. plasmids were transfected into cos cells by electroporation. pre-mrna splicing analysis was performed by rt-pcr. the ese finder web resource was used to predict the mutagenesis effects on the eses. results: alteration of one of the putative eses, the predicted binding site for srp , induced exon skipping. restoration of this site within the alu sequence promoted the incorporation of exon -alu in the mrna. however, restoration of both eses leaving the alu sequence intact resulted in exon skipping. furthermore, substitution of the eses for the first seven nucleotides of the alu element, and insertion of this sequence next to the eses increased exon skipping. deletion or modification of the alu '-end enhanced exon inclusion in the mrna. in the patient carrying the clcn alu insertion, dent's diseases is caused by disruption of an ese and by inclusion of splicing inhibitory sequences leading to exon skipping. this work was supported by grant pi from fondo de investigación sanitaria. factor h-associated hemolytic uremic syndrome (fhd-hus) is a rare disease with incomplete penetrance. it is not clear why and how carriers of the same mutation will eventually develop or not develop the disease and this uncertainty is sometimes responsible for anxiety in the carriers badly affecting their quality of life (particularly of parents with children carrying the mutation). in the attempt of estimating disease risk in subjects with factor h gene mutation, the families of fhd-hus patients (all of which had a documented mutation on the scr ) currently being treated at our center, were screened to identify the carriers after having been informed on the purpose of the analysis. twenty-eight subjects (age range - yrs), out of analyzed, revealed heterozygous mutations in the carboxy-terminal region of fh gene ( %). among subjects carrying the mutation, ( %) had exhibited the disease at a mean age of years (range . - ), of which ( %) before age , whereas the remaining subjects (mean age of yr -range - ) were healthy at time of the study. the figure shows the probability of carriers to be hus-free by age (no event occurred after age yrs). in the meantime that predisposing factor are identified, the presented survival curve (fig. ) can be an useful tool to estimate the residual risk of hus in individual carriers according to their specific age. cerebello-oculo-renal syndrome (cors) (also called joubert syndrome (js) type b) and meckel (mks) syndrome belong to the cilliopathy group of developmental autosomal recessive disorders associated with primary cilium dysfunction. nephronophthisis (nphp), the most frequent genetic cause of renal failure in children and young adults, is associated with retinal degeneration and cerebellar vermis aplasia in cors. mks is characterizd by renal cystic dysplasia, central nervous system malformations and hepatic developmental defects. these syndromes are genetically heterogenous: mutations in ahi and nphp can cause cors and mutations in mks can lead to mks, while mutations in mks and nphp are found in both syndromes. using snp mapping, we identified missense and truncating mutations in a novel genee, nphp , in both cors and mks. interestingly, all sequence changes were either nonsense or frameshift mutations in fetuses with mks whereas patients with cors had either only one or no truncating mutation. we then show that inactivation of nphp mouse orthologue recapitulates the cerebral and renal defects of cors/mks. we further demonstrate that nphp protein co-localizes at the basal body/centrosomes with nephrocystin- and nephrocystin- , the protein products of both nphp and nphp , known disease genes for nphp. in addition, missense mutations of nphp protein found in cors patients diminishes its interaction with nephrocystin- . taken together. our findings demonstrate that mutations of this novel ciliary gene can cause the multiorgan syndromes of either cors or mks, which therefore represent a continuum of the same underlying disorder. severe antenatal bartter's syndrome ga + , bw: g). both had classical signs of antenatal bs including very poor thrive, polyuria ( - ml/kg b.w./h) and responded to indomethacin treatment. direct sequencing was performed on pcr-amplified genomic dna. the entire coding region of both genes was analyzed. the kcnj gene was normal but both children were homozygous for a single base substitution ( t>a) in exon of the slc a gene predicting a premature stop codon (y x). the parents of both children and two siblings were heterozygous for the same mutation. by restriction enzyme analysis, the t>a substitution was absent among chromosomes from healthy subjects. conclusion: two children with severe antenatal bs were identified and the clinical phenotype was characterized. we identified in both children a novel mutation causing a premature stop codon of the bumetanide-sensitive-sodium-potassium-chloride co-transporter (nkcc ). despite large potassium supplements and indomethacin treatment, both children show persistent polyuria, vomiting, and insufficient thrive. background: mutations of nphs encoding the transmembrane slit diaphragm protein nephrin cause congenital nephrotic syndrome of the finnish type, characterized by massive proteinuria and the development of nephrotic syndrome before months of age. about different nphs mutations have been described. a large number of these are missense mutations resulting in single amino acid replacement mostly located in the extracellular domain. some nphs mutations have been associated with mild phenotypes responding to angiotensin-converting enzyme and prostaglandin synthesis inhibition. patient history: we report on a son of consanguineous turkish parents with a novel nphs alteration and steroid-resistant congenital nephrotic syndrome. after normal pregnancy and delivery at weeks of gestational age the boy presented with edema and proteinuria at the age of months. he responded to angiotensin converting enzyme inhibitor treatment reducing his proteinuria from a maximum of g/g creatinine to g/g creatinine and allowing him to develop normally until the age of months when cardiovascular insufficiency in the course of a hyperpyretic infection led to hypoxic encephalopathy. genetic testing revealed a homozygous in-frame -bp insertion in exon of nphs . both parents were found to be heterozygous. no mutations were found in nphs or in exons and of wt . the alteration results in an insertion of a glycine in an extracellular immunoglobulin domain of nephrin. the pathogenicity of this alteration is unclear. nephrin may be misfolded and mislocalized as in some missense mutations of the extracellular domain. alternatively the alteration might lead to an altered extracellular homo-and heterodimerization of nephrin. functional studies are currently underway to determine the effect of this novel alteration in nphs . objectives of study: interleukin receptor antagonist (il- ra) gene polymorphism has been found to affect disease susceptibility and activity in several inflammatory diseases. we investigated the association between il ra gene polymorphism and childhood nephrotic syndrome (ns) in a turkish population. methods: we analyzed the genetic polymorphism of il- ra gene in patients with childhood ns and healthy controls by using pcr. five alleles of the il- ra gene were identified and designated as il- ra* , il- ra* , il- ra* , il- ra* , and il- ra* , according to the variable number of tandem repeats in intron . results: in the ns group, the allele frequencies of il- ra* , il- ra* , il- ra* , il- ra* , and il- ra* were . , . , . , . , and . % compared with %, %, %, %, and % in the controls. a high allele frequency of il- ra* (x = . , p= . ) and a lower allele frequency of il- ra* (x = . , p= . ) were found in childhood ns. the other polymorphisms were not significantly different from normal controls. conclusions: a high allele frequency of the il- ra* allele may affect the disease susceptibility in childhood ns. objectives of study: congenital anomalies of the urinary tract (caut) are common in humans, and the incidence is increasing with recent advances in prenatal ultrasonographic examinations. interstitial fibrosis, which correlates with infiltration of inflammatory cells is common finding in the kidney with long-term ureteral obstruction. up-regulation of monocyte chemoattractant protein- (mcp- ), may be a common regulatory pathway involved in the progressive renal damage with any etiologies leading to interstitial fibrosis. mcp- gene polymorphism - a/g had been suggested to influence circulating mcp- levels and gene expression thus, might be one of the genetic markers for progression of renal damage. our aim was to investigate the frequency of mcp- genotypes and allele - g in patients with caut. objectives of study: congenital urological anomalies are well recognized as causing renal dysfunction. on the other hand, patients without congenital anomalies but with urinary bladder dysfunction (bd) could also develop renal parenchymal damage. it has been reported that angiotensin converting enzyme (ace) i/d polymorphism was a risk factor for renal parenchymal damage in certain renal diseases including vesicoureteral reflux. the aim was to determine i/d polymorphism as a potential risk factor for renal parenchymal damage in patients with congenital obstructive uropathy and to compare them to patients born with normal anatomy and innervation of bladder, sphincter and pelvic floor but which could develop upper urinary tract abnormalities. objectives od study: to determine the frequency of pyelocaliceal dilation (pcd) in asymptomatic infants and its connection with presence of other urinary tract anomalies (uta) and urinary tract infection (uti). methods: ultrasonographic screening (us) of urinary tract (ut) was performed on unselected population of healthy infants ranging between days and months of age ( boys and girls). kidneys were divided into two groups according to grade of pcd. group i consisted of kidneys with pcd, whose anterio-posterior diameter was - mm, while patients from the group ii had a-p diameter wider than mm.patients were followed up (ranging - months) by serial ultrasound examinations and with other methods for presence of uti and uta if necessary. results: in examined population , % had uta, and , % had uti. pcd was found in infants ( , %). in the group i, consisted of infants ( males and females) pcd increased during the time in , % infants, remained unchanged in , %, decreased in , %, and disappeared in , % patients. uta was found in ( , %) infants, and uti in ( , %) infants. in the group ii, consisted of male infants, pcd has not changed in ( , %) infants, decreased in ( , %), while dilation disappeared in ( , %) patients. uta was found in ( , %), and uti in ( , %) infants. conclusions: us of ut is useful and valuable method for detecting pcd. our results indicate that mild pcd in infants increases the risk for uta approximately times and uti times, while severe pcd raises the risk for uta approximately times, and uti times. early diagnosis and early treatment of uta and alertness for possible uti should be the final goal of the kidney damage prevention. therefore we recommend that us of ut should be done in all children in the first months of life. in order to determine factors involved in kidney development, the spatial and temporal expression pattern of intermediate filaments (cytokeratins, vimentin) , epithelial growth factor (egf) and transforming growth factor alpha (tgf-α), was investigated in developing kidneys (mesonephros and metanephros) of - week human embryos. immunohistochemistry for detecting specific antibodies was used on paraffin sections. in the - week human mesonephros, vimentin was moderately expressed in all mesonephric structures, while cytokeratins were seen only in the mesonephric nephrons. moderate to strong expression to egf and tgf-α detected in all mesonephric structures, decreased with advancing development. in the - -week metanephros, vimentin was mildly expressed in all metanephric structures. later on, its expression increased in collectin system and interstitium. in the th developmental week, first to appear were cytokeratins and in the ureteric bud and ampullae, while from the th week onward, both cytokeratins showed increasing expression in the collecting system and nehrons. at early stages, egf and tgfá showed moderate to strong reactivity in the collecting system, the metanephric mesenchyme and cups. from the th week onward, expression of both factors decreased in differentiating nephrons. expression of all investigated developmental factors was in line with subsequent mesonephric degeneration. expression pattern of intermediate filaments in the metanephros might be associated with mesenchimal to epithelial transformation of developing nephrons. some mutations of cytokeratins are lethal, while others might lead to some multifactorial disorders. egf and tgf-α expression patterns of the metanephros indicate their role in induction, proliferation and growth of metanephric structures. their disturbed expression might cause reduction in kidney growth. we have demonstrated that renin-angiotensin system (ras) and mitogen-activated protein kinase (mapk) family constribute to the renal development. growing evidences indicate that aldosterone, a final element or ras, is an independent and powerful mediator of various renal disease. purpose of this study was to evaluate the role of endogenous aldosterone in renal development including cell proliferation and apoptosis, and the expression of mapk family. newborn rat pups were treated with spironolactone ( mg/kg/d) in olive oil or vehicle for d. to identify cellular changes, kidneys were examined for proliferating cell nuclear antigen (pcna) by immunohistochemical (ihc) stain, and apoptotic cells by tunel stain. immunoblot, ihc stain and rt-pcr for mapks, phospho-mapks, and p gene were performed. spironolactone treatment resulted in decreased body weight, decreased pcna-positive proliferating cells and increased tunel-positive apoptotic cells, especially renal cortical epithelial cells (p< . ). in the spironolactone-treated group, c-jun n terminal kinase (jnk)- and phospho-jnk- protein expressions were significantly increased, whereas extracellular signal -regulated kinase (erk)- and p protein expressions were sigificantly decreased compared with the control group (p< . ) in immunoblot and ihc stain. expressions of erk- , phospho-erk- and , and p sere not changed by spironolactone treatment. in rt-pcr, erk- and p mrna expressions were significantly increased in the spironolactone-treated group (p< . ). we conclude that aldosterone inhibition in the developing rat kidney decreases cellular proliferation and increases apoptosis, and modulates the expressions of jnk- , erk- and p . mapk family expression may be implicated to differentially participate in aldosterone-related intracellular signaling pathways in the developing kidney. objectives: early detection of anomalies of the kidney and urinary tract (ut) helps to prevent complications but is hampered in moldova by diagnostic and logistic problems. to assess the extent of late diagnosis we studied the clinical data of all children referred to us for suspected ut infection (uti) in / and found to have renal or ut anomalies. methods: children ( males; age months- years) found to have anomalies of the kidney and ut and treated conservatively were studied (newborns and infants < months were seen elsewhere). work-up included ultrasonography in all, voiding cysto-urethrography (vcug) in %, urography in % and scintigraphy in % of patients. results: reasons for referral were febrile uti ( %); abdominal pain ( %), diarrhea and vomiting ( %), enuresis ( %) and dysuria ( %). uti was confirmed by urine culture in two thirds of cases. age at diagnosis of renal or ut anomaly was < year in %, - years in %, - years in %, - years in % and > years in %. renal hypo/dysplasia was found in , solitary kidney in and a horseshoe kidney in children. anomalies of the ut included hydronephrosis due to ureteral obstruction ( up and uv-obstruction), vesico-ureteral reflux ( ), duplex systems ( ) and bladder anomalies or mild infravesical obstruction ( ). serum creatinine was in the normal range in all children. urolithiasis was found in patients. conclusions: anomalies of the kidney and ut were diagnosed in nearly half beyond the age of years, thus with considerably delay. based on the results of this study a new strategy of renal ultrasound screening in newborns including prenatal diagnosis and of closer co-operation with referring physicians has been implemented. objective of the study: the purpose of this study was to report the outcome of infants with antenatal hydronephrosis. methods: between may and june , all patients diagnosed with isolated fetal renal pelvic dilatation (rpd) were prospectively followed at asingle tertiary renal unit. inclusion criteria were presence of rpd equal to or greater than mm on prenatal ultrasound after weeks gestation, at least six-months of follow-up, and at least two postnatalus scans. the events of interest were presence of uropathy, rpd resolution, urinary tract infection (uti), and hypertension. rpd was classified as mild ( - . mm), moderate ( - . mm) and severe (> mm objective of the study: the aim of this study was to compare the accuracy of ultrasound renal parameters to discriminate between significant uropathy and idiopathic renal pelvis dilatation. methods: neonates who were found to have isolated fetal renal pelvis dilatation (rpd) underwent systematic investigation and were prospectively followed. a us scan was performed after the first week of life and all infants underwent vcug. neonates with rpd larger than mm were examined by renal scintigraphy. receiver-operating characteristic (roc) plots were constructed to determine the accuracy of three indexes: fetal rpd, postnatal rpd, and sfu grading system. results: a total of infants were included in the analysis. ninety-five fetuses ( %) presented bilateral renal pelvis dilatation. seventy-nine infants ( %) presented urinary tract anomaly, corresponding to renal units. the most frequent detected uropathy was ureteropelvic junction obstruction ( ), followed by primary vesicoureteral reflux ( ), and megaureter ( ) conclusions: our data support the view that fetal and postnatal us renal parameters are useful markers to identify infants with clinically significant uropathies. there was no significant difference in performance among the indexes. objective of the study: the aim of this study was to evaluate the diagnostic accuracy of ultrasound (us) renal parameters to identify vur in infants withisolated antenatal hydronephrosis. methods: neonates who were found to have isolated fetal renalpelvis dilatation (rpd) underwent systematic investigation and wereprospectively followed. a us scan was performed after the first week of life and all infants underwent vcug. neonates with rpd larger than mm were examined by renal scintigraphy. receiver-operating characteristic (roc) plots were constructed to determine the accuracy of three indexes: fetal rpd, postnatal rpd, and sfu grading system. results: a total of infants were included in the analysis. seventeen infants ( . %) presented vur, corresponding to renal units. to discriminate between renal units with and without vur areaunder the curve (auc) was estimated by the roc curve, which was . ( % ci= . - . ), . ( % ci, . - . ), and . ( % ci, . - . ) for fetal rpd, postnatal rpd, and sfu grading system, respectively. there was no statistically significant difference between the indexes. the optimal threshold for fetal rpd was mm with a sensitivity of % ( % ci, - ) and specificity of % ( % ci, - ), for postnatal rpd the respective figures were: % ( % ci, - ) and % ( % ci, - ) for the cut-off of . mm. conclusions: our data shown that the magnitude of rpd is a poor predictor of presence of primary vur. there was no significant difference in performance among the indexes. objetive: we investigated the prevalence of renal calcification in children with autosomal ressecive polycystic kidney disease (arpkd) and studied the metabolic changes thats could cause this complication. methods: patients with arpkd. girls/ boys; range age m to y. criteria inclusion presence typical imaging findings: enlarged kidney and diffusely increased renal echogenicity and poorly defined renal margins on sonography; suggestive imaging features with positive results renal or liver biopsy, results patients, girls and boys, range of age - y, had ct scan renal clacification bilaterally. without renal clacifications < year. children renal calcifications, sistemic hypertension, portal hypertension and gastrointestinal bleeding and one renal colic. renal insufficiency patients, it was mild in (gfr > ml/min/ , mt ), moderate in (gfr - ), and severe in one (gfr< ). all with renal insufficiency had distal tubular acidosis. hypocitraturia urine patients. urinary calcium, uric acid, oxalates, and cystines normal in all. tuberoussclerosis (tsc) -an autosomal dominant inherited genetic disorder -is characterized by development of hamartomatous growths in many organs.two causative genes, tsc (chromosomal locus q ) and tsc (chromosomal locus p . ) have been identified. tsc gene is adjacent to pkd , the major gene for autosomal dominant polycystic kidney disease (adpkd) on chromosom p and contiguous germline deletion of both genes results in severe polycystic kidney disease phenotype at birth. at months of age bilateral abdominal masses were occasionally palpatedin a previously healthy girl. ultrasonography demonstrated enlarged (approximately cm) kidneys with multiple large cysts resembling those seen in adpkd. renal function and blood pressure was normal. suspicion of tuberous sclerosis was raised due to numerous hypopigmented cutaneous macules on the trunk and extremities. echocardiography demonstrated rhabdomyomas in the left ventricle with no hemodynamic significance. an isolated juxtapapillary astrocytoma was found in the left eye. her psychomotor development was normal with no history of seizures. cerebral magnetic resonance imaging revealed multiple subependymal nodules with noobstruction of the cerebral fluid pathways. by multiplex ligation-dependent probe amplification (mlpa) a large dna deletion was identified spanning from tsc exon to pkd exon permitting the diagnosis of tsc -pkd contiguous gene syndrome. cardiac rhabdomyoma and cutaneous manifestations were found in her father as well but no renal changes. at years of age the girl is doing fine with ace blockers against hypertension. renal function is still normal. the size of the cardiac rhabdomyomas is diminishing while the cerebral and ocular hamartomasare unchanged. this additional report focuses tsc in an infant presenting with polycystic kidneys and cutaneous lesions. improvements in ultrasound technology and the appropriate timing of antenatal ultrasound has led to refined prenatal diagnosis and enhanced accuracy of diagnosis of fetal renal anomalies and makes it possible to treat obstructive and/or refluxing uropathies before the onset of clinical symptoms.a retrospective review of patients; girls ( , %) and boys ( , %) admitted to our clinic between january -december with antenatal urinary anomalies were investigated to determine the urinary tract anomalies, and the follow-up results are presented. routine prophylaxis was started at admision and the imaging studies were performed. the mean gestational age at detection was , ± , weeks. the mean age of admittance was , ± , days and the average follow-up period was , ± , months. antenatal ultrasonoghrapy examination showed anomalies in / renal units. of these antenatally observed renal units, had postnatal urinary tract anomalies. of these postnatally observed renal units, urinary tract anomalies were detected (multiple urinary tract anomalies in patients) ( table ) . fifty-two ( , %) children had surgical interventions such as; ureteroneocystostomy, pyeloplasty, nephroureterectomy, puv resection. eighty-one ( %) of our patients had urinary tract infection during follow-up and renal scar was detected in ( %) patients. acute renal failure developed in patients and chronic renal failure developed in patients and three patients died. we conclude that all infants with fetal urinary abnormalities should be evaluated, so that we can recognize and treat congenital anomalies that may affect renal function or cause urinay tract infection, renal scarring. the majority of patients with fetal urinary anomalies can be managed safely with close conservative follow-up. fetal urinary tract obstruction at days gestation (e ) produces small kidneys with cysts, whereas obstruction at days (e ) generates large kidneys with cysts. in the present study, we investigated the mechanism for the generation of small kidneys by urinary tract obstruction at an earlier gestational age, e . fetal lambs underwent urethral and urachal ligation at e (n= ) or e (n= ). fetal lambs were delivered by c-section , , days after obstruction, or at term ( days gestation). unoperated kidneys of e , e , e , and at term served as controls. the percentage cystic area of kidneys obstructed at e and e was not different days after obstruction ( ± % vs ± %). after days, however the percentage of cystic area became larger in kidneys obstructed at e ( ± % vs ± %), and was significantly larger days after obstruction ( ± % vs ± %). proliferating cells, detected by pcna staining, were found in cysts and tubules of obstructed kidneys increasing toward term, and were more abundant in kidneys obstructed at e . on the other hand, pcna-positive cells in the nephrogenic zone were reduced in obstructed kidneys. the decrease was more prominent in kidneys obstructed at e . apoptotic cells, identified by tunel staining, were detected in the inner medulla of obstructed kidneys equally in kidneys obstructed at e and e during the fetal stage. at term, tunel-positive cells were rarely present in normal kidneys or kidneys obstructed at e , but were found abundantly in the interstitium and occasionally in cysts and tubules of kidneys obstructed at e . in conclusion, urinary tract obstruction at an earlier gestational age produces small kidneys by inhibition of mesenchymal cell proliferation, which may be due to compression by cysts. a. results: detrusor hyperreactivity, most commonly in i and iv or v grade was found in . % of vur children. the maximum detrusor pressure was above cm h . detrusor-external dyssymetry was found in % of children, most frequently in grade i and iv or v grades, and detrusor-internal dyssymetry was recognized in . % of children with vur, most frequently in grade i and iv or v. in . % of children with i-iii grade of vur cystometric capacity was reduced but child with v grade had increased capacity of the urinary bladder. glomerular filtration according to schwartz equation was normal and independent of vur grade. decrease in osmolality below mosm/kg h in nocturnal urine was only detected in the group of children with iv and v grade of vur,. there was no correlation between detrusor tension and osmolality of urine and glomerular filtration rate. conclusions: ). dysfunction of the lower urinary tract, with detrusor hyperactivity was detected, as the most frequent dysfunction in % of children below year old with i-v degree of vur, ). the maximun detrusor pressure in the voiding phase was highest in grade i and iv iv-v reflux children. hypomelanosis of ito was first described as a disorder characterized by unusual unilateral or bilateral macular hypopigmented whorls, streaks and patches. subsequently, neurologic, skeletal and ocular involvement were described. kidney involvement has only been exceptionally reported. herein, we describe a case of a male infant with hypomelanosis of ito and renal involvement. the patient was born at weeks of gestation by cesarian delivery. the ultrasound scan at weeks of gestation revealed bilateral enlargement of kidneys, decreased corticomedullary differentiation and cysts located in the cortical and subcapsular regions. these findings were confirmed at two months of life by ct scan. skin examination showed hypopigmented linear and round diffuse lesions located on the right leg and arms. the ophthalmological examination showed anterior capsular and posterior subcapsular cataract of the left eye. as previously reported in other cases of hypomelanosis of ito, the patient presented a transient leucocytosis (max . /mm ) during the first months of life.the renal biopsy showed a classic picture of glomerulocystic kidney disease, whereas the skin biopsy confirmed the clinical diagnosis of hypomelanosis of ito.three other cases of kidney disease in hypomelanosis of ito have been reported. of these, one case presented abnormalities of the glomerular basement membrane, and one case presented with polycistic kidney disease. the third case had renal cystic dysplasia with a histological picture containing glomerular cysts. alltogether these reports suggest that genes involved in hypomelanosis of ito are important for normal renal development and may be implicated in cystogenesis, when mutated. here we report on a male newborn (birth weight g, length cm) who presented with progressive edemas, oliguria and failure to thrive during the first week of live. on clinical examination he showed bilateral microcoria and decreased muscle tone. laboratory work-up revealed large proteinuria ( g/g creatinine), hypoalbuminemia ( g/l) and renal failure ( objectives. to investigate the incidence, nature, and management of associated genitourinary malformations in children with multicystic dysplastic kidney (mcdk). methods. in this retrospective study, we analyzed the medical records and imaging studies of children with mcdk. in children ( %) anomalies of the urinary tract were suspected prenatally in ultrasound studies. in the remaining children the diagnosis of mcdk was made postnatally. results. the male/female sex ratio was : . the left side was involved in ( %) children. voiding cystourethrography was done in ( %) children, the isotopic m tc-dmsa scan of the kidney in ( %). urogential anomalies were present in ( %) children. among them, contralateral urologic anomalies were found in patients (vesicoureteral reflux in and hydronephrosis in ), and ipsilateral in (vesicoureteral reflux in , ureterocele in , and hydroureter in ). genital abnormalities such as uterine didelphys and hydrocele were found in children. fourteen ( %) patients underwent follow-up examinations with ultrasonography (mean follow-up . years, range months to years). compensatory hypertrophy of the contalateral kidney was found in most children and decreased size of ipsilateral dysplastic kidney was found in out of children with follow-up. no cases of hypertension or tumor developed during the follow-up. conclusion. ultrasound can be used safely to diagnose unilateral mcdks and associated genitourinary malformation. although the risk of hypertension and development of malignancy is low, follow-up evaluation of contralateral renal function and genitalia will be needed. in cases of hydronephrosis and/or urinary tract infection, voiding cystourethrography is necessary and possibility of association with genital anomalies should be considered until the puberty. a. background: ectopic ureter is a rare anomaly. its incidence is at least four times higher in females and also more than % of the ectopic ureters drain duplicated systems in females. the most common presenting symptoms of an ectopic ureter are urinary tract infection and incontinence. diagnosis is often delayed and may remain undiagnosed until adulthood. case report: a -month-old girl was admitted to our hospital with the complaints of fever and discomfort. her mother recognized intermittent dribbling of urine while changing her napkin. physical examination revealed fever ( . °c), diaper dermatitis and intermittent dribbling of urine. urinalysis revealed leukocytouria, acute phase reactants were elevated (crp: . , esr: ) and renal function tests were normal. the patient was hospitalized with the diagnosis of acute pyelonephritis. tc m dimercaptosuccinic acid (tc-dmsa) scan revealed an increase in the size of the right kidney and decreased uptake in the upper half of the same kidney. ultrasound was performed with the suspicion of an ectopic ureter and it showed right duplicated kidney with marked dilatation of the upper collecting system. the ureter was also dilated in its whole length and ended ectopically distal to the bladder. contrast-enhanced magnetic resonance urography (mru) demonstrated right obstructed duplicated system with vaginal ectopic insertion of upper pole ureter. discussion: this case was presented to underscore the role of careful physical examination in the diagnosis of this rare anomaly that is by paying attention to the complaints of the family. ultrasound is the initial, important diagnostic modality in these patients especially if done by experienced radiologists. the diagnosis can be confirmed with mru by depicting the exact insertion of the ectopic ureter. objectives of study: to evaluate the occurrence and severity of vesicoureteral reflux (vur) in young infants with a history of mild prenatal hydronephrosis. the usefulness of voiding urosonography (vus) in the diagnosis of vur was also evaluated. methods: forty seven infants ( males, females) with a history of mild prenatal hydronephrosis, diagnosed between st to th week of gestation, were enrolled in the study. postnatal ultrasound was performed within the first month of life. voiding cystourethrography (vcug) and at the same time, contrast-enhanced harmonic vus was performed at the age of . - . months. results: the prenatal ultrasound revealed an anterior-posterior pelvic diameter of - mm in fetuses and - mm in . postanatal ultrasound showed an anterior-posterior pelvic diameter of - mm in infants and - mm in . vur was found in of ( . %) infants (grade i: , ii: , iii: ). the vur was detected by both vcug and vus in of children, only by vcug in and only by vus in of infants. the vur that was missed by vcug was more severe (grade ii and iii), compared with this one missed by vus (grade i). conclusions: even though prenatal hydronephrosis was associated with a quite important occurrence of vur, this was of mild or moderate severity. comparison between the two imaging modalities showed that the vur missed by vus were with no clinical significance (grade i), whereas the vur missed by vcug were more severe. although further study is needed, vus could be an alternative method, mainly in girls, in whom the imaging of the urethra is not necessary, thus avoiding the radiation exposure. early treatment with indomethacin in a neonate with a bartter syndromea case report neonatal bs is a rare genetic disorder characterized by sodium, potassium and chloride urinary wasting, hypokalemic metabolic alkalosis with hyperreninemia and hyperaldosteronism in the absence of hypertension and high level of urinary prostaglandins. indomethacin therapy is controversial because of toxicity for gut and kidney. a premature boy of unrelated couple was born by cesarean section at weeks because of early rupture of membranes and fetal distress. birth weight was g, length cm and apgar score / / . pregnancy was complicated by severe polyhydramnios. baby was mechanically ventilated for first hours and treated with antibiotics because of suspected sepsis. marked polyuria and dehydration were present from st week. metabolic parameters revealed hypokalemia, hyponatremia and hypochloremic metabolic alkalosis. serum creatinine was slightly elevated and gfr in normal ranges. blood pressure was normal with raised plasma renin activity and aldosterone level. sodium excretion via urine and level of renal and systemic prostaglandins were increased. nephrocalcinosis was detected on us from week. additonally to electrolyte supplementation indomethacin was started on the th day at a dose of mg/kg/day. in first months child experienced septic episodes, candida pyelonephritis and was operated because of bowel obstruction. dna analysis of affected child found new mutations in romk gene: p l and q x in herited from parents who carried one mutation each. at months height and weight are at and head circumference at percentile with slightly retarded psychomotoric development. he continues on . mg/kg/day indomethacin therapy. blood electrolyte profile is normal without supplements. us shows no progression of nephrocalcinosis. early treatment with indomethacin may prevent life-threatening complications and reduce the development of nephrocalcinosis. nimuselide, a cox inhibitor is widely used in india for relief of pain and fever. we describe cases of fetal renal abuse leading to neonatal renal failure due to maternal ingestion of nimuselide in the third trimester of pregnancy. results: all patients were diagnosed as having renal failure in the first few days of life.there were boys and one girl.. all the mothers had normal pregnancies except for oligohydramnios that was detected during the last months of pregnancy in all cases. children presented with anuria from birth. the remaining two had non-oliguric renal failure with metabolic acidosis as the presenting feature in one and poor feeding and lethargy in the other. usg revealed normal sized kidneys. one patient also showed increased echogenicity. out of the anuric children underwent peritoneal dialysis for a period varying from to weeks without recovery of renal failure. the remaining were managed conservatively. two of these patients are now in chronic renal failure at ages and years. only one patient recovered completely after days of anuria. all the mothers had taken nimuselide in the last trimester for periods varying from few days to several weeks for relief of pain or fever. some of them had taken multiple courses of short duration. the mother of the child who recovered completely had taken nimuselide in the last days before delivery. renal biopsy done in one baby revealed renal tubular dysgenesis. conclusion: nimuselide intake in the last trimester of pregnancy can be associated with oligohydramnios and neonatal renal failure that can be irreversible. renal tubular dysgenesis may be the underlying pathology. objectives of study: pkd is the most common inherited renal disease. aim of ours study was to analyse clinical and laboratory features of the different types pkd. patients and methods: we described the clinical presentation of children with pkd ( boys, girls) diagnosed in pediatric nethrology department between and . the patient's age range was from months till years. we retrospectively studied the family histories, clinical and biochemical data (physical examination, level of arterial blood pressure, blood and urine creatinine levels, serum levels of urea, glomerular filtration rate), ultrasonography, scintigraphy. results: the analysis of the family histories revealed adpkd in patients ( boys, girls), arpkd in ( boys, girls) and nondifferential pkd in ( boys, girls) children. pkd diagnosed by antenatal ultrasound in cases ( adpkd, arpkd). the mean follow-up adpkd were , year (range - years), arpkd - , year (range - , years). conclusion. patients with arpkd demonstrated the early beginning of an arterial hypertension and progressing chronic renal failure. one girl with neonatal form of arpkd died. chronic renal failure developed in ( , %) cases of pkd. objectives: this prospective study was to answer the question on the need of long-term follow-up and correlation of renal functions with the age at surgery and grade of o.u. prior to surgery in patients after surgery of obstructive uropathy (o.u.). methods: selected biochemical markers of glomerular and tubular functions and ultrasonographic findings in patients ( boys) who underwent surgery due to uni-or bilateral o.u. of grade iii. and iv. (age at surgery < months) in - were examined at mean age of . ± . years. the results were compared to healthy controls and/or to reference values according to age. consequently, patients were devided into groups according to the age at surgery ( - months, - months, - months) and grade of o.u. prior to surgery. results: serum concentration of cystatin c (s-cysc) was significantly higher in patients when compared to control group (p< . ). while s-creatinine was within reference interval in all patients, s-cysc was increased in . % when compared to reference interval. decreased tubular resorption and concentration ability was found in % and % patients, respectively. non-specific aminoaciduria was detected in . % patients. on ultrasound, . % kidneys after surgery had residual dilatation of renal pelvis. the differences in renal functions in patients according to their age at first surgery were not significant except for u-nag activity with significant negative linear trend with higher age at surgery. the grade of o.u. prior to surgery did not have significant influence on renal functions. conclusions: mild tubular dysfunction and slightly reduced gfr in the part of patients make longterm nephrologic follow-up reasonable. our results support the trend of postponing early postnatal surgical intervention in patients with positive ultrasound screening of o.u. and normocreatininemia. objectives of study: to evaluate, during almost five years of follow-up, the changes among preoperative and postoperative renal function in infants ( m/ f) with prenatal severe hydronephrosis (hn) and upj obstruction. methods: upj obstruction was diagnosed by a mag renal scan, performed at - weeks of age to establish baseline differential renal function; surgery was made if there was evidence of obstruction injury, and/or progression of hn and/or symptoms. the group was re-imaged months after surgery, after months, year and then annually. results: initial differential renal function was moderate in . % of males and in % of females and good in . % and in % respectively. also, % of kidneys required surgery because of declining function, with mean differential renal function in the affected kidney of % that improved to % already at months after pyeloplasty. there was no significant functional improvement, in the kidneys that underwent correction because of increased hn or symptoms and final renal function was > %. after pyeloplasty t was > min. in % and - min. in % of cases (p< . ) there was no statistically significant correlation between initial grade of hn and initial renal function. surgical treatment was performed between - months of age and there was no significant difference in postoperative results, ascribed to patient age at surgery. ma values, greater than controls at diagnosis, reduced at months after surgery in all, but % of children. during the follow-up, the mean ccr and bp values were in normal range for age in all children. conclusions: our findings showed improvement also in kidney with preoperative uptake less of %. this may be to explain in according to an inverse correlation between degree of renal dysplasia and gestational age. objective of study: is to determine the postnatal course and follow-up of children with fetal hydronephrosis. methods: in years period ( ) ( ) ( ) ( ) ( ) ( ) ( ) we followed infants with antenataly detected hydronephrosis. all infants were submitted to ultrasonographic examination of kidneys and bladder. if indicated, the isotope renography, micturating cysto-urethrography, i.v.urography and mr were performed. results: the diagnosis of hydronephrosis was established during - th weeks of gestation by obstetritian. first postnalat ultrasound investigation was performed during neonatal period in most children ( %). in ( , %) infants we diagnosed idiopathic hydronephrosis, in ( , %) vesicouretheral reflux (vur) grade ii-iv, in ( , %) hypofunction of one kidney, in ( , %) ureteropelvic junction obstruction (upjo), in ( , %) ren duplex and ureterocele, in ( , %) ampular pelvis and in ( , %) afunction of one kidney. after - months we found normal ultrasound in ( , %) children. the ultasound results were stable in ( , %) children and in ( , %) there was progression of hydronephrosis. four ( , %) infants underwent immediate surgery. conclusions: in a group of infants with antenataly detected hydronephrosis the diagnosis was confirmed postnataly in % infants. more than % of infants required long term follow-up. in , % the immediate surgey was required. this data support the need for antenatal detection of hydronephrosis. in the same period we followed up infants with urologic abnormalities which were not detected antenataly.the fetal ultrasound is reliable screening method in detection of urologic abnormalities. the considerable number of anomalies which were not detected antenataly are the result of insuffitient use of fetal ultrasound investigation. hemolytic uremic syndrome (hus) is defined by acute renal failure, microangiopathic hemolytic anemia, and thrombopenia. perinatal asphyxia (pa) may cause renal failure after birth and is often associated to disseminated intravascular coagulopathy (dic) with platelet consumption. however, no biological investigation permits to distinguish clearly neonatal hus from dic. we report three neonates with renal failure due to different degrees of pa. they presented biological features compatible with hus such as fragmentocytes ( %), thrombopenia (< , /mm ), anemia (< g/dl). serum creatinine on day was , , mmol/l respectively, requiring peritoneal dialysis in one patient. haptoglobin was undetectable for all three patients. factor h and i were in the lower normal range; components of the complement system (c , c ) and adamt activity were decreased. two patients received daily fresh frozen plasma infusions over the first weeks. renal function improved in two patients until day ; one patient has chronic renal failure. all other parameters suggestive for hus were normal on day , , and respectively. no severe neurological consequences were noted for either of them. pa may be responsible for multiorgan damage via ischemic lesions. ischemia may result in endothelial cell injury, the crucial event for the development of thrombotic microangiopathy. we hypothesize that endothelial cell damage concomitant with pa may lead to a vicious circle resulting in consumption of platelets and plasma factors involved in hemostasis and/or fibrinolysis. early use of fresh frozen plasma may correct these alterations. renal biopsies might have been useful but are technically difficult in newborns. in conclusion, pa and neonatal hus are difficult to distinguish and endothelial cell damage may be a common pathyphysiological aspect and might requirespecific treatments. a. medynska, m. nalesniak, k. kilis-pstrusinska, d. zwoliñska congenital posterior urethral valves (puv) are the most common cause of lower urinary tract obstruction in male neonates. we aimed to review our experience with puv children ( boys) in respect to retrospective analysis of the clinical course of disease. we analyzed: ultrasound during pregnancy, age of disease onset, clinical symptoms at admittance to hospital, outcome. average lenght of follow-up was , years, varying between month and years.obstruction of urinary tract was suspected by prenatal ultrasound in patients. the initial presenting symptoms were as follows: urinary tract infection boys, failure to thrive patients, increased abdominal circumference - , abdominal pain , enuresis - , acute renal failure , and chronic renal failure children. in association with puv renal dysplasia/hypoplasia in patients, undescended testis , bladder trabeculation were found. the diagnosis of puv was confirmed by voiding cystourethrograms and/or cystoscopy. primary vesicouretral reflux was documented in pts. hydronephrosis and/or megaureter were observed the most often in boys. the diagnosis of puv was established in pts at the age of less month, in pts between - months, and in between - years. surgery was performed in pts in neonates period including primary valve surgical ablation and/or cutaneostomy vesicostomy. chronic renal failure was diagnosed in boys in first year of live. of them progressed to end-stage renal disease. globally during the follow-up pts developed end-stage renal disease. pts have done a graft. only boys survive without progression to chronic renal failure. the presentation of puv is variable and currently antenatal detection is the most common mode. outcome boys with puv is poor. patients need nephrologic assesment from birth. background: furosemide is among the most frequently used drugs in the neonatal unit but few studies analyze the beneficial effect and complications in this patient group. objectives of the study: to analyze the therapeutic clinical effect and to document side effects of furosemide therapy in extremely preterm infants born < weeks gestational age (ga). methods: twelve infants born < weeks ga were prospectively included during the fall . the following parameters were documented prior, during and after furosemide administration: clinical status, serum/urine electrolytes, creatinine, albumin, blood gases and furosemide exposure. ultrasound of the kidneys and a wrist radiograph were performed at - weeks to rule out osteopenia/rickets and nephrocalcinosis respectively. no statistical analysis were done due to the small study size. results: general oedema, respiratory rate, apneic spells and oxygen supplementation decreased. arterial/venous pco decreased and partial oxygen saturation increased indicating improved lung function. hco increased and ph decreased. urinary excretion of sodium, potassium, chloride and calcium increased while phosphate excretion decreased. serum sodium and chloride decreased and potassium increased initially. six infants had electrolyte disturbances and metabolic alkalosis. one infant died during the study period. in the remaining infants, of had worsening of their patent ductus arteriosis, had osteopenia or rickets and had nephrocalcinosis. the total side effect score was increased in the infants with the highest furosemide exposure. conclusions: this small study suggests that furosemide is beneficial in extremely preterm infants born < weeks ga and that the associated side effects correlate to the total drug exposure. we recommend caution for long term administration of furosemide. conclusion: although children in our study suffered significant neonatal hie resulting in arf, glomerular and tubular function recovered sufficiently to cope with increasing body mass and metabolic needs. unlike reported studies, we did not find any significant evidence of cri in the survivors of neonatal hie and arf. one with marginal microalbuminuria will need further observation. c was born after a monozygotic monoamniotic twin pregnancy (gestational age= weeks). she presented with twin-twin transfusion syndrome with hypotrophy (birth weight= g, other twin= g), severe hypovolemia, anemia and acute renal failure. she required a blood transfusion, mechanical ventilation ( days), and peritoneal dialysis ( days). she recovered without bronchodysplasia but with chronic renal failure (creatininemia at months= μmol/l). the following months were uneventful but, as usual in tts, she exhibited growth retardation and slight mental delay compared to her twin. she reached terminal renal failure at years of age and was successfully kidney transplanted. after age of years, she presented with increasingly frequent and severe pulmonary infections predominantly in lower lobes of both lungs. after extensive explorations, the diagnosis of bilateral bronchiectasis was made. the search for classical aetiologies of such pathology was negative. the symmetric aspect and the absence of other etiologies lead to the consideration of bronchiectasis as a congenital pathology. numerous publications demonstrate the role of the renin-angiotensin system (ras) in renal and cerebral damages in tts. authors demonstrate the role or ras in development of vasculature in fetus but also of cartilage and muscle in different organs including lung. associations between tts and lung pathologies need to be further investigated. urofacial ( the urofacial (ochoa) syndrome (ufs) is a rare disease that occurs in both sexes and is more frequent when the parents are closely related. it has both urinary and facial abnormalities. ufs is a rare autosomal recessive disorder and a potential gene has been mapped to chromosome q -q . they present a bladder voiding dysfunction due to impaired neural communication between the bladder and the spinal cord, resulting in incomplete emptying of the bladder. this usually results in enuresis, urinary tract infection, hydronephrosis and in some severely affected patients, end-stage renal disease developed. the facial abnormality is a characteristic expression that, when these patients smile, their facial musculature inverts and they appear as if they are crying. we report a year-old girl who has inverted facial appearance, voiding dysfunction and vezicoureteral reflux. she had constipation and did the intermittan uretral cathaterization for five years. after a detailed evaluation, she was diagnosed as ochoa syndrome due to inverted facial expression. we report this case, because early diagnosis of ufs is very important for early assessment and management of urinary problems to prevent development of chronic renal failure. we think that only a smile can give a strong high light for this unusual 'inverted' facial expression and patients can be screened earlier for severe voiding dysfunction. tar syndrome is a congenital malformation syndrome characterized by bilateral absence of the radii and a thrombocytopenia. the known urinary anomalies with tar are duplex ureter, dilatation of renal pelvis, horseshoe kidney, and functional problems like vesicouretheral reflux and pyelonephritis. case: nine years old patient with tar syndrome was admitted with a complaint of bright red urine repeated three times. the microscopic hematuria without dysmorphism of erythrocytes accompanied with no proteinuria were determined in repeated urine sample microscopy. iga, ana, anti dna serology were negative. urine culture was clean. stone formation ( x mm) in the upper pole of the right kidney was established by the abdominal ultrasonography. postoperative chemical analysis of the stone, revealed that it was consisted of oxalate monohydrate and dihydrate. but the patient discontinued his follow-ups afterwards for a year. in this period, he had macroscopic hematuria attack once. when he applied for the second time, he reported macroscopic hematuria. cystoscopy was done for etiology. many tortuous and engorged vessels were seen by this evaluation in the bladder mucosa ( figure ). there was no active bleeding point. result: in this report, kidney stone and telangiectasia found co-incidentally in the bladder of a patient with tar syndrome during the examination of hematuria are discussed as there is no case report demonstrating nephrolithiasis and telangiectasia in tar patients in the literature. figure : many tortuous and engorged vessels in the cystoscopy. antenatal hydronephrosis (anh) is one of the common fetal abnormalities detected on ultrasound (us). the long-term renal prognosis for infants with mild to moderate postnatal hydronephrosis (hn) is unclear and controversial. a systematic review of the published literature was performed to determine an evidence based approach in infants with antenatally diagnosed hn and to identify those at risk of significant post natal nephro-uropathy (pnu). key questions were identified. does anh predict renal tract pathology in neonates? what is the value of prophylactic antibiotics in infants with anh? can postnatal us diagnose significant pnu? when is the optimal time to screen infants postnatally? which imaging modalities are necessary to diagnose the cause of the hn? how many neonates with anh would need to be investigated to prevent one case of esrf/crf? a search strategy was formulated. out of titles only seven studies met the validity criteria for inclusion. the results indicate that antenatal us is a valid screening test for pnu (sensitivity %, specificity %), but is not a predictor of pnu. the detection rate of hn by us is the same whether it is done early or late in neonates. two normal ultrasounds over a minimum of one month are required to screen for pnu. infants with a renal ap diameter over mm are at risk of a significant pnu and should be investigated further. us is not a substitute for cystourethrogram or dynamic isotope studies to determine the cause of hn. none of the studies addressed the role of prophylactic antibiotics. there was insufficient data to calculate the total number of cases that would need to be investigated to prevent one unfavourable outcome (esrf/crf). high quality population based cohort studies with long term follow-up into adulthood are required to determine the optimum postnatal management of mild to moderate hn in infants with anh. jeune asphyxiating thoracic dysplasia: a case report jeune asphyxiating thoracic dysplasia (jatd) is one of the congenital hepatorenal fibrocystic syndromes. it is characterized by renal, hepatic, pancreatic abnormalities with associated skeletal abnormalities including a long and narrow thorax, metaphyseal irregularities, and shortness of the ribs and long bones. this report describes a pediatric patient with jatd developed end-stage renal failure. a -year-old boy was admitted with complaint of vomiting and pallor. he had dysmorphic appearance including trigonocephaly, short stature, long thorax and short limbs and fingers, polydactyly and fascial dysmorphism. laboratory findings revealed severe anemia (hb . g/dl), high bun and creatinine levels ( mg/dl and . mg/dl respectively) and normal liver tests. abdominal usg showed a severe intrahepatic biliary tract dilatation and intraparenchymal cysts in liver, pancreas and kidneys. mr pancreatocholangiography was consistent with caroli's disease. jatd should be considered when caroli's disease exists with skeletal abnormalities. follow-up antenatal hydronephrosis: one centre experience the most common renal abnormality detected antenatally is hydronephrosis ( % to % of all pregnancies). in this paper, we report follow-up our patients with antenatal hydronephrosis (ah) between and . diagnosis of hydronephrosis was made > mm of antero-posterior diameter (ap) of the renal pelvis. ah was detected in patients on antenatal ultrasound examination. of the patients with ah, ( . %) were found to have hydronephrosis postnatally and ( . %) postnatal scans were normal. in of these patients ( . %) had bilateral and ( . %) of these patients had unilateral hydronephrosis. in these patients with ah, uretero-pelvic junction obstruction (upj) ( . %), reflux ( . %), uretero-vesical junction obstruction ( . %), posterior urethral valves ( . %) and mega-ureter ( . %) were identified. in follow-up period, ( . %) patients with reflux, ( . ) patients with upj were treated with surgery (p< . ). in conclusion, upj was most important cause of ah and most of them were treated with surgery. hyponatremia and renal tubular acidosis in severe vesicoureteral refluxa case report sahlgrenska academy, department of pediatric, gothenburg, sweden case report: st child to healthy parents without heredity for kidney or metabolic disease. antenatal bilateral hydronephrosis. postnatal examination showed bilateral vur grade v, normal urethra. antibiotic prophylaxis was started, no urinary tract infection (uti) occurred. normal s-creat and s-na + at weeks of age. the electrolytes remained normal during the next months. normal growth. the boy was thirsty with high urine volumes. at month of age feeding problems began with retarded weight gain. no vomiting or diarrhoea. at admission to the hospital the child was dehydrated, s-na + mmol/l, s-cl - mmol/l, s-ph . , bicarbonate mmol/l, s-creat μmol/l. crp mg/l, urine culture negative. u-na + mmol/l, u-ph . , u-osmolality mosm/kg. the anion gap was normal and there was no lactacidosis. the s-aldosterone was elevated , nmol/l, s-cortisone normal. treatment included intravenous rehydration, na + supplement and oral bicarbonate. blood chemistry normalised and the child's general condition improved rapidly. conclusions. children with severe reflux are at high risk for uti but may also develop impaired tubular function with diabetes insipidus, renal tubular acidosis and hyponatremia. the mechanisms include down-regulation of vasopressin receptors and impaired distal tubular function. close clinical monitoring of these children with regular blood chemistry and weight controls is important. purpose: we aim to prospectively study the natural history of minimal to severe grades of antenatal hydronephrosis (anhn) in our local chinese population and correlate the renal pelvic diameter (rpd) with the outcome. patients and methods: cases of anhn were prospectively followed up along a predefined protocol using us, mag and mcu in all. obstruction (pujo or vujo) was defined as a need for surgery based on symptoms and deteriorating function, not on mag drainage time. results: neonates were followed up for minimum of years. eighty percent had normal or minimal hn on postnatal scans (rpd - mm), . % had mild ( - mm) or moderate ( - ) hn and . % severe hn (> mm). seventy-eight percent infants had benign course; . % had partial obstruction which improved; . % had vesicoureteric reflux (vur) one of which required surgery. another . % required surgery for obstruction. the roc curve for obstruction requiring surgery showed optimal cut-off point of . mm (sensitivity %, specificity . %). prolonged diuretic t / was not predictive of surgery. severity of hn did not correlate with presence or grade of vur. fifteen patients developed uti despite antibiotic prophylaxis and had focal scars, all occurred in association with high grade vur or obstruction. the prognosis of infants with minimal or mild anhn is good. however rpd is poorly correlated with vur. the chances of obstructive lesions requiring surgery are high when the rpd is above mm. in those with high grade reflux or obstruction, urinary tract infection may lead to renal scars. objectives of study: cystinosis is a rare disease presented initially with renal fanconi syndrome, and renal glomerular failure develops later in childhood. without cysteamine treatment, patients affected with cystinosis uniformly died during childhood in the absence of renal replacement therapy (rrt). cysteamine is not available here and in some other areas of the world. the aim of this paper is to describe a beneficial effect of acacia gum in a patient with cystinosis and chronic renal failure. method: years old girl with cystinosis presented with symptomatic uremia as she didn't receive cysteamine. serum creatinine . mg/dl, blood urea mg/dl. the girl was hospitalized and vomiting controlled with intravenous fluid and pyridoxine. chronic dialysis was not available for her and the parents refused treatment with intermittent acute peritoneal dialysis. the girl was treated with a new therapeutic regimen (therapy ; ( ): ) combining the traditional conservative management of crf (dietary and pharmacologic) with addition of acacia gum (ag) g/day as an urea lowering agent aiming at improving her condition without dialysis. results: treatment was associated with amelioration of the uremic symptoms and improved general well being. after weeks of treatment, serum creatinine . mg/dl, blood urea mg/dl. during months of follow-up she continued in experiencing improved well being and urea levels was kept below mg/dl without dialysis. conclusion: it was possible to improve the health of patient with cystinosis despite the nonavailability of cysteamine and the appropriate rrt. objectives of study: the pattern of renal tubular disorder (rtds) has been infrequently reported in the literature, and the pattern of rtds in iraqi and arab children is not known. methods: from june to august , it was possible to evaluate children with suspected rtd to determine the type of their tubular defect. there was evidence of rtd in only patients; males ( %) and females ( %). their ages at referral ranged between months and years (mean . years). in patients with oculo-cerebro-renal syndrome, there was no evidence of rtd and one patient had hyperoxaluria which not a rtd. results: seven types of rtds were identified. the three most common disorders were: idiopathic hypercalciuria ( %), cystinosis ( %) and renal tubular acidosis rta ( %). four of the patients with rta have proximal rta, and four have distal rta. four of the patients with hypercalciuria have also significant hyperoxaluria > mg/kg/day. conclusion: the pattern of rtds in iraqi children differs from the previous studies: in germany the three most frequent disorders were cystinosis, xlhr, and idiopathic hypercalciuria. objectives of study: few literatures reported the incidence of ocular abnormalities in chronic renal failure (crf). the aim of this paper is to determine the incidence of ocular abnormalities in childhood crf. methods: from january to december , patients with crf (at the university hospital in al kadhimiyia) were examined to determine the presence of ocular abnormalitites. fifty patients were males ( . %) and ( %) were female. their age at referral ranged from months to years (mean year). they were followed for a period ranged from days to f years. results: corneal cystine crystals were the most common ocular abnormalities associated with childhood crf observed in patients with nephropathic cystinosis ( . %). congenital cataract & glaucoma were observed in patients ( . %) with oculo-cerebro-renal syndrome (ocrs). congenital cataract & chorioretinal hypoplasia were present in patient with ocrs. hypertensive retinopathy occurred in patients. acquired cataracts occurred in one patient with hinman syndrome in association with hypocalcaemia and non-compliance with calcium and onealphacalciferol supplementation. retinitis pigmentosa in one patient with laurence moon biedl syndrome. bilateral optic atrophy in one patient with familial nephropathy associated with club feet. proptosis in one patient with membranoproliferative glomerulonephritis. conclusion: ocular abnormalities are relatively common in childhood crf occurring in approximately %. objective: hypocalcaemia has been reported as a complication of phototherapy especially in neonates. we studied the relation between serum calcium level and urine calcium to creatinine ratio in neonates under phototherapy. method: icteric newborns ( males and females) treated by phototherapy entered into study by non accidental sampling. the consent was taken from parents on admission. all were breastfed healthy newborns. weight was checked and serum samples for calcium and bilirubin and urine aliquots for calcium, creatinine and osmoloality were sent on arrival (group i), after hour of starting (group ii) and hour after discontinuing phototherapy (group iii). hypercalciuria was defined by uca/ucr > . , hypocalcemia was defined by serum calcium < mg/dl in the term and < mg/dl in the premature. chi , anova, wilcoxon rank test and spearman were used to compare frequency, means, median and correlation. p< . was considered significant. two groups were designed, pateints whose therapy were finished at least months (group ) and those either on therapy or less than months passed from the last protocol of cytostat (group ). demographic data, cumulative dosages of anticancer drugs, history of other nephrotoxic agents, nephrectomy, radiotherapy and acute renal failure were recorded. we used ctc ( ) to evaluate renal function. chi and mann whitney u test and biniary logistic regression were used to compare percentage, scoring and correlation respectively. p value less than . was considered significant. result: out of patients were in group and ones were in group . the mean of age was . years (± . sd). the median (range) of therapy and termination was months ( - months) and month ( - month) in group and month ( - ) and months ( - months) in group respectively. the percentage of reversible renal failure, proteinuria, abnormal serum calcium and magnesium, metabolic acidosis and urinary concentration defect was higher in group . (table ) these differences were statistically significant (p< . ). we found no correlation between ctc score and dosage of drugs, age, sex, history of radiotherapy or nephrotoxic agents (p> . ). conclusion: mild to moderate tubular dysfunction has been observed in survivors of leukemia. routine follow-up of renal functions is recommended. v. tramma, k. giourtzis, v. fotoulaki, k. nousia-arvanitaki aristotle university, th pediatric clinic, thessaloniki, greece although cftr is expressed in the kidney, patients with cystic fibrosis (cf) have not been reported to have major renal abnormalities with the exception of urolithiasis. the aim of this study was to determine renal function and the potential risk factors for renal stone formation in cf patients older than years of age. the findings of metabolic evaluation of cf patients having confirmed urolithiasis (mean age: , ± , ) were compared with those of cf patients without urolithiasis (mean age: , ± , ) and those of healthy volunteers (mean age: , ± , ). evaluation included plasma sodium (na), potassium (k), chloride, bun, creatinine, uric acid, calcium (ca), phosphorus (p), magnesium (mg) and parathormone (pth). twenty-four hour urine collection for creatinine, uric acid oxalates, ca, mg, k + , na + and microalbuminuria was also performed. glomerular filtration rate (gfr) was calculated and fresh urine samples were examined for the presence of crystals, erythrocytes, glycosuria and microorganisms. patients with cf and urolithiasis showed significantly increased values of bun (p: . ), pth (p: . ) and gfr (p: . ), very low urine mg levels (p: . ) and microalbuminuria (p: . ) as compared to cf patients without urolithiasis. there was no correlation of urolithiasis with hypercalciuria and hyperoxaluria. furthermore, all cf patients showed significantly increased pth levels (p: . ), very low urine mg levels (p: . ) and microalbuminuria (p: . ) as compared to healthy volunteers. conclusions: renal dysfunction was demonstrated in older cf patients, probably, secondary to the primary defect of renal chloride channels. extracellular volume regulators, such as hormones, may also be implied. urolithiasis may be the result of renal dysfunction. conclusions: the morbidity of hsp had obviously increased in recent years. the familial cases, the initial symptoms of no palpable purpura at onset and the cerebral, pulmonary, cardiac and pancreatic involvement should be paid attention. objectives of study: systemic lupus erythematosus (sle) is an autoimmune disease affecting multiple organs and tissues including central nerve system, cardiovascular system and kidney. although etiologic mechanisms of sle are incompletely known, overproduction of immunoglobulin g autoantibody may contribute to onset of this disease. while still incompletely understood, the etiology of systematic sle is considered to involve both genetic and environmental factors. we encountered two boys with severe sle from unrelated families and analyzed polymorphisms of the gene that encodes cytotoxic t-lymphocyte associated (ctla)- , a protein important in t-cell activation and immune tolerance. abnormal function of the gene may participate in causation of autoimmune disease including sle, resulting in production of immunoglobulin against various self-antigens. case report: in family , a boy showed serious cardiovascular complications associated with heart failure while his mother also had clinically active sle including nephritis. a boy in family developed severe renal complications and peripheral vasculitis accompanied by disseminated petechiae in the lower extremities; his paternal grandfather had died from fibrinous pneumonia caused by sle. results: analysis of the ctla- gene indicated that the boy in family and his mother possess a gg genotype in ctla- exon at + together with a -bp fragment length of the ' untranslated region (utr) in exon . the boy in family also showed gg at + . no association with disease activity was found for polymorphism of the promoter region in exon at - in either family. conclusions: disorders of the ctla- gene, especially a gg genotype in exon at + and/or bp fragment length of the 'utr in exon , may be involved in early development of sle in japanese children such as the boys described here. this disorder is transmitted mainly as x-linked trait, and is caused by mutations in the col a gene encoding α chain of type iv collagen. in some families, x-linked as is associated with diffuse leiomyomatosis. we present clinical, pathologic and molecular-genetic findings in japanese family with this inheritance mode of as in association with leiomyomatosis. case report and results: as was diagnosed in a one-year-old boy with recurrent aspiration pneumonia caused by esophageal stenosis from leiomyomatosis. he had macroscopic hematuria and bilateral cataracts. diagnosis was confirmed by electron microscopy coupled with type iv collagen chain subtype staining in a renal biopsy specimen. thickening and irregular contours of the glomerular basement membrane (gbm) and splitting of the lamina densa were evident by electron microscopy. immunofluorescent staining for type iv collagen chains failed to show staining for α (iv), α (iv), or α (iv) in the gbm, associated with lack of α (iv) and α (iv) staining in the bm of bowman's capsule. his mother, who exhibited esophageal leiomyomatosis and is heterozygous for as, showed a discontinuous staining pattern for α (iv) along the epidermal bm. genetic analysis in the boy revealed the deletion of the first two exon of col a together with deletion of the ' end of col a . conclusion: identification of an as patient during infancy is extremely rare. clinical manifestations, including macrohematuria, cataracts and leiomyomatosis caused by the large deletion involved col a to col a , led to early presentation with as. functional voiding disorders of the bladder occur in the absence of any anatomic/neurological abnormality and present with wetting. invasive urodynamic studies are discomforting, not easily available in emerging countries and costly. this study aims to validate non-invasive urodynamics. children below years, with possible voiding disorders evaluated prospectively. non-invasive evaluation included history, examination, frequency volume charting, ultrasonography, urinalysis and renal functions. micturating cystourethrogram was carried out for children with urinary tract infection. all children underwent invasive urodynamic studies (uds) and the significance of association of the parameters of non-invasive assessment with invasive urodynamics was determined. the chi square test was used for statistical analysis using the epi software. children underwent invasive uds. the commonest abnormality was detrusor instability (di) in ( . %). dysynergic voiding (dv) noted in ( . %), lazy bladder in and an occult neurogenic bladder in . the study was normal in . repressing the disease progression may be . mg/kg/day or more background: henoch-schoenlein purpura is classified into the small vessel vasculitis. there may be no reliable indicator of the disease activity. steroid treatment ( mg/kg/day of prednisolone) has been thought of as a means with which alleviate abdominal pain. however, this dose seemed to be not effective to intervene the disease progression to nephritis. objectives: forty-three japanese children with henoch-schoenlein purpura were enrolled in this study. fibrinogen degradation product e-fraction (fdp-e) value was measured once or twice a week in the patients. coagulation factor xiii was simultaneously measured in of the patients in the early phase of illness. with an aim to alleviate abdominal pain, . - . mg/kg/day of prednisolone had been administered to of the patients. results: at presentation, only of the patients had low factor xiii activity. on the contrary, of them had elevated serum fdp-e value. longitudinal fdp-e measurement revealed that patients whose fdp-e value normalized within the second weeks of illness had minimal risk of nephritis. in this group, of had microhematuria. in the other patients group with prolonged (after fourteen days of illness) elevation of fdp-e values, of had nephritis. furthermore, of had proteinuria after three months of illness. these patients who had received prednisolone therapy with less than . mg/kg/day in the early phase of illness. the other patients with . mg/kg/day or more prednisolone therapy had no nephritis. summary: the disease activity of hsp and hspn might reflect the duration of elevated serum fdp-e. more than . mg/kg/day of prednisolone may repress the disease progression to nephrits. background: all major organs are involved more or less in thalassemia and most of them have been studied thoroughly in previous literature. renal system involvement has not been scrupulously scrutinized yet. method: in a randomized prospective study, renal findings of children and young adults, aged - years, with thalassemia major (group ) were compared to other cases of thalassemia intermedia (group ). blood urea nitrogen, serum creatinine, uric acid, calcium, phosphate, urinalysis, and sonographic findings were evaluated. results: mean age was ± . years in group and ± . in group . mean serum ferritin level was ± ng/ml in group vs. ± . ng/ml in thalassemia intermedia group (p< . ). % of subjects of group had received or was on hydroxyurea at the time of evaluation. serum uric acid was significantly higher in patients with thalassemia intermedia ( conclusion: significant renal involvement is not a frequent complication in children and young adults suffering from thalassemia. hyperuricemia and microscopic hematuria is more common in thalassemia intermedia than thalassemia major. case: a -year-old female patient was born at term (weight g, lenght cm) and for aspiration of amniotic fluid required resuscitation and mechanical ventilation for days. perinatal hypoxia was a cause of her acute renal failure but dialysis was not needed. patient's follow-up during next yrs showed mild form of chronic renal failure (crf) without hypertension: serum creatinine (scr; range during follow-up [rdf] - μmol/l), glomerular filtration rate (gfr; rdf - . ml/min/ , m ) and p (rdf - mg/ h). at the age yrs we performed renal biopsy (rb) because girl's p and scr increased ( mg/ h, μmol/l, respectively) and gfr decreased ( ml/min/ . m ). rb showed c q-nephropathy (c qn) with focal glomerular sclerosis and hyalinosis. c qn is a rare disease and as a first diagnostic step is differentiation against lupus nephritis. progression of c qn to crf is infrequent. probably two renal diseases were a cause of crf in our patient -hypoxic renal damage during neonatal period and c qn. objective: renal dysfunction has been reported in survivors of neoplastic disease. early diagnosis of renal damage may decrease the morbidity in those with partial or complete remission. we studied the frequency of nephrotoxicity in pediatric patients whose therapy were completed. method: pediatric cancer patients ( f, m) who were at least one year off therapy, enrolled in a prospective cross sectional study from to in oncology department of ali asgar children hospital. demographic data, cumulative dosages of anticancer drugs, history of other nephrotoxic agents, nephrectomy, radiotherapy were recorded. fasting blood and urine samples were collected to calculate fractional excretion of mg, ca, p, upr/ucr, clcr, urine osmolality and blood gas analysis. result: the mean of age was . years. out of patients had lymphoproliferative malignancies (group ) and had solid tumors (group ). the mean of therapy was . month. treatment was discontinued for . month in average. the median of blood ca, p, mg, bicarbonate,and cr were . mg/dl, . mg/dl, . mg/dl, . meq/l and . mg/dl, respectively. the median of fractional excretion of ca was . % this rate was . % for p excretion and . % for mg excretion. clcr was . ml/min/m in median. the medians of urine osmolality was mosmol/kg/h o. the median of urine protein to urine creatinine ratio was . mg/mg. these values were not different between two groups (p> . ) but urine concentration was defective in solid tumors group (p= . ). mild to moderate nephrotoxicity was seen in . % of cases. using binary logistic regression we found no correlated factor (p> . ). conclusion: mild to moderate tubular dysfunction has been observed in survivors of chemotherapy. routine follow-up of renal functions are recommended. the study is to discuss the treatment of hemolytic uremic syndrome (hus) after acute stage. methods: there were children who lived through acute stage of hus then continued treating. besides angiotensin converting enzyme inhibitors (acei) and early restriction of protein intake, the study was to use therapeutic schedule according to clinical classification, response to prednisone and pathological manifestation, which referred to clinical classification diagnosis and treatment of child with glomerulus disease (the program) established by nephrology group in pediatric branch of chinese medical association (cma). results: after months to years follow-up mild type children maintained the normal blood pressure and renal function and urine examination, except for recurrence. in gravis type children maintained the normal blood pressure and renal function and urine examination, another children who manifested as durative abnormality of urine examination developed into end stage renal failure (esrd) and died in the th, th and th month at last. another gravis type children untreated after stage of hus died in the th day to th day of the course. conclusion: it could improve the prognosis of children after acute stage of hus evidently to use therapeutic schedule according to clinical classification, pathological manifestation. objective: to find the prevalence of hematuria in patients with thalassemia major. methods: of total patients with thalassemia major under regular blood transfusion, cases were randomly selected. history was reviewed and physical examination was done. urinalysis was performed in all the patients. in those with hematuria ( or more rbc/hpf) or suspicious to hematuria ( - rbc/hpf) second urinalysis was done at the next transfusion time. more investigations were done in those with persistent hematuria. results: the patients had age range of months to years and male to female ratio was . . hematuria was detected in ( %) and suspicious in patients ( . %). sixty four percent of the patients with hematuria were female and it was persistent in urinalysis in % of cases. in % of the patients with hematuria, blood transfusion was started before the end of first year. in those with hematuria or suspicious to hematuria, % had sterile pyuria and % had proteinuria (these figures were . % and . % respectively, in those without hematuria). hypertension was not detected, but patients had secondary diabetes mellitus. conclusion: hematuria is not uncommon in patients with thalassemia major and is more prevalent in girls and in those with early transfusion. background: it has been widely recognized that cyclosporine a (cya) is a useful immunosuppressive drug in renal transplantation. although it has been also accepted that cya is an effective drug for pediatric nephrotic syndrome in the past two decades, the effective serum concentrations are not revealed. the functional roles of cya has been reported that cya inhibits the production of interleukin (il- ) in vivo and in vitro. aim: in this study, we investigated the correlation of serum concentrations of cya levels with il- levels in pediatric nephrotic syndrome cases. methods: seven children ( boys and girl, mean age . ± . years) with minimal change nephritic syndrome were enrolled in this investigation. cya (mean dose, . ± . mg/kg/day) was administrated in two divided doses before meal with or without administration of predonisolone. blood samples were collected just before, , , and hours after administration of cya. the serum concentrations of cya and il- were measured immediately. results: the peak blood concentrations of serum cya were observed at hour after administration. the concentrations of serum il- levels reduced at hour after administration of cya, and kept the same levels during hours afterwards. the serum concentrations of cya which inhibited more than % of the serum concentrations of il- required ng hr/ml. conclusions: we confirmed that cya inhibited the production of il- in children with nephrotic syndrome. these findings suggest that the necessary serum concentrations of cya to maintain the sufficient suppressive rate were more than ng hr/ml in pediatric nephrotic syndrome. this study aimed to evaluate the circulating angiotensins in female adolescents with type diabetes (dm ) and to compare with the results obtained in healthy age-matched adolescents to disclose possible changes in plasma peptide concentrations that could be related to microalbuminuria and metabolic control. patients were divided as female adolescents with dm (n= ) and adolescent age-matched controls (n= ). diabetic patients were evaluated at our endocrinology center and healthy adolescents were selected from our primary care unit. plasma levels of angiotensin (ang) i, ang ii and ang-( - ) were determined by radioimmunoassay. glycohemoglobin and microalbuminuria were also measured. results were expressed as medians or means and standard deviation. kruskal wallis was used for median comparisons and t-test for means. the level of significance was p< . . adolescent dm patients exhibited high levels of glycohemoglobin ( . ± . %). microalbuminuria was detected in ( %) patients with a disease duration of . ± . years. angiotensin concentrations were significantly increased in dm patients (p< . compared to controls) and ang-( - ) levels were -fold higher than control values. on the other hand, the levels of ang-( - ) in microalbuminuric patients were significantly lower than in non-microalbuminuric diabetic adolescents (p< . ). the comparisons between ratios of ang-( - )/ang i and of ang ii/ang i suggested a predominance of ang ii formation rather than ang-( - ) in microalbuminuric diabetics when compared to normoalbuminuric patients. our results showed an overall increase of angiotensins in a young female diabetic population, and further suggested a pathophysiological role for angiotensin-( - ) in dm . the pediatric nephrologist is often faced with the difficulty of determining adequate iron supplementation in children with chronic kidney disease (ckd). soluble transferrin receptor (stfr) and the stfr to log(ferritin) ratio (stfr-f index) have been proposed as markers of iron deficiency (id) independent of inflammation; however, their relationship with c-reactive protein (crp) and their age dependency have not been established. we therefore embarked on a prospective study of healthy children undergoing minor surgery to determine reference ranges for stfr (dade behring n-latex stfr analyser, dade behring bn prospec) and stfr-f index. we studied the relationship between crp and ferritin, transferrin, stfr and stfr-f index. we also compared the relationship between mean corpuscular volume (mcv) and ferritin, stfr and stfr-f index in children. results: for ages . . , . ) with mcv, which we used as a marker of id in the absence of a non-invasive gold-standard; however, only stfr-f index, but not ferritin, transferrin and stfr, was independent of crp. this study shows that ferritin, transferrin, and stfr, but not stfr-index, are dependent on acute phase reactions. it is therefore hypothesized that stfr-f index provides a more useful marker for monitoring the iron status in ckd patients. conclusions: low osmolality is a crucial factor to facilitate water absorption at least in the rat small intestine, while the absorption of sodium may be influenced by the concentration of sodium and glucose. (definition iccs). standard treatment consisted of general advice on voiding and drinking habits, alarm treatment and occasionally vasopressin. constipation was diagnosed on clinical considerations (history, stool charts, physical examination, occasionally x-ray). all patients received general instructions according to bowel habits. laxatives were prescribed when the patient was diagnosed as constipated. treatment goal was daily bowel movements. treatment results were evaluated months and years after discharge. results: patients were included. mean follow-up was . yrs. overall success rate (full response) was . % ( months) and . % ( years). laxative use: . % (n= ) of the patients received laxatives, % (n= ) did not. in patient information was lost. there was no significant difference in success rate between the laxative group compared with the non-laxative group (p= . , chi-square). treatment modality: . % (n= ) received general advice only without laxatives, all but one had a full response. . % (n= ) were treated with advice and alarm, ( . %) of them received laxatives. response to alarm treatment was . %. no significant difference in success rate between the laxative and non-laxative group (p= . , chi-square). patient was dry after vasopressin and laxatives. conclusion: the majority of patients with mse can achieve nocturnal continence without laxatives. constipation treatment with laxatives may be supportive, but is not essential in the treatment of mse. aim: hypocalcemic tetany is a known complication of plasmapheresis. we studied the changes in ionised and total calcium, and magnesium concentrations during plasmapheresis, with and without supplementing the replacement fluid with calcium and magnesium. methods: plasmapheresis was carried out by using . % human albumin solution (has) with or without supplements for the first % of the exchange, and fresh frozen plasma (ffp) for the last %. we measured ionised and total calcium and total magnesium at the beginning and end of the has, and after minutes of ffp infusion. results: we undertook pairs of plasmapheresis runs with and without supplements in children who had a variety of renal conditions. during the exchange with unsupplemented has, the total calcium fell from . to . mmol/l (ci . - . , p< . ), the ionised calcium fell from . have raised significant problems in minor surgeries. but the developmental mechanism of ponv is not clear until now. previously, we have experienced a case with ihn and ponv who showed extremely high plasma antidiuretic hormone (adh) level at the onset of ihn and that elevated adh level induced by minor surgery was supposed a trigger of ihn and ponv. in this study we investigated various values including plasma adh in cases taking kidney biopsy in order to clarify the mechanism of ihn and ponv. methods: fifteen patients taking percutaneous kidney biopsy were study subjects (mean age . years). plasma adh, serum electrolytes and osmolality were measured before and - hours after kidney biopsy. urine samples were collected to measure electrolytes and osmolality. results: high plasma adh level ( . ± . pg/ml) was observed in out of subjects ( %). serum sodium level dropped significantly in these cases. six of cases showed ponv, we divided all cases into groups: ponv group and non-ponv group. the result was that plasma adh level was significantly high in ponv group. conclusion: our study make it clear that elevated plasma adh level is frequently seen in children taking kidney biopsy and suggest that hydration with hypotonic saline solution after surgery is inappropriate because of the risk of developing ihn. it also become clear that high plasma adh level might lead to ponv as the same mechanism seen in motion sickness. it is suggested that adh secretion by stress after minor surgery is associated with not only ihn but also the onset mechanism of ponv. polyarteritis nodosa (pan) occurs more commonly in patients with familial mediterranean fever (fmf) and visceral hematomas are seen in almost half of the patients. we report here a year-old girl with pan and fmf presented with multiple visceral hematomas. the patient was on colchicine therapy for four years because of fmf but uncompliant to therapy. she addmitted with the complaints of fever, malaise, abdominal pain and artralgia lasting for two months. she was pale and extremely cachectic with atrophic muscles of extremities. she had fever, hypertension, hepatosplenomegaly and arthritis. she had anemia with normal renal and hepatic function tests, albumin levels, and electrolytes. multiple hypoechogenic mass lesions were detected on liver and bilateral kidneys on ultrasonography and computerised tomography and diagnosed to be hematomas by laparascopic examination. urinalysis, hematological tests for bleeding and blood marrow examinations were normal. bacterial cultures and serological tests did not reveal any infectious agent. serum complement levels were normal with negative antinuclear antibody, anti-dna, p and c antineutrophil cytoplasmic antibodies. renal angiography showed multiple aneurysms in bilateral renal arteries leading to the diagnosis of pan. she was successfully treated with intravenous pulse methylprednisolone followed by oral perdnisolone and oral cyclophosphamide together with colchicine and antihypertensive agents. she has been followed up for four years without any complaints and normal laboratory and radiological findings except multiple scar formations on kidneys on dmsa-renal scanning. results: the stone-free rate was % after one eswl session. the above rate increased to % and % after the second and the third session respectively. regarding surgical treatment with pcnl, the overall stone-free rate was %. in children initially treated with pcnl, an eswl session was performed later successfully, for residual calculi. open surgical removal was required in children with structural anomalies. the patients with staghorn calculi underwent nephrolithotomy combined with eswl in cases of residual fragments. patients underwent ureterscopic procedures to address ureteral stones and complete fragment removal was obtained. no major sideeffect were observed, during the above procedures. conclusions: it seems that the advances in instrument technology provide a variety of safe and effective methods in the management of paediatric urolithiasis. the incidence of open surgery has thus fallen. minimally invasive methods must form the first choice of treatment, while open surgery should be undertaken mainly in cases of coexisting congenital abnormalities. in all children the following parameters were estimated: a) timetable of ne, b) feeling/volume chart (frequency and biggest quantity of urination=functional capacity of bladder), c) ultrasound of urinary tract (size of kidneys, bladder capacity, bladder wall thickness, postvoiding residual urine) and d) urodynamic parameters (uroflowmetry and water cytometry). the ud bladder parameters were then correlated with the us and voiding diary findings. results: all children had sufficient data registered to allow reliable analysis. ud studies showed that children with mild pne had normal urodynamics findings, us parameters and voiding diary findings as well. ud studies reveal a relatively high incidence of instability in children with moderate and mainly in those with serious ne. conclusions: in children with pne, urodynamics did not have a significant additional value compared to baseline diagnostics and it should be avoided. on the contrary, findings from urodynamic studies in children with serious ne show that it has a useful role in this type of enuresis evaluation and management. objectives of study: hyperlipidemia, especially when started during early childhood will increase the risk of atherosclerosis. it is also a major risk factor for allograft nephropathy and post-transplant hyperlipidemia, so its diagnosis and treatment is highly suggested. in this study we have evaluated the effect of hemodialysis on the lipid profile of children with end stage renal disease (esrd). methods: twenty-two children with esrd who were on maintenance hemodialysis in shiraz pediatric hemodialysis unit were studied. they were asked not to take greater than % of their total daily calories as fat at least month before sampling. after a -hour overnight fasting and before starting dialysis, blood samples were taken for lipid profiles. for each patient with total cholesterol, tg or ldl-c levels more than th percentile for age and gender or hdl-c level less than mg/dl, was defined as dyslipidemia. results: nineteen out of children ( . %) had abnormal lipid profiles. atherogenic factor of tg/hdl-c ratio more than as a major risk factor for cardiovascular disease was in %. conclusion: dyslipidemia is common in hemodialysed children. so, hemodialysis set-up change and antilipimic medication, and replacement of l-carnitinine is recommended for correction of dyslipidemia in this group of patients. objectives of study: bipolar renal length measurement is an integral part of the assessment of urinary tract in childhood, and is routinely performed on ultrasonography and renal scintigraphy investigation. correlation between kidney size measurement on ultrasonography and dimercaptosuccinic acid (dmsa) scintigraphy is not well recognized. the purpose of this study was to comparison renal size measured by dmsa scintigraphy and ultrasonography to find if there is acceptable agreement between renal lengths by these two methods. methods: as cross sectional retrospective study, patients enrol in this study and their dmsa scan results and kidney ultrasonography reports compared. the agreement between renal size measured by two methods for left and right kidneys were evaluated separately using bland-altman plot. pearson's correlation coefficient was used to examine their correlation. statistical significance was calculated by paired-student t-test. the same tests were used to for kidneys with normal dmsa scans. results: correlation coefficient showed close correlation between kidney length measured by ultrasound and dmsa scan, but there were significant differences between two methods (paired t-test, p< . ). comparison between renal size measured by ultrasonography and dmsa scan using the methods of bland & altman plot in all patients and the group with normal kidneys showed a systematic bias of about + . mm for left and + . mm for right kidneys. conclusion: despite of close correlation between dmsa scan and ultrasonography for kidney length measurement; kidney size is overestimated by about percent in dmsa scan study and this matter must be considered in practice. medical treatment of cystinuria is often considered disappointing. patients undergo frequent surgery which is often followed by early relapse. the aim of our study was to prospectively evaluate, in a paediatric population, the efficacy of a conservative medical approach for long-term treatment of cystinuria, to prevent the formation of new renal stones and reduce the number and dimension of pre-existing stones. twenty-one stone former cystinuric patients were treated with a combined approach which included cystine-binding drugs. free and bound urine cystine levels were routinely measured every four months. drug dosage was adjusted in order to maintain a steady free urine cystine level below mmol/mmol creatinine (a three fold increase of normal level). in the patients who completed the study, renal stone episodes were reduced from . to . episodes/year, and in several patients the number and dimension of pre-existing renal stones were reduced. during the entire follow-up, percutaneous lithotripsy to remove an obstructive stone was required in only one subject. no relapse was observed months after treatment. the dosage required to achieve target levels was very closely correlated to patient body weight: older children required a lower dose to achieve target levels. in conclusion: medical management of cystinuria is feasible. the treatment must be personalised, at least in pediatric age. the amount of required drug is strictly depending from body size. it is mandatory to obtain a low free urine cystine level before any invasive procedure to reduce the risk of early relapse. objective: to study the pathophysiology of nutcracker syndrome (ns) and to assess the role of the upright position imaging and superior mesenteric artery (sma) angle measurement in the diagnosis. methods: doppler us findings in children with ns and in healthy control subjects were compared. the mesenteric angle, peak velocity (pv) and anteroposterior (ap) diameter of the left renal vein (lrv) at the hilar and aortomesenteric portions were measured in both the supine and upright positions. the means ±sd of the sma angle, ap diameter and pv ratio between the two portions were calculated and cut-off levels for the diagnosis of ns were established. results: the diameter and pv ratios were significantly different between the patient and control groups both in the supine and upright positions (p< . ). differences (d) between the supine and upright positions were also significant for the diameter of the lrv at the aortomesenteric portion, diameter ratio and sma angle in both groups. upright position imaging revealed comparatively narrower sma angles and more pronounced entrapment findings in patients with ns. the sma angle measurement had a sensitivity of . % and a specificity of . % in the supine position and . % and . % in the upright position when the cut-off values were set to less than ° and °, respectively. the upright position has significant effects on the lrv hemodynamics and angle of sma both in patients and healthy subjects. sma angle measurement may be a useful adjunct parameter in the diagnosis of ns. ). in addition, a statistically higher rate of pathological abnormalities on renal biopsy was noted in the group with microscopic hematuria combined with proteinuria and also in cases with more severe hematuria. conclusions: school urinary mass screening has greatly contributed to diagnosing chronic renal diseases. continuous medical observation is required when abnormal urinalysis is observed, and a more aggressive medical approach such as renal biopsy should also be performed if necessary. this study compared the outcome of children with proliferative ln (who class iii/iv) using a new protocol comprising pulse intravenous methylprednisolone, mmf +/-cyclosporine, with standard prednisolone and cyclophosphamide/azathioprine. method: twenty-three children with proliferative ln (age range at diagnosis . - . years) who were followed up for . - . (range . - . ) years, were included in this retrospective study. group i (n= ) received prednisolone with cyclophosphamide and/or azathioprine. group ii (n= ) received the combined mmf protocol with mmf dose of mg/m /day. poor outcome was defined as death or chronic renal failure. survival analysis was performed using the log-rank test. effect of treatment on growth at last follow-up was assessed using height standard deviation score (htsds). differences between the groups were analyzed using the mann-whitney and fisher's exact test. results: at last follow-up, significantly more group i compared to group ii patients had higher serological activity as defined by low serum complement c ( % vs % respectively, p= . ). in addition, -year actuarial survival was higher in group ii ( %) compared to group i ( %). all the group ii patients achieved complete remission of proteinuria compared to group i ( . ± . vs . ± . g/d/ . m respectively, p= . ). group ii patients also had lower htsds on long-term follow-up compared to group i (- . ± . vs - . ± . respectively, p= . ). conclusion: combination immunosuppressive protocol involving mmf +/-cyclosporine resulted in better renal outcome in children with proliferative ln without compromising on growth. this regimen allowed steroid tapering to alternate day dosing without increasing lupus activity. background: a full dose of corticosteroid is required to induce complete remission (cr) in steroidsensitive nephrotic syndrome (ssns), unless it is possible to taper and discontinue along with the course after cr. however, the mechanism of this change in steroid sensitivity remains unknown. p-glycoprotein (pgp) has a function to eliminate given corticosteroids from cytoplasm, which results in inducing corticosteroid resistance. therefore, we analyzed a drug delivery perspective using the real-time polymerase chain reaction (pcr) of multiple drug-resistant gene (mdr ; encoding pgp) messenger rna (mrna) expression. patients and methods: fourteen patients with steroid-sensitive nephrotic syndrome (ssns; male/ female: / , age: - years old; mean . ) were enrolled in this study. mdr mrna gene expression of peripheral blood nucleated cells (pbnc), before and after cr (a total of nineteen sets of blood samples), were quantified using real-time pcr and then carried for analysis. results: the mdr mrna levels before cr were variable in each patient. however, there was an apparent decrease in the mdr gene expression of pbnc after cr (p< . ). the results suggest that pgp may play a role in the ability to taper corticosteroids after cr in ssns. : week prednisone mg/m /day + weeks mg/m every other day). all other patients (b) received daily prednisone . - mg/kg/day for weeks and - % of initial dose for week, followed by alternate day steroids ( week) with tapering by . mg every - weeks down to . - mg. "frequent relapses" (less than months after discontinuation of initial steroid therapy or of first relapse therapy) were treated with chlorambucil . - . mg/kg/day for weeks and half of this dose for - months. results: seven patients (with long treatment) were lost to follow-up and were studied. six of ( %) of a had a relapse . ± . months after the end of initial therapy; became infrequent and frequent relapsers. of ( %) of b relapsed . ± . months after the end of initial therapy; became infrequent and frequent relapsers. frequent relapsers ( % in a and % in b) were treated with chlorambucil and all but one achieved long remission (> year). conclusions: first relapse occurred later after onset of ssns in patients with long ( weeks) as compared to short ( weeks) initial steroid therapy but the time interval between the end of initial therapy and the first relapse and the proportion of relapsers were similar. longer initial therapy may result in a lower number of frequent relapsers. nearly all patients had long remissions periods that were, however, achieved at the expense of early administration of chlorambucil. conclusions: the medium age of pts with metabolic stones was found to be higher than the medium age of pts with infectious stones. the familial occurrence of kidney stones was found to be important %. the ultrasonographic examination is the most important one. the stones composed by calcium oxalate and calcium phosphate were found to have the highest percentage. metabolic abnormalities were found in % of patients and hypercalciuria was the most common disorder. hypocitraturia is considered to be a risk factor the calcium stones. in an attempt to explore the new treatment for the childhood-onset intractable steroid-dependent nephrotic syndrome (sdns), we have recently performed the treatment with high-dose mizoribine (mzr), the inhibitor of inosine monophosphate dehydrogenase, and suplatast tosilate dimethylsulfonium std), a selective th cytokine inhibitor, which were both made in japan. mzr has been commonly used for the treatment of frequently relapsing sdns in japan at a dose of - mg/kg/day (maximally mg/day) divided into two doses (kidney int : , ). we used high-dose mzr (mean: . mg/kg/day) once before morning meal for adolescent patients with frequently relapsing sdns who had been treated with long-term cyclosporine (csa) resulted in moderate to severe csa nephropathy. with this treatment for years, seven out of patients weaned off csa and experienced less relapses without apparent adverse effects by high-dose mzr. std is a both il- and il- inhibitor and commonly used for childhood asthma. we used std at a dose which is for the treatment of asthma for children with sdns (mean . years) without previous csa treatment. after one year follow-up with std treatment, the relapse rate of nephrosis was decreased from . ± . to . ± . per year (p= . by wilcoxon signed-ranks test), where as the dosage of orally given predonisolone was also decreased from . ± . to . ± . mg/kg/day (p= . by wilcoxon signed-ranks test). objectives of study: to evaluate the efficacy and safety of long-term cya treatment for pediatric sle patients. pediatric sle patients in their teens suffer from many relapses and severe side effects caused by steroid and cyclophosphamide. there have hardly been any reports on the long-term cya treatment in children. methods: we retrospectively compiled cases of childhood-onset sle female patients (mean: . years) admitted to our department from to . the initial treatment was methylprednisolone pulse therapy followed by prednisolone (psl). at the onset, patients had class lupus nephritis and showed class . after several relapses, cya was added and used for to months. the dose of cya ranged from . to . mg/kg/day, and the target trough level from to ng/ml. results: under this low-dose cya treatment, patients had no relapse while had a relapse after months. in all patients, psl was reduced to alternate day treatment (mean: . mg/ days), and patients under years gained the target height. of all patients, developed hypertrichosis, gingival hyperplasia, transient elevation of s-cr with acute gastro-enteritis. although case had elevated s-cr after months of cya treatment, it returned to normal level within months after the cessation of cya. five patients had second biopsy after years, and showed mild tubulointerstitial (t-i) changes. two had third biopsy after years and both showed mild t-i changes only. the presence of t-i changes had no relation to s-cr, u-beta mg and u-nag. conclusion: low-dose cya treatment might be an effective and safe second line treatment for sle patients with many relapses in teens. it is also important to perform renal biopsy periodically to detect cya-induced renal damage which hardly shows any abnormalities in blood or urinary tests. hypersensitivity to inulin is rare; two cases of food allergy and some cases of allergy after inulin infusion have been reported. an -year-old boy suffering from severe iga nephropathy (igan) is reported with both anaphylactic reaction and concomitant relapse of his nephropathy due to inulin infusion, used for measuring gfr years after first symptoms. pruritus, sibilants and cough were observed during a first renal function test. prick and intradermal tests were negative for inulin. the patient presented with pallor and asthenia during a second inulin infusion performed under dexchlorpheniramin, leading to immediate infusion stop. he was read mitted because of fatigue and nausea; acute renal failure was diagnosed days after inulin infusion. a drug-induced acute interstitial nephritis was first suspected. however, due to the presence of macroscopic hematuria and proteinuria, a renal biopsy was performed and showed acute proliferative relapse of igan. few data are available about inulin-induced hypersensitivity. chandra described anaphylaxis and cardiorespiratory arrest immediately after administration of sinistrin. a retrospective study of all recorded cases of hypersensitivity associated with renal function tests was performed by our pharmacovigilance unit. , tests using inulin clearance were realized both in adults and children; patients experienced side effects which were divided into groups: respiratory symptoms, rash and general signs. most side effects were minor and no life threatening complication occurred. the underlying mechanism of inulin hypersensitivity is not well known. although % of patients with inulin-associated hypersensitivity underwent a first renal function test, we can speculate that presensitization with food inulin may occur, sometimes leading to severe problems such as in our patient with iga-mediated immunological dysregulation. . we have previously demonstrated a composite heterozygous nphs mutation of both v x and r h in a chinese patient with srns. however, it is not clear the molecular mechanisms of mutant podocinlead to proteinuria. some evidences proved the possible interaction between podocin and trpc . this study explored the effects of mutant podocin on the free cytosolic ca + and apoptosis of podocyte in order to clarify the possible causative mechanism of mutant podocin. methods: . the pdsred n -wild/mutant podocin was constructed by using site-directed mutagenesis. . mouse podocyte clone was cultured and transfected with pdsred n -wild/mutant podocin. . free cytosolic ca + was measured using the fluorescent indicator, fluo -am. results: the low level of free cytosolic ca + was detected in normal podocyte and the transfected podocytes with r h mutant podocin. the v x mutant podocin increased the free cytosolic ca +more evidently than the over-express podocin in transfected podocytes. podocyte apoptosis were not detected in the blank-vector (just pcdna . ) transfected podocytes and normal podocyte. the v x and r h mutant podocin increased the podocyte apoptosis more evidently than the over-express podocin in transfected podocytes. conclusions: the v x mutant podocin might induce podocyte apoptosis via the increment of free cytosolic ca +. however, whether the increment of free cytosolic ca + is induced by trpc and the involved signal pathway should be further investigated. y. xing, q. fan, j. ding objectives of study: podocytes slit diaphragm (sd) associated molecules (nephrin, podocin and cd ap) play a critical role on maintaining the integrity of glomerular filter. vegf is produced by podocyte, and acts on endothelium and podocyte itself. but, it is not clear whether there are some relationships between vegf and sd associated molecules. our study detected the expression of sd associated molecules and vegf in adriamycin (adr) nephrotic rats. methods: the adr rat was established by adr injection. distributions of sd molecules and vegf were detected by immunochemistry. the mrna and protein of sd molecules and vegf was examined by real-time pcr and western, respectively. nephrin phosphorylation were detected by immunoprecipitation. results: distribution of nephrin, podocin and cd ap changed evidently, and the staining intensity of vegf decreased evidently. nephrin mrna increased at day , and returned to the normal at day and ; podocin and cd ap mrna constantly increased from day until day . the protein of nephrin increased at day until day ; podocin was dramatically upregulated at day , and thereafter recovered again, but was downregulated at day ; cd ap prominently increased at day and day . tyrosine phosphorylation of nephrin was decreased evidently at day , and vegf mrna did not show significantly changes at any time points observed. however, vegf protein reduced significantly from the th day, and also reduced evidently at days and days . conclusion: the abnormality of nephrin, podocin and cd ap may be one of the mechanisms that lead to proteinuria in adr-induced nephrotic rats. the occurrence of proteinuria in adr rats may be also associated with the reduced vegf protein, which may be related with the reduction of nephrin phosphorylation. these results suggested there may be some relationship between vegf and sd molecules. the objectives of study: mutations in genes encoding structural proteins of slit diaphragm can lead to nephritic syndrome. just recently, another gene trpc mutation was identified in autosomal dominant fsgs. trpc encodes ion channel protein trpc , whose expression has not been clarified completely in kidney. this study aims to explore the expression and distribution of trpc in normal human, mouse and rat renal tissue and the mouse podocyte clone (mpc ). methods: distributions of trpc in normal human, mouse and rat renal tissue and cultured podocyte was observed with immunochemistry staining. the mrna expression of trpc , , , , and was detected by using rt-pcr. the protein expression of trpc in human, mouse and rat renal cortex and differentiated mpc was detected with western. results: trpc showed weak staining in glomeruli and strong in renal tubules and vessels in human kidney, however, strong in glomeruli and was mainly distributed along the capillary loops and mesangium in mouse and rat kidney. the staining of trpc was observed in differentiated mpc , which is distributed evenly on the cell membrane. the specific pcr band of trpc , , , , and was detected in mouse kidney and differentiated mpc . the sequence of the amplified pcr products is same as that published in genebank. the specific kda protein band of trpc was detected in normal human, mouse renal cortex and differentiated mpc . conclusion: the expression of trpc was verified in normal human, mouse and rat kidneys and in differentiated mpc . these results will benefit for further screening the possible mutation of trpc in acquired nephrotic syndrome, and investigating the relationship between trpc and the proteinuria-related podocyte molecules. methods: twenty children with kd ( boys and girls, aged from to months) were enrolled in our study. kidney sizes (including kidney length and kidney volume) were measured during acute stage in these patients. twenty age-and sex-matched healthy children and febrile children served as healthy controls and fever controls. left kidney length and age were used for correlation analysis and analysis of covariance. results: kidney lengths in patients with kd were significantly larger than those of healthy children (p< . ). the mean sd score of kidney length was . ± . for these patients (p< . , vs - . ± . in normal control). kidney volume analysis yields the similar result ( . ± . cm vs . ± . cm , p= . ). there was no kidney enlargement in the fever controls. up to % of the children with kd have absolute nephromegaly (>mean+ sd). this incidence is as frequent as that of lymphadenopathy and extremities change, the diagnostic criteria of kd. conclusion: these results confirm the presence of large kidneys in the children with kd and also provide another useful indicator for kd diagnosis if the diagnostic criteria is not yet well established. during renal inflammation macrophages infiltrate the renal parenchyma, and their number correlates with the intensity of inflammation. macrophage migration inhibitory factor (mif) was described originally to be a product of t-cells and macrophages. mif plays an important role in renal tissue injury. to our knowledge, the studies that assessed the role of macrophages in acute renal infection were few and the role of mif was not evaluated. the aim of this study was to assess mif in uti and compare the urinary excretion of mif in pyelonephritis, cyctitis and also control group to find a non-invasive and sensitive method to differentiate them. in this prospective case-control study pediatric patients with uti ( patients with acute pyelonephritis, patients with acute cystitis) and healthy children were recruited. urine mif concentration was quantitated by elisa and corrected for urine creatinine. the mean ratios of urine mif/cr were calculated as . (sem= . ) pg/μmol creatinine in acute pyelonephritis, . (sem= . ) in acute cystitis and . (sem= . ) in healthy individuals. urine mif/cr ratio was significantly higher in pyelonephritis than the ones in acute cystitis (p= . ) and control (p= . ). roc analysis was demonstrated that urine mif/cr ratio could considered potentially useful index to detect acute pyelonephritis [p= . , area under curve (auc)= . ]. the optimal cut-point of . pg/μmol creatinine for urine mif/cr ratio could potentially separates acute pyelonephritis patients from healthy individuals (sensitivity and specificity of % and . %, respectively). the underlying histopathological characteristics in biopsied renal diseases are of great importance in determining the long-term prognosis and provides useful information in clinical practice. ethnicity seems to play a critical role in the epidemiology of biopsied renal diseases the aim of this study is to provide data of clinical manifestations of biopsy-proven native renal diseases in iranian children. in this retrospective study, iranian children who were diagnosed as renal disease between and january , were evaluated. diffuse and focal mesangial proliferative glomerulonephritis was present in . % of all biopsies performed. mpgn, fsgs and mcd were observed in . %, . % and . % the most common clinical syndrome at any age is nephrotic syndrome ( . %), followed by nephritic syndrome ( . %), nephrotic-nephritic syndrome ( . %), recurrent macroscopic hematuria ( . %), asymptomatic urine abnormalities (aua) ( . %) and azotemia was seen in . % of patients. mesangial proliferatiove gn ( / = . %), poststreptococal gn ( / = . %) are the most frequent pathologies with acute nephritic syndrome presentation. the most frequent causes of aua were mesangial proliferative gn and hsp. thrombotic microangiopathy (hus) was the most prevalent cause of arf. inthis study, chronic tubulo interstitial nephritis ( . %) and alport ( . %) were the most common causes of crf presentation in our patients. in conclusion, mpgn remains the most common histopathological subtype in children with renal biopsied disease. the incidence of fsgs continues to be high in iranian children. the aim of this study is to assess postnatal kidney volume development and to compare the intrauterine and extrauterine kidney growth curves in premature infants. one hundred neonates were enrolled in this study. all infants had their kidney volumes measured by renal ultrasound examination. group ga consisted of neonates whom were evaluated within hours after birth, and their gestational ages were used in the analysis. group ca included premature infants born before weeks of gestation and was evaluated - days after birth, and their conceptional ages were used in the analysis. left kidney volume, body weight, body height and age were used in the correlation analysis. kidney volumes in group ca infants were significantly larger before weeks of age, but smaller after weeks of age than those of group ga infants (p= . ). there was a significantly better growth in body weight (p= . ) and body height (p< . ) in group ga infants. however, a larger kidney volume was noted in group ca infants with the same body weight (p< . ). conclusion: chart of postnatal growth of normal kidney volume before weeks of conceptional age in premature infants is presented. our data suggests that intrauterine growth may have a regulatory influence on kidney growth, and the reduced kidney volume in the premature infants may start from the early extrauterine period. objectives of study: to illuminate the role of prohibitin (phb), a tumor suppressor which inhibit cell proliferation by repressing e f-mediated transcription, in tubulointerstitial fibrosis (tif). methods: renal biopsy specimens were obtained from children with primary glomerulonephritis. phb and α-sma proteins expression were detected by immunohistochemistry. subcellular location of phb in nrk- f was detected by confocal microscope. changes of phb protein and mrna expression in cells upon tgf-β stimulation were detected. after transfected with phb plasmid, cell cycle and α-sma protein and mrna expression in cells treated with or without tgf-β were detected. results: phb protein was found at normal renal tissues, with a positive distribution in interstitial cells and tubular epithelial cells. phb was down-regulated in tissues with tif and negatively correlated with tif degrees (p< . ). phb is majority located at cytoplasm as well as at nucleus in nrk- f. phb protein and mrna expression in cells were decreased when treated with tgf-β , and the effects were both time-dependent and dose-dependent. extraneous phb inhibited cells proliferation induced by tgf-β , and phb over-expressing cells failed to enter the cell cycle compared with non-transfected cells (p< . ). α-sma was not expressed in control cells while de novo expression of α-sma in cells upon tgf-β stimulation was increased. overexpression of phb did not affect basic α-sma expression but dramatically repressed tgf-β -initiated α-sma expression (p< . ). conclusions: extraneous phb suppresses renal interstitial fibroblasts proliferation and cell phenotypic change induced by tgf-β , which indicates phb as a potential target to halt tif progression. results: the prevalence of urine abnormalities of first screening was over . %, and that of the second screening was about . %. the prevalence was different with various methods. the specificity of method b was higher than method a. testing two urine samples for each child had higher specificity. the direct cost of method a and b was - . and - . rmb, respectively. for screening twice, the corresponding cost was no more than - . and - . rmb, respectively. using method a to screen twice for each child was convenient and economical, which also reduced the false positive rate effectively. the prevalence of urine abnormalities of junior highschool children was significantly higher than that of elementary school-children in xh and the peak point was seen at the point of years old. however, there was no significant difference between children in ja and yp. more than months of follow-up diagnosed cases of iga nephropathy. conclusions: urine abnormalities of school-children could be detected through urine screening at school. for shanghai, method a with screening twice was convenient, economical, and could reduce the false positive rate effectively. objectives: angiopoietin-like protein (angptl ) is involved in lipid metabolism and angiogenesis. the present study was to examine angptl expression in human kidneys with proteiuria, in adramycin rats (adr), and in puromycin induced podocyte damage. methods: immunohistochemistry was performed on kidney biopsies from children with mcd, mn, fsgs, tbmn. in adr, angptl expression was determined by quantitative real-time rt-pcr in glomeruli and tubuli dissected from frozen section of kidneys with laser microdissection system. in mpc , a conditionally immortalized mouse podocyte cell line in vitro, angptl , perlecan and agrin were detected through real-time pcr with the induction of puromycin. detachment assay was performed in podocytes tranfected by angptl -pcdna . . results: in human kidneys, co-labeling showed angptl expressed in the cytosol of wt positive cells. quantitative computerized analysis showed that angptl in glomeruli in mcd and mn were significantly higher than that of tbmn, fsgs respectively (p< . ). in adr, angptl in glomeruli increased significantly at st or th day (p< . ) after adriamycin injection compared with control. and the expression of angptl in glomeruli was correlated with h urinary protein (r= . , p< . ). in mpc both protein and mrna expression of angptl on podocytes were up-regulated with the induction of puromycin. in podocytes transfected by angptl -pcdna . the expression of perlecan or agrin increased significantly compared with control (p< . ). the attachment ratio was shown . %± . % hs after puromycin treatment on podocytes transfected by angptl compared with . %± . % on normal podocytes, and . %± . % on untransfected podocytes. conclusions: angptl is predominantly expressed in podocytes which could be involved in podocyte damage and the development of proteiuria. ( ), iv ( ) and iii ( ), respectively. only one patient had microhematuria. we found that of them had a very low c serum levels. clq and c deposits were all strong positive in renal tissues. our findings suggest that biopsy should be strongly considered in this patient population. the significant renal involvement (class iii, iv, or v ln) could be found in sle patients with very lower proteinuria with or without hematuria. patients in bfb group received computer-assisted biofeedback program while those in ddavp group took minin. both therapies were carried out for month and then months follow-up was taken. parameters of follow-up included enuresis diary-urine flow rate and aqp in urine. results: pne patients were recruited ( boys, and girls), whose mean age was ( . ± . ) years. at the end of treatment and three months later, total effective rates in bfb group were significantly higher than those in ddavp group. uroflowmetry findings showed that in bfb group maximum flow rate, voided volume and ratio of coordinative detrusor-sphincter contraction increased after treatment. ratio of normal flow curve increased at second follow-up (p< . ). in ddavp group voided volume and voiding time decreased after treatment. ratio of normal flow curve and coordinative detrusor-sphincter contraction had no change after treatment. two bands of aqp ( and ) were detected in the morning urine. density of patients bands was significantly lower than that of the controls. density of bands in ddavp group after treatment were significantly higher than that before, but there was no difference between datas before and after treatment in bfb group. conclusions: bfb and ddavp are both effective therapies for pne in children. bfb is helpful in correcting voiding dysfunction and ddavp can increase aqp protein in the urine. with higher effective rate within four month, bfb is strongly recommended. objective: to describe the clinical course of non-parasitic chyluria in a thai pediatric case. this is the first report in children. results: the -year-old boy presented milky urine lasting for one year. urine tests showed heavy proteinuria (protein to creatinine ratio . mg/mg), lipiduria (triglyceride mg/dl). the proof of a pronounced hypertriglyceriduria led to the diagnosis of chyluria. his renal function was normal. numerous red cells and lymphocytes were observed in the urine, and postprandial cystoscopy revealed milky cloudy urine emanating from right ureteral orifices. retrograde pyelography demonstrated pyelolymphatic backflow. serum immunoglobulin g for wuchereria bancrofti and circulating filarial antigen in the peripheral blood were negative. chest x-ray, abdomen computed tomography and intravenous urography did not demonstrate abnormal mass or malformation. proteinuria and lipiduria ceased before sixth week of a medium-chain triglyceride-rich diet. there was no recurrent chyluria after weeks of mct-rich diet were completed. conclusion: in non-parasitic chyluria with unknown etiology, the low-fat diet with mct supplementation alone is effective. the prognosis is excellent. there was a significant improvement of waz comparing data at admission and at the end of follow-up (p< . ). there was also a significant improvement of whz comparing data at admission and at the end of follow-up (p= . ). only ( . %) patients presented with a whz less than - . at the end of the follow-up. conclusion: children with primary vur presented an improvement in somatic growth with medical management. objective: the aim of this study is to investigate the clinical practical value of using doppler ultrasound to detect renal blood flow in renal parenchymatous diseases of children. methods: the renal arteries, segmental arteries and interlobar arteries were detected by doppler ultrasound. the parameters were peak systolic velocity (vmax), minimum velocity in diastole period (vmin), vmax/vmin (s/d), resistive index (ri) and pulsatility index (pi). there were cases of healthy children, cases of acute poststreptococcal glomerulonephrits, cases of primary nephrotic syndrome and cases of chronic renal failure. results: the doppler renal blood flow in normal school children was high velocity and low resistant type. typical cases of acute nephritis with edema and oliguria appeared low velocity and high resistant type, ri, pi and s/d of all renal arteries were significantly increased, vmin are significantly decreased (p< . ). after to weeks all parameters returned to normal. during edema period and convalescence, the renal blood flow of primary nephrotic syndrome is low resistant type, ri, pi and s/d of segmental arteries and interlobararteries were significantly decreased (p< . ). the feature of low circulating blood capacity was not alleviated even though edema was vanished and urine output was increased. the doppler in chronic renal failure was high resistant and low velocity type. ri, pi and s/d were all significantly increased, vmin were significantly decreased (p< . ). when ri was great than . , the extent of damage in kidney function was serious and the prognosis was bad. conclusion: renal blood flow provided a new non-invasive method for clinic diagnosis and evaluation of the prognosis in children renal parenchymatous diseases. we concluded that the dms is an important cause of congenital nephrotic syndrome. the outcome of our patients was poor and most of our patients died before years old. objectives: the antiphospholipid syndrome is defined by the association of arterial/venous thromboses or obstetrical fetal loss with the presence of antiphospholipid antibody. this syndrome may be primary or secondary, particularly in association with systemic lupus erythematous. this study is to examine the frequency of anticardiolipin antibodies and the association between anticardiolipin antibodies with some symptoms in children with lupus nephritis. methodology: twenty-five children with lupus nephritis from / to / in department of nephrology, children's hospital o were included in the study. we find the relationship between anticardiolipin antibodies with hematologic and renal involvement. results: anticardiolipin antibodies was positive in patients ( %), for anticardiolipin igm antibody ( %), for anticardiolipin igg antibody ( %). there was a positive correlation between the presence of anticardiolipin antibodies and thrombocytopenia. in patients with positive anticardiolipin antibodies, patients had mta on renal biopsy. conclusion: anticardiolipin antibodies are associated with thrombocytopenia and mta. aim: the methodologies for quantitating urinary calcium excretion have not been standardized. the aim of this study was to compare urinary calcium/osmolality (uca/osm) ratio with calcium/creatinine (uca/cr) ratio and to assess the correlation of both ratios with daily urinary calcium excretion for the diagnosis of hypercalciuria in children. patients and methods: children aged - years (mean . ± . years) were included in the study. they were randomly selected from previous study's larger patient population. non-fasting, second morning urine samples were collected from all children. children were divided into two main groups: ) children with uca/cr < . (mg/mg) and ) children with uca/cr < . . -hour urine samples were collected from the second group, who were further divided into two subgroups: a) children with daily calcium excretion < mg/kg/day and b) hypercalciuric children (daily calcium excretion > mg/kg/day). results: mean uca/osm ratio was significantly lower in the first ( ) group than the second ( ) group ( . ± . vs . ± . mg/l/mosm/kg, p< . ); but there was no difference between a and b subgroups. the correlations of both uca/osm and uca/cr ratios with -hour calcium excretion were poor (r= . for both). conclusion: uca/osm ratio correlated with spot uca/cr ratio. but its superiority on uca/cr ratio in the diagnosis of hypercalciuria could not be shown. interestingly, values of -hour calcium excretion as a definite diagnosis test of hypercalciuria; did not correlate mathematically with those ratios of hypercalciuric or non-hypercalciuric children. using uca/osm ratio as a screening test would not separate hypercalciuric children. background: microalbuminuria is a biomarker of renal damage. the presence of microalbuminuria in patients with a solitary kidney has been described, but the pathophysiology leading to its occurrence is poorly understood. it is postulated that microalbuminuria is the early result of hyperfiltration. methods: we concomitantly measured inulin clearance, filtration fraction (ff) and microalbuminuria in children with a single kidney. correlation between the occurrence of microalbuminuria and a high filtration fraction was done. microalbuminuria was defined as an albumin/creatinine ratio (acr) > g/mol for boys and girls. normal filtration fraction was defined as < %, and normal inulin clearance as > ml/min x . m . during the same study, we also measured microalbuminuria in children with severe grade iii to v vesico-ureteral reflux (vur). results: children with a single kidney were evaluated. patients ( %) had a normal ff, and only one ( %) in that group had an abnormal acr. patients ( %) had elevated ff, and ( %) had an abnormal acr. the presence of an abnormal acr was highly correlated with an abnormal ff (p= . ). the mean gfr between the groups with normal or abnormal microalbuminuria did not differ significantly ( ± ml/min x . m vs. ± ml/min x . m , respectively). there was no significant association between microalbuminuria and a high ff in patients with severe reflux (p= . ). discussion: we found the presence of microalbuminuria to be significantly associated with an elevated ff in children with a single kidney. this finding goes in line with the pathophysiology of a reduced nephron mass, leading to hyperfiltration, and ultimately to glomerular sclerosis. the benefit of renin-angiotensin-aldosterone blockade in these patients remains to be proven. chyluria is the excretion of chyle from the urinary tract and indicates the presence of an abnormal communication between intestinal lymphatics and the urinary tract. it can be of parasitic or nonparasitic etiology. southern brazil is not an endemic region for filariasis. aim: report a case of a -yrs caucasian adolescent girl referred to our out-patient clinic. history: yrs before, she started to pass milky urine with white clots. no edema. normal blood pressure. she was investigated in another hospital and underwent a renal biopsy, that was normal. a diagnosis of nephrotic syndrome was made. she was treated initially with steroids and after changed to cyclosporin, lisinopril and simvastatin. conclusion: chyluria, although a rare conditione specially in children and adolescent in nonendemic areas, should beconsidered in the differential diagnosis of nephrotic syndrome. macroscopic examination of the urine, that is milky and cloudy, is simple and very helpful. also, triglycerides are found only in the urine of patients with chyluria. these simple tests will avoid unnecessary treatment, which is not without side effects. low-density lipoprotein apheresis (ldl-a) has been tried in the treatment of patients with steroidimmunosupression resistant nephrotic syndrome (ns) due to focal segmental glomerulosclerosis (fsgs). we would like to report a child case study of fsgs with ns and renal insufficiency due to mitochondrial abnormality treated by ldl-a and to clarify the therapeutic effects of this treatment. a -year-old boy was referred to our hospital with complaints of heavy proteinuria and edema. a routine examination revealed proteinuria of . g/day, serum albumin (alb) of . g/dl and creatinine clearance (ccr) of . ml/min. renal biopsy specimen showed fsgs and perceptive deaf nass was recognized, necessitating a hearing aid. the a g point mutation in mitochondrial gene was detected by using genomic dna isolated from peripheral blood leukocytes and by the molecular analysis using an allele-specific polymerase chain reaction (pcr). oral prednisone ( mg/kg/day for eight weeks), intravenous methyl-prednisone pulse therapy ( . g/day,three times a week on the consecutive days for three weeks) and oral cyclophosphamide ( mg/day for eight weeks) were not effective to reduce proteinuria. a protocol of ldl-a was designed for treatment twice-a-week for four weeks and then once-a-week for six weeks. following treatment by ldl-a, serum total cholesterol and ldl were markedly changed form to mg/dl and from to mg/dl, respectively. a small but significant increase in alb from . to . g/dl and a remarkable decrease in proteinuria from . to . g/day were also successfully obtained. conversely, no marked changes in ccr were detected. the results of the present study indicate that a rapid decrease in proteinuria and an excellent increase in alb by ldl-a provide a possible therapy for drug-resistant ns due to fsgs with mitochondrial abnormality. glomerular filtration rate (gfr) can be estimated in children by various formulas based on body height and serum creatinine (s cr ) measurements such as the schwartz formula (egfr sch =kxbh/s cr ). we evaluate the performance of egfr sch in estimating gfr in a pediatric cohort when compared to i-iothalamate clearance (igfr), used as the reference standard for measuring gfr. between and , we obtained igfr and egfr sch on subjects. for subjects who had more than one igfr, the first measurement was used for analysis. mean age was ± (range - , % age= ), % male. mean s cr was . mg/dl (median . ), mean igfr ± ml/min/ . m and mean egfr sch ± ml/min/ . m . figure shows a scatter plot of the data with a line representing perfect agreement. figure shows a residual plot comparing the difference between estimated and measured gfr to egfr sch . pearson r correlation between the two variables was . (ln scale). accuracy of egfr sch within % and % was % and %, respectively. the median difference between igfr and egfr sch was . ml/min/ . m (median % difference %). for igfr > , - , - and < ml/min/ . m , egfr sch overestimated gfr by %, %, % and %, respectively. however, the median difference between igfr and egfr sch for the same groups was , , and ml/min/ . m , respectively. in conclusion, agreement between egfr sch and igfr is poor. egfr sch overestimates igfr at all levels of gfr, but bias of egfr sch vs. igfr increases progressively with higher gfr levels. in clinical instances when an accurate estimation of gfr is critical for patient management, the use of egfr sch should be reconsidered. until a more applicable estimation equation is developed, isotope measurement of gfr remains the ideal method to determine gfr in this population. background: immunosuppressive therapies other than corticosteroids, potentially associated with serious adverse effects, are urgently required for children with frequently relapsing nephrotic syndrome (frns). this study evaluated the efficacy and safety of long-term treatment with a moderate dose of cyclosporine (cya) in children with frns. methods: in this prospective, open-label multicenter trial, patients, from to years old, were randomly divided into two groups. for the first months, both groups received cya (sandimmune) in a dose that maintained the whole-blood trough level between to ng/ml. during the next months, the dose of cya was adjusted to maintain a trough level between and ng/ml in group a, while group b received a fixed dose of . mg/kg per day of cya. the primary end point was the rate of sustained remission. results: at months, the rate of sustained remission was % in group a (n= patients), as compared with only % in group b (n= ) (p= . ). the hazard ratio for relapse was . ( % ci, . to . ) in group a as compared with group b (hazard ratio= . ). at months, the rate of progression (to frns)-free survival was % in group a and % in group b (p= . ). mild arteriolar hyalinosis of the kidney was found in ( . %) of patients in group a and ( . %) of in group b; no patient had striped interstitial fibrosis or tubular atrophy. conclusion: cya given for years in a dose producing a trough level between and ng/ml for the first months, followed by a trough level between and ng/ml for the next months is an effective and relatively safe treatment for children with frns. with this regimen, about % of patients are expected to remain relapse-free during years of treatment, without the most critical adverse effect of cya, i.e., interstitial changes of the kidney. renal stone disease has been regarded as an uncommon problem in children especially in the first year of life. we evaluated clinical findings and metabolic examination of children with urinary tract stone presenting in the first year of life. there were boys ( %) and girls ( %), the mean age of admittance was , ± , months. the average follow-up period was , ± , months. urolithiasis was diagnosed during evaluation for uti and incidentally. positive family history for urolithiasis was reported in ( , %) patients. in / ( , %) patients urinary metabolic examination was not normal (table ). in of patients ( %), stones were located in kidneys which was bilateral in ( %) patients and one patient had passing stone which had never seen in ultrasonographic examination. stones were examined in subgroups. in ( %) patients stones were measured mm or smaller (group ), in patients ( %) they were between - , mm (group ) and in only patient the stone (cystin) was larger than mm (group ). stones measuring mm and larger were found highly associated (in of children, %) with abnormal ultrasonographic findings mainly hydronephrosis. in group , stones disappeared spontaneously in / ( %) patients. urinary tract infections (uti) were present in ( %) patients. one fourth of cases had associated genitourinary tract abnormalities mainly vesicoureteral reflux in ( %) patients. we conclude that the presenting symptoms of urolithiasis in the first year of life show a wide spectrum so that high index of suspicion is important for early detection. stones measuring mm and smaller may have great chance to disappear. we also emphasize the importance of screening for uti in patients with urolithiasis under year of age. background: long term complications of glycogen storage diseases (gsds) include delayed puberty, hepatic adenoma and renal disease. in the present study we aimed to detect renal involvement in children with glycogen storage disease and to determine the most accurate laboratory test to be the gold standard for early detection of this renal dysfunction. methods: twenty-seven children known to have gsd were included in this study. fifteen healthy age-and sex-matched children were also included as controls. routine urine analysis, urinary β microglobulin and microalbumin were done for all patients and controls. renal function tests, serum electrolytes, alkaline phosphatase, urinary calcium, blood and urine ph, urinary and plasma aminogram, in addition to calculation of glomerular filtration rate (gfr), bone x-ray to detect rachitic manifestations and abdominal ultrasound to measure renal size were done for all patients. results: twenty-one patients had one or more renal abnormality. the most common was increased urinary β microglobulin ( / ) followed by abnormal gfr whether low or high ( / ) and microalbuminuria ( / ). sonographically there was nephrocalcinosis in one case and renal stone in another one. the auroc curve for β microglobulin was . , (p= . ) and . for urinary microalbumin/creatinine ratio (p= . ). the best cutoff level to predict renal abnormality for urinary β microglobulin was . mg/l with % sensitivity and % specificity and the best cutoff value for urinary microalbumin/creatinine ratio was . with % sensitivity and % specificity. in conclusion: renal abnormalities are common in patients with gsd. urinary β microglobulin can be considered the gold standard for early detection of renal dysfunction in these patients. the aim of this study was to investigate the role of neutrophil activation, protein oxidation and ceruloplasmin in the pathogenesis of hsp, which has been not investigated previously. serum activities of myeloperoxidase (mpo) and arylesterase (aryl) and levels of free thiol, ceruloplasmin (clp) and total oxidant status (tos) were measured in children with hsp ( boys, girls; mean age . ± . years) at the onset of the disease and during remission in comparison with matched healthy subjects. patients at active stage had significantly higher mpo activity ( ± vs. ± u/l, p< . ), higher clp ( ± vs. ± mg/dl, p< . ) and tos values ( . ± . vs. . ± . μmol h o /l, p< . ) than controls. patients had significantly lower aryl activity ( ± vs. ± u/l, p< . ) and lower free thiol levels ( ± vs. ± μmol/l, p< . ) than controls. there were patients with gis involvement, with joint and with renal involvement. no significant differences were found in the oxidant stress markers between patients with or without organ involvement (p> . ). significantly positive correlations were found between tos and mpo (r= . , p= . ), and tos and clp (r= . , p= . ) at the disease onset; while a negative correlation was found between mpo and thiol (r=- . , p= . ) during remission. in conclusion, protein oxidation and neutrophil activation may play important roles in the pathogenesis of hsp. gastrointestinal system, joint and/or renal involvements were not together with different magnitude of oxidant stress. further studies are required to identify oxidizing substances and to develop therapeutic strategies to reduce oxidant stress in hsp. , ) . if the first remission occurred after days, the median time to relapse after discontinuation of steroid therapy was significantly lower than in children with shorter remission time ( . vs . months; p< , ). in conclusion children who fail to achieve a prompt remission after a first episode of ns are more likely to have frns or sdns. these retrospective data provide the rationale for individualizing the initial steroid treatment of mcns according to the time to obtain a remission. a prospective study is needed to validate this approach. the aim of this study was to determine the influence of osmolality of the first morning urine (ofmu) to efficacy of the desmopressin therapy in enuretic (pne) children and to compare the values of ofmu in enuretic and non-enuretic children. methods: we investigated ofmu in group of children with pne and in group of control non-enuretic children. pne group was divided into subgroup i (ofmu < mosm/kg h o) and subgroup ii (ofmu > mosm/kg h o). additionally, we measured ofmu months after the initiation of desmopressin therapy and recorded the number of wet nights. regarding the number of wet nights we divided pne group to subgroups: subgroup a (< wet nights/month), subgroup b ( - wet nights/month), and subgroup c (> wet nights/month). results: the statistically significant difference between control group and pne group regarding ofmu was not found (p= . ). all children from subgroup i had < wet nights/month during desmopressin therapy. children from subgroup ii had < wet nights/month, and had > wet nights/month during desmopressin therapy. the difference between those two groups was statistically significant (x = . , p= . ). in children from subgroup a the difference between ofmu-s during and before treatment was mosm/kg h o, in children from subgroup b it was mosm/kg h o and in children from subgroup c it was , mosm/kg h o. there was the statistically significant difference among those subgroups. conclusion: children with pne had usually similar ofmu like non-enuretic children. low ofmu is a good prognostic factor for desmopressin therapy of pne, especially in patients whose ofmu is < mosm/kg h o. children with bigger difference of ofmu before and during therapy had better response to desmopressin therapy. we can conclude that ofmu can help in choosing the appropriate therapy for pne in children. yh. ng , kl. chan kk women's and children's hospital, pediatric nephrology, singapore, singapore singapore general hospital, neonatology, singapore, singapore aim: to evaluate the clinical course and outcome of primary vesicoureteric reflux (vur) in patients with antenatal hydronephrosis in a neonatal unit. method: a prospective observational study of neonates with antenatal hydronephrosis born between january and december in the neonatal unit of singapore general hospital. neonates with significant hydronephrosis postnatally underwent micturating cystourethrography (mcu). records were reviewed with regards to the clinical course and outcome of primary vur. results: of neonates with antenatal hydronephrosis, ( %) had significant hydronephrosis postnatally and underwent mcu. . % ( / ) were diagnosed with primary vur at median age of weeks. there were more male (n= ) than female infants with primary vur. ( %) infants had bilateral vur. % (n= ) of the renal refluxing units (rru) had low grade vur and % had high grade vur with the majority ( %) being grade iii vur. repeat mcu for rru at years showed that % (n= ) had spontaneous resolution of vur, % had improved vur grade and % had similar vur grades as before. infants develop vur in the contralateral kidney which was previously normal. infants ( rru) underwent dmsa with renal scarring noted in infants. all infants were noted to have renal scarring without a history of urinary tract infection (uti). interestingly, male siblings were found to have grade iii vur with renal scarring with subsequent spontaneous resolution. none of the study subjects underwent surgery. median age of follow-up was . years (range . - . years). conclusion: unlike neonates with vur detected after uti, infants with primary vur were predominantly male, had higher grade of vur with spontaneous resolution in the majority. early diagnosis of primary vur may provide the opportunity for reduced incidence of reflux nephropathy. t. neveus , g. läckgren , j. wahlberg , n. wahlin uppsala university children's hospital, uppsala, sweden uppsala university hospital, department of transplantation surgery, uppsala, sweden objectives and methods: loin pain hematuria syndrome is a rare entity consisting of recurrent macroscopic hematuria with debilitating loin pain. it has only been described in adults, etiology is unclear and treatment is controversial but the therapy with best recorded success is to remove the kidney and reposition it in the pelvis. our objective was to show that the condition exists in childhood as well. results: aj, a previously healthy -year-old girl, was admitted because of recurring cystitis-like symptoms with microscopic hematuria but without bacteriuria. ultrasound and urography were normal. the episodes continued during the following years with increasing hematuria, now macroscopic, and increasing loin pain that was somewhat exercise-dependent. a renal ct scan was normal, as was cystoscopy, urography and ultrasound, but during cystoureteroscopy dilated vessels were noted in the mucosa of the right renal pelvis. antegrade pyelography, high resolution renal ct angiography, invasive renal angiography, mag renogram were all normal, gfr . nephrological evaluation, including kidney biopsy and coagulation tests were also normal and during cystoscopy blood could be seen emerging from the right ureteral orifice. by this time the patient was years old and was dependent on opioids in order to be able to go to school. after long discussions with the nephrologist, urologists, pain specialist and transplantation surgeon, the family opted for autotransplantation as a last resort. this was performed january and the girl became almost momentarily pain-free. nowadays she does not need any analgesics, but after prolonged exercise (like several days of horseback riding) she may experience slight pain in the left loin and/or hematuria. conclusions: idiopathic loin pain hematuria syndrome exists in childhood and may possibly be treated with renal autotransplantation. j. van der deure, a. ockhuijsen, m. sondaar deventer ziekenhuis, st department of pediatrics, deventer, the netherlands objective: enuresis is a common pediatric problem. psychosocial factors (psf) influence the results of enuresis treatment in children. aim: to determine the short and long term effects of psf on enuresis treatment in a general pediatric population. methods: we reviewed the data of our enuresis patients treated from - . relevant contributing psf were categorized. initial follow-up was at months after training. a written questionnaire was sent years after training. treatment success was defined as > % improvement in dry nights. results: pts were included. in pts ( . %) contributing psf were recognised. categorized problems: family related n= ( %), behavioural problems n= ( %), motivation/support n= ( . %), learning disabilities n= ( . %). overall success rate was . % at months and . % at yrs (overall resp quest . %, psf . %, psf %, > psf %). success rate in the psf group was . % ( psf . %, > psf . %) at months and . % ( psf %, > psf %) at yrs. statistics: success rate in the group with psf is significantly lower as compared to no psf at months (p< . (chi-square), or . , % ci . - . ) and at yrs (p= . (chi-square), or . , % ci . - . ) success rate at months is significantly lower in pts with > psf, compared with psf. (p= . (chi square), or . , % ci . - . ) . no significance could be demonstrated at yrs (p= . , chi-square) but this may be due to the variety in response rates. t. papalia, r. greco, r. bonofiglio hospital annunziata, nephrology, cosenza, italy actually a new litholitic therapy includes the phytotherapy agents as phyllantus niruri (pn), a plant used for years in brazil to treat urinary stones. in this work we estimate the effect of pn intake (uristone gr/die) in children ( m/ f, ± years old) with urolithiasis. the pn has been administered for short term (from to months) in children wih caox urinary stones and for months in with struvite stones. besides all children treated with dietary intervention: high fluid intake, sodium restriction, normal calcium intake and a diet low in animal protein. urinary and plasma analysis, body weight, map, ph, creatinine clearance, urinary excretion of mg and citrate were determined at baseline, month and at the end of the study. the patients were studied by renal ultrasonography at baseline, , , months. nobody of them had been undergone extracorporal shock wave lithotripsy. there were no differences in the mean values of urinary and plasma parameters before and after pn intake, except for a significant reduction in the mean urinary calcium in hypercalciuric pts ( ± , vs , ± mg/kg/die). in this follow-up n° patients showed a faster stone clearance after a regular intake of pn and the others showed a smaller stone diameter. previous reports showed pn has a potent inhibitory effect on caox crystal adhesion and/or endocytosis by renal tubular cells and inhibitory effect on crystal growth, which might be related to the higher incorporation of gags into the calculi. our results suggest pn appears to represent a nontoxic and a low cost alternative for the prevention and treatment of stone disease, especially in the children. further studies are necessary to validate these preliminary findings. d. weitzel, c. schäfer, k. hohenfellner, u. pfeffer, m. neukirch german clinic for diagnostic, pediatrics, wiesbaden, germany objective: does sonographic quantification of the renal parenchyma allow estimation of isotopic renal function? method: sonographic kidney images of patients (age to months; mean ) were measured retrospectively. in all images of both kidneys taken from dorsal the volume on the base of length, width and depth was calculated. the parenchymal area (pa) in the longitudinal and cross section was calculated by planimetry. the distribution of renal function via mag was compared with sonographic values as volume and pa of each kidney in relation to whole kidney volume and pa respectively. patients with reduced global kidney function and time space of more than months between isotopic study and sonography were excluded. results: interrater variability regarding planimetry of pa in longitudinal section (from dorsal taken images) was as good as measurement of kidney length (correlation coefficient (k)= , - , and , - , respectively). all sonographic parameters correlated significantly with the isotopic parameters of renal function. the latter correlated best with the pa in longitudinal section (from dorsal taken images) k , . the combination with planimetry in cross section did not improve correlation (k , ). difference of the proportional pa of the left kidneys (in correlation to whole kidney pa) in comparison to isotopic proportional renal function lead to mean difference of - , % with a standard deviation , %. if only kidneys with split function of - % the mean difference of proportional pa was - , % and the standard deviation , %. conclusion: the distribution of total pa of both kidneys correlates significantly with the distribution of renal function (left and right) in isotopic studies. if sonographic planimetry might change the indication for isotopic studies in respect of renal function needs to be proofed in prospective studies. background: childhood incontinence is a common important urologic problem. especially daytime incontinence is often neglected by the parents until it turns out to be a significant clinical problem. the aim of this study was to evaluate the clinical characteristics of the patients with incontinence that were followed in our nephrology clinic. study design: patients were followed between the dates of . . - . . and they were admitted solely due to incontinence or with concomitant urinary tract infections were enrolled. results: the study comprised patients ( m, f; mean age . ± . years). fourty-two patients had only nocturnal enuresis (ne) ( primary, secondary). twelve patients had daytime incontinence (di) ( primary, secondary) and had both ne and di ( primary, secondary and both primary ne and secondary di). all, except two (neurogenic bladder), had functional incontinence. twelve patients had additional fecal incontinence and had constipation. sixty-two percent of the patients had one or recurrent urinary tract infections (uti) in their past history, % had accompanying vesicoureteral reflux and % had urinary stones. ultrasound revealed unilateral or bilateral dilatation in % and other anomalies in % of the patients. nineteen patients had abnormal dimercaptosuccinic acid scintigraphy findings. timed voiding schedule and double voiding were recommended to all patients with daytime incontinence, % of the patients received anticholinergic treatment and % received antimicrobial prophylaxis. discussion: overall, approximately / of our patients had associated uti and / had abnormal dmsa findings. therefore every patient with uti should be questioned about urinary incontinence and be treated carefully if present. the aim of the study was to determine early parameters of ultrasound and dmsa scanning diagnostics of reflux nephropathy (rn) in children. we examined children with rn and vesicoureteric reflux (vur). all children were comparable on gender and age. all patients underwent color doppler ultrasound (cdus), x-ray and dmsa scan. they were divided into two groups: ) children with unilateral rn a according to classification of smellie j. et all, (n= ) ; ) children with vur without renal damage (n= ). we established that data of cdus (diastolic velocities (vd) , ± , mm/sec, systolic velocities (vs) , ± , mm/sec, resistive indices (ri) , ± , , pulsatility indices (pi) , ± , ), dmsa scanning (time of the maximal accumulation , ± , sec, maximal activity , ± , sob/sec, mean velocities of accumulation , ± , mm/sec, the contribution to the common accumulation , ± , %) are characteristic for patients with rn a. data of cdus (vd , ± , mm/sec, vs , ± , mm/sec, ri , ± , , pi , ± , ), dmsa scanning (time of the maximal accumulation , ± , sec, maximal activity , ± , sob/sec, mean velocities of accumulation , ± , mm/sec, the contribution to the common accumulation , ± , %) are characteristic for patients with vur without renal scars. the ranges of cdus and dmsa scanning were significantly different between children from comparing groups (p< , ). our result suggest that data of cdus (vd, vs, ri, pi), dmsa scanning (time of the maximal accumulation, maximal activity, mean velocities of accumulation, the contribution to the common accumulation) can be used to early diagnostics of scarring in children with vur. the purpose of this study was to determine normal reference values for urinary uric acid/creatinine ratios in healthy turkish children. in this study, random urine specimens from children ( boys, girls) aged month to years were analyzed for uric acid and creatinine, and urinary uric acid/creatinine ratios were determined from each sample. uric acid/creatinine ratios were the highest in children aged - months and showed a significant decrease with age (p< . ). uric acid/creatinine ratios were not significantly different between the sexes except - years. girls between - years had higher urinary uric acid/creatinine ratios when compared with boys (p< . ). there was no correlation between urinary uric acid/creatinine ratios and protein intake. our results show that urinary uric acid/creatinine ratio changes with age. when assessing the urinary uric acid/creatinine ratio, a child's age should be considered. we provided normal reference values of urinary uric acid/creatinine ratio for using in our region. the aim of the study was to investigate microbiological marker of activity of uti. e. coli and s. aureus p were isolated from urine of children with uti. the children were divided into groups: . with pyelonephritis in the acute period (n= ); . with pyelonephritis in the period of remission (n= ); . with cystitis in the acute period (n= ); . with cystitis in the period of remission (n= ) healthy children consists the group of control. definition of bactericidal activity of urine (bau) was carried out by our original method. the essence of the method consisted in measuring of the optical density (od) of the bacteria after their contact with urine (experience) and isotonic solution of nacl (control) after minutes of endurance in meat peptone mediums with c during - hours. bau was calculated under the formula: bau (%)=(odc-ode)/odc* %, (odc -control group, ode -experience group). we established that the level of bau did not correlate with urine ph (r= , ), osmolality (r= , ), lysozymuria (r= , ), lysinuria (r=- , ). we established that the low level of bau was marked in children of control group ( - %). the patients in active period of uti had high level of bau (> %). the parameters of bau didn't depend from the level of uti (pyelonephritis or cystitis). the level of bau reduced in the period of remission of uti. we established that the level of bau correlated with bacteriuria (r= , ), leucocyturia (r= , ). the level of bau didn't depend from the degree of urine dissemination (r=- , ). so, the level of bau is correlated with laboratory parameters of uti and can be used as new additional microbiological marker of diagnostics of activity of uti. the evolution of the alport syndrome in brazilian children vesicoureteric reflux (vur) is common in children with urinary tract infections (uti). if vur coexisting with uti there is a high risk of progression to end-stage renal disease (esrd). the correct diagnosis is important. we observed children ( girls and boys) aged mo to yrs at the time they have been diagnosed as having vur. the follow-up period was mo up to yrs after the diagnosis. all children with vur grade have been operated. after antireflux operation incidence of uti dramatically decreased even this cannot prevent progressive kidney damage in some patients. children with less severe vur have been put on prophylaxis. controlled mcu was performed usually after year later. if vur disappeared medication have been stopped. vur grade - had a tendency of resolution under conservative treatment in . % of the patients. in children associated urinary tract malformations were found: duplicated system, dysplastic kidney, kidney agenesia, dystopic kidney, urethral stenosis and bladder outlet obstruction. in patients nonfunctioning kidney have been found. dysfunctional voiding was common finding. blood pressure and physical development have been controlled. kidney size, function and scar formation have been followed by dmsa scan. we observed kidney growth at mos intervals. during the follow-up period infants have had reversible renal insufficiency. one patient with bilateral vur grade went into renal failure at the age of yrs. conclusions: vur is still one of the most common leading causes to esrd in childhood. even the existing controversy concerning treatment modalities it is obvious that low grade vur does not need operative treatment. it is indicated in high grade vur to prevent repeated and severe uti but it cannot preserve progression of the disease because of high incidence of coexisting kidney dysplasia. results: from forty children with nephrolitiasis, ( %) were boys and ( %) were girls. the mean age was . ± . months. the youngest age was months old. the most common clinical presentation was abdominal discomfort ( %), followed by uti ( %), microscopic hematuria ( . %), macroscopic hematuria ( %), spontaneous urinary calculi ( %), flank pain ( %). nine of children were presenting with chronic renal failure (crf). statistical analysis showed that age had correlation with the present of crf in children with nephrolitiasis (p= . ). the clinical presentations of nephrolitiasis were varied. abdominal discomfort and uti were the major signs and symptoms. there was correlation that age may influence the present of crf in children with nephrolitiasis. objective: renal involvement is one of the most frequent and serious manifestations of sle. we analyzed the treatment and renal outcome of patients with lupus nephritis. methods: seventy-seven identified patients were retrospectively analyzed from jan. to dec. . the outcome was divided as complete remission ( -hour proteinuria < . g, plasma creatinine level normal and sledai < ), partial remission (abnormal renal damage index improved > %, -hour proteinuria > . g, sledai < ) and no response, respectively. results: fifty-four patients were biopsy proven ln ( %). fifty-seven patients followed up more than month. all the eleven patients with class i or ii achieved remission, using prednisolone together with either hcq, or tripterygium or mmf or cyclophophamide (ctx). in forty-three patients with class iii or iv or v, they were given prednisolone together with mmf or ctx. we found that remission was in cases, part remission cases and no response in cases. associations between methylenetetrahydrafolate reductase (mthfr) c t polymorphisms and several vascular diseases have been reported. this is a clinical study designed to investigate the possible effects of (mthfr) c t polymorphisms on the developement of henoch-schönlein purpura (hsp), renal involvement, and clinical course. fourty-one patients with hsp ( m/ f) mean age ( , ± , years) were included in the study. eighteen of the patients had renal involvement. the control group consisted of healthy children. blood samples were obtained for mthfr c t transition, homocysteine, folic acid and vitamine b in the patients and controls. the genotype frequencies (cc/ct/tt) of mthfr in the hsp group were , / , / , and , / , / , in the control group, respectively (ns). the genotype frequencies (cc/ct/tt) were , / , / , in the patients without renal involvement and , / , / , in those with renal involvement, respectively (ns). homocysteine levels were , ± , in the hsp patients and , ± , μmol/l in controls (ns). vitamine b levels were , ± , pg/ml in the hsp patients and , ± , pg/ml in the control group (ns). folic acid levels were , ± , in the hsp and , ± , ng/ml in the control group (p< , ). no significant relationship was present with the mthfr genotype and plasma homocysteine, folic acid and vitamine b levels. no association with mthfr gene polymorphism and homocysteine plasma levels could be detected in patients with hsp and hsp nephritis. although mthfr gene polymorphisms have been found to be associated with several vascular diseases, the results of this study indicate that other mechanisms should be operative in the developement of hsp and hsp nephritis. we report the symptoms, signs and laboratory values at onset and during month-follow-up of hsp in a prospective study of children ( girls, boys) with mean age of . years ( . - . y). the first sign of hsp was purpura in ( %), oedema or other joint symptoms in ( %), abdominal pain in ( %) and melena in ( %) patients. petechiae appeared on the average days after the first symptoms ( - d) if purpura was not the first sign (n= ). % of the cases were diagnosed between september and march. the mean delay from the first symptoms to the diagnosis was days ( - d our results based on an unselected and prospective patient material demonstrate that renal symptoms in hsp children develop early, are common and should be followed up at least months. the kidney is a metabolically active organ, so any alteration in kidney function might affect nutrient utilization. objective: analyze the nitrogen balance (nb) as a marker for adequate food consumption in children with chronic renal insufficiency (cri). material and methods: patients ( boys, girls) diagnosed and managed in the nephrology and nutrition departments. they were placed in two groups depending on age: group a: patients aged ± . years, follow-up ± . years, glomerular filtration rate (gfr) estimated by cr-edta: ± ml/min/ . m ; group b: patients aged . ± years, follow-up . ± . years, gfr estimated by cr-edta: ± ml/min/ . m results: group a had a worse weight and height evolution: weight: - . ± . sd in group a vs . ± sd in group b; height - . ± . sd vs - . ± . sd (respectively). group a showed a significant increase in tnf blood levels (p< . ) that was inversely related with weight and height. bn was significantly greater in group a ( . ± . gr/day) than in group b (- . ± gr/day) (p< . ) and this was related with higher calorie (p< . ) and protein (p< . ) intakes. there was no difference in alimentary nutritional breakdown. nb improved significantly over the follow-up (p< . ). there was no relation between nb and gfr. there was a significant increase in triglyceride levels and significantly lower blood urea levels in group a (p< . ). we conclude that nitrogen balance depends on protein and calorie consumption and is independent of the severity of renal affectation. we present a case of a months old boy, who was delivered to our intensive care unit because of high fever, acute renal failure and dilatation of the urinary tract. his hemoculture and urinary culture were positive for e. coli and a severe urosepsis was diagnosed. his urethral catheterization was unsuccessful, so a suprapubic puncture was performed to relieve the urinary system and provide sufficient urinary flow. after the urinary sepsis was cured with adequate board spectrum antibiotics, a voiding cystourethrography (vcug) was performed to reveal the suspected anatomical abnormality, vesicoureteral reflux (vur) respectively. meanwhile a continuously growing nodular tumor of the penis was observed. the vcug showed the signs of urethral stenosis, but posterior urethral valve and vur was excluded. the doppler ultrasound found a solid vascularised tumor, x . cm in its diameter. during the surgical operation the tumor couldn't been totally removed, as it was infiltrating the surrounding tissues and the urethra. the histopathological examination of the biopsy specimen confirmed a juvenile xanthogranuloma (jxg). this is an uncommon, benign, non-langerhans cell histiocytosis, primarily seen in infancy as a solitary cutaneous lesion, predominantly in males. systemic form of the disease is rarely seen. usually it resolves spontaneously without any further treatment, but the differentiation from a malignant neoplasm is essential. according to the authors' search, this is the nd reported case in the literature and the first pediatric report of the jxg of the penis. urine examination using x-ray diffractometry background and goal: x-ray powder diffraction analysis is widely used in chemistry and pharmacology and for other industrial purposes. in medical science it is used for analyzing kidney stones and investigating retained crystals in tissue sections. in the department of mineralogy and petrology we investigated urine samples, at first diagnostically to detect urinary amino acids, glucose and compounds and, secondly, to detect calcium oxalate hydrate, which can be employed for early detection of renal tubular injury when no significant differences in renal function values exist. materials and methods: after sedimentation and dehydration, authors investigated more than urine samples of children using x-ray diffractometry. results: of them were glucosuric due to diabetes mellitus; in these cases glucose could be detected in each of their urine samples. in cases different amino acids due to aminoacidopathy were detected. the urine samples of children -kidney stone problems in history -were examined, in one case struvit, in the other cases ca oxalate crystals were identified. also, samples of children were examined, hours after at least hours long anesthesia, ca oxalate hydrate appeared in their urine referring to renal tubular injury due to inhalational anesthetic agents. in cases urine samples of children treated in the intensive care unit were analyzed, in % ca oxalate crystals could be detected. in cases healthy children's urine were investigated, as control ones. conclusion: x-ray diffractometry, as a highly sensitive method can be used efficiently in clinical measurements. further investigations are needed in order to determine its place in clinical trials. authors emphasize the importance of collaboration of different sciences, as well. drug intake in the background of sudden death? microalbuminuria was significantly more in patients more than years of age as compared to younger patients on bivariate analysis (p= . ). on logistic regression analysis, though microalbuminuria was more in patients more than years of age, it was not statistically significant. the association between microalbuminuria and urinary specific gravity levels of < . was statistically significant (p= . ), similar results were seen on logistic regression analysis. there was no correlation between microalbuminuria and hospitalizations, crises, previous blood transfusions, hemoglobin electrophoresis and serum creatinine levels. conclusion: identification of risk factors for microalbuminuria may allow earlier intervention to prevent renal complications in patients with ssd. in developing countries at primary health care level urinary specific gravity should be done routinely in patients with ssd to identify cases at risk of microalbuminuria. m. bak, e. serdaroglu, y. bicilioglu aim: the aim of the present randomized-controlled study was to compare desmopressin (dp), alarm and combined treatments in nocturnal enuresis. the study included children ( boys and girls) with nocturnal enuresis. the mean age was . ± . years (ranged - years) and the mean wet-nights was . ± . day per month before treatment. the patients were followed for one month before treatment and randomized to dp ( patients), alarm ( patients) and combined ( patients) treatment groups. the dp group was received μg orally one-hour before sleep and alarm group was used wet-stop bedwetting alarm device after education of parents. the patients were followed months in treatment period and months after discontinuation of treatments. results: wet-nights per months was significantly reduced between before treatment and last month of treatment in dp ( . ± . to . ± . , p< . ), alarm ( . ± . to . ± . , p< . ) and combined treatment ( . ± . to . ± . , p< . ) groups. treatment success (> % decreasing in wet-nights) and complete response ( % dry) rates was %, %, % and %, %, % in dp, alarm and combined treatment groups respectively. the more rapidly decreasing in wetnights was observed between dp used and only alarm treatment group but this effect disappeared after months. relapse rates was %, % and % in dp, alarm and combined treatment groups respectively between successfully treated patients (p= . ). conclusion: alarm treatment is the best intervention with low relapse rates and no potential adverse effect in nocturnal enuresis. dp group has higher relpse rate but adding to dp may achieve more rapid decreasing in wet nights especially in patients and parents expecting rapid result. aim: it is often difficult to collect urine from infants. use of specifically designed urine collection pads gives reliable results for routine biochemistry tests in adult urine. their use for routine and metabolic tests in paediatric urine has not been investigated. the aim of this study was to evaluate whether the pads give reliable results for routine and metabolic biochemistry tests in paediatric urine. methods: urine collected by bag or clean-catch from infants < y without metabolic disorders was divided into two aliquots, one of which was added to a collection pad, incubated for min at °c, then recovered by aspiration. routine and metabolic analyses were performed on pad/non-pad aliquots. additionally, selected metabolic analyses were performed on pad/non-pad urine from patients with diagnosed inborn errors and urine spiked to simulate metabolic disorders. for quantitative analyses, pad/non-pad results were compared using bland-altman bias plots, passing and bablok regression and paired t-tests. results: routine tests (urea, electrolytes, creatinine, osmolality, calcium: creatinine, phosphate: creatinine, magnesium: creatinine, urate: creatinine, n= ) showed close concordance with no clinically significant pad/non-pad differences. in infants without metabolic disorders, aminoacids (n= ), organic acids (n= ) and mucopolysaccharides (n= ); and in patients with metabolic disorders -phenylketonuria (n= ), mucopolysaccharidoses ii (n= ) and iii (n= ), inborn errors of organic acid metabolism (n= ) and cystinuria (n= ), all showed excellent pad/non-pad concordance. sugar chromatography in urine spiked with glucose/galactose/fructose showed identical staining intensity in pad/non-pad samples. conclusion: urine collection pads give reliable results for a wide range of routine and metabolic tests in paediatric urine. a post-translational modification of arginine residues in proteins and subsequent proteolysis result in release of symmetric dimethylarginine (sdma). sdma is considered an end product of metabolism, excreted primarily by the kidney. several previous studies have reported a significant relationship between glomerular filtration rate (gfr) and plasma sdma. to determine the potential value of sdma in the assessment of gfr in children we have measured sdma in samples taken during routine measurement of glomerular filtration rate (gfr) using plasma clearance of inutest. patients ( male) requiring routine gfr measurement were studied. median (range) age . y ( . - . ) , height (ht) cm ( - ), and surface area . m ( . - . ). gfr was measured using the plasma clearance of inutest, and plasma sdma and creatinine (pcr) by liquid chromatography stable isotope dilution electrospray mass spectrometry-mass spectrometry method. estimated gfr (egfr) was calculated from the formula x ht (cm)/pcr (μmol/l). median gfr was ml/min/ . m ( - ), plasma sdma . μmol/l ( . - . ), pcr . μmol/l ( . - ), and egfr ml/min/ . m ( - ). as expected both plasma sdma and pcr increased with a decline in gfr. compared to gfr the correlation with /sdma, r= . (p< . ) was better than for /creatinine, r= . and similar to that for egfr, r= . . comparing sdma with inutest gfr for detection of gfr < ml/min/ . m the area under the roc curve was . (p< . ). the equivalent areas for pcr and egfr were . and . , respectively. in conclusion plasma sdma is an endogenous marker of gfr in children and is superior to pcr because it appears to be independent of body size. since the calculation of egfr requires accurate measurement of height, plasma sdma may provide a practical alternative for assessment of gfr in children. thrombotic microangiopathy (tma) consists of thrombocytopenia, microangiopathic hemolysis, and thrombi in the microvasculature of vital organs. broad categories of causes of tma include infectious (verotoxin-induced hus), hematologic (ttp), complement based (atypical hus), immune-mediated (sle, anti-phospholipid antibody syndrome), and drug-induced (cyclosporine). thorough investigation is required to detremine the underlying etiology in order to provide specific therapy and information about prognosis. a year girl presented with short stature and was found to have hypertension, proteinuria, renal failure (creatinine umol/l), and anemia (hgb g/l). platelets were normal. she also had spondylometaphyseal dysplasia, scoliosis, lymphopenia, mild pulmonary hypertension and aortic stenosis. on pulmonary function testing, her dlco was decreased. chest ct demonstrated small micronodules. a ventilation-perfusion scan was normal. renal biopsy showed features of tma. she was treated with dialysis and underwent renal transplantation one year later. there has been no disease recurrence months post-transplant. genetic and immunologic workups were negative, including anti-cardiolipin antibodies. a thrombophilia workup was negative apart from a heterozygous mutation in mthfr. c levels were mildly reduced. anti-neutrophil antibodies were negative. complement system studies, including factor h, and smarcal analysis for schimke immuno-osseous dysplasia are underway. although the descriptive diagnosis of tma can be applied here, the underlying pathophysiologic diagnosis has still to be defined. it is of particular importance that further efforts be made to identify the etiology given the potential risk of disease recurrence in the renal graft. background: long term outcome of renal functions after liver transplantation (lt) in wd is not studied yet. aim: the aim of this study was to determine the long term outcome of renal functions in children receiving lt for wd. patients and methods: renal functions were examined in (f/m: / ) liver transplanted patients for wd before and long after lt and compared with renal functions of patients (f/m: / ) with lt for a hepatic disease other than wd. the mean age of subjects was . ± . years in the patients group and . ± . years in the controls. the mean duration of follow-up was at least years. glomerular and tubular functions were assessed using the conventional equations for measured creatinine clearance (gfr), tubular phosphate reabsorption (tpr), daily protein and calcium excretion in both groups. results: mean gfr before lt was . ± ml/min/ . m in the study group and . ± . ml/min/ . m in the controls (p= . ). the mean tpr before lt was found to be . %± . % in the study group and %± . % in the controls (p= . ). daily protein excretion rate before lt was found to be high in both groups, as well as urinary calcium excretion. an increase in gfr was observed in the study group after lt (p> . ), while it was slightly decreased in the controls (p> . ). tpr increased significantly in the study group after lt ( . %± . %) (p= . ) and although it was found to be significantly lower in the study group than the controls before lt, in the long term follow-up the difference between the groups was disappeared (p= . ). conclusion: tubular dysfunction is frequent in patients with wd. liver transplantation for hepatic failure secondary to wd is a lifesaving procedure. it corrects the underlying hepatic defect as well as renal defects and leads to long-term survival. rather conflicting results are available regarding the neurocognitive development of children with ckd, due to small sample sizes, cross-sectional study designs, differing methodological approaches and historical trends in patient selection for renal replacement therapy. we prospectively examined in a standardized, multi-center effort children with ckd aged . - years. children were treated either conservatively (n= , gfr < ml/min/ . m ) or by dialysis (hd: n= , pd: n= ). a sub-sample of children underwent repeated testing after - months. bayley and snijders-oomen developmental tests were performed and the measured values normalized to standard deviation scores (sds). general cognitive development averaged at - . (± . ) sds. % of the patients scored <- . sds, i.e. below the th percentile of the normal population. no significant differences were observed between pre-dialysis (- . + . ) and dialyzed patients (- . + . ). impaired neurocognitive function was marked in infants (- . + . sds), whereas school children showed a distribution similar to healthy children ( . + . sds, p< . ). the global neurocognitive sds remained unchanged in the longitudinal sample (t =- . ± . ; t =- . ± . ). in summary, our preliminary results demonstrate a high prevalence of neurocognitive impairment in infants with ckd. we assume that this finding reflects the improved survival of children with complex disorders affecting not only the kidney but also brain development. the poor performance of this age group highlights the importance of close neurocognitive follow-up and early developmental interventions. objectives of study: to make a diagnosis of a girl with kidney subcapsular hydrops, abnormal urinanalysis and hypertension. methods: physical examination and laboratory investigations were analyzed. results: a years old girl was admitted because of kidney subcapsular hydrops, proteinuria without edema, and hypertension ( / mmhg) for days. no trauma or familial hypertension history were provided. no hydrops was found before the age of year. urinary rbcs were - /hp and protein was mg/kg/ hr. the serum albumin was normal. ultrasound examination revealed normal sized kidneys, increased echogenicity in both kidneys, and subcapsular hydrops on the upper pole of the right kidney connected with an old renal fissure. ucg and fundus examinations were normal. gfr of the right kidney was slightly decreased as compared to the left ( ml/min vs. ml/min, by dtpa scan). by puncture of hydrops, yellow clear fluid was drained, the analysis showed similar composition to that of original urine, so subcapsular urinoma was diagnosed. urine collection from two kidneys separately was performed by cystoscopy; nonselective proteinuria of + was found in urine from the right and + from the left kidney. analysis revealed urea . mmol/l, potassium . mmol/l, creatinine . mmol/l in the right kidney urine compared to urea . mmol/l, potassium . mmol/l, and creatinine . mmol/l in the left, which suggested that the right kidney function was compromised. according to proteinuria from both kidneys with microscopic hematuria, without edema and hypoalbuminemia, glomerulonephritis was diagnosed. the girl was diagnosed with glomerulonephritis and subcapsular urinoma. it was a rare case because of their co-incidence. reasons for the hypertension, if caused by the glomerulonephritis or the pressure by subcapsular urinoma, as well as reasons for subcapsular urinoma need to be clarified during the follow-up. the aim of this study was to detect factors that could interfere with the results of des treatment. methods: fifty-six patients . to . years old with des without improvement by previous therapies were randomly distributed into two voiding training programs: group (g ): patients submitted to kegel exercises training sessions for three months; group (g ): patients submitted to biofeedback sessions over a two month period. both groups adhered to a voiding and drinking schedule, received adequate toilet posture instructions and were reinforced through the maintenance of voiding diaries. clinical evaluation was carried out before each programs initiation and , , and months after end of the program. all patients were submitted to renal and dynamic ultrasound before and months after each program's conclusion. the following variables were analyzed: gender, age at diagnosis, treatment group type, vesico-ureteric reflux, constipation, urinary tract infection, asymptomatic bacteriuria, bladder wall thickening and post void residual (pvr) urine. the logistic regression model was applied to identify independent variables associated with response to treatment. results: urinary continence was improved after completion of either training program. success in diurnal urinary incontinence varied from . to % in g and from . to . % in g . success in nocturnal urinary incontinence varied from . to . % in g and from . to . % in g . in multivariate analysis three variables remained independently associated with bad response to treatment: constipation with soiling, bladder wall thickening and pvr urine (p< . ). conclusion: studies using multivariate regression analysis to identify predictors of response to behavioral therapy are important for the development of selection criteria for prescribing these therapies to children. we report the case of a four-year-old child born to consanguineous parents, who presented first at two months of age with respiratory failure. during the admission he developed panyctopenia, hypertension and nephrotic range proteinuria. the metabolic workup revealed methylmalonic academia and aciduria along with homosystinuria; highly suggestive of cobalamin deficiency. the renal biopsy showed chronic thrombotic microangiopathy (tma). the muscle biopsy showed the presence of nemaline rods on electron microscopy. cobalamin c deficiency was confirmed by genetic analysis as the patient was homozygous for the mutation c / . at the age of one, he was noted to be visually inattentive and developmentally delayed. on ophthalmology examination there was evidence of bilateral maculopathy and dysfunction of rods and cons on electroretinogram. he subsequently went on to develop bilateral bovine maculopathy. since his initial presentation he has been maintained on hydroxycobalamin, betaine and folate; with no further relapse of proteinuria or panyctopenia. however, despite adequate doses of hydroxycobalamin, the maculopathy progressed. to our knowledge, this is the first report of a child with both tma and bovine maculopathy. the aim of the study was to assess the rate of vesicoureteral reflux (vur) in patients with lower urinary tract dysfunction (lutd) of nonneurogenic origin. dysfunctional voiding may result in lower urinary tract symptoms in children and is commonly associated with urinary tract infections and vur. we investigated patients with voiding dysfunction during last three years: boys and girls, a mean age of . years, with a mean follow-up of months, all with normal renal function. mean pre and post treatment symptom scores were . and . respectively. vur was detected in % of the children with unstable bladders and . % of the children with stable bladders as detected by video urodynamic investigation, % of the children with urinary tract infection (uti) on admission, and % of the children with no history of uti on admission. the co-existence of vur in our group with voiding dysfunction was . % ( patients). all patients with vur had low grade reflux (grades i-iii) and of them bilateral, the remaining unilateral. renal us was performed in patients and revealed hydronephrosis in patients, while the remainder showed no abnormalities. vur was found to be present in % of the children with abnormal us findings, while only % of the children with normal us findings were affected. furthermore, the patients that had spontaneous resolution of reflux showed a markedly greater improvement in symptom scores. a significant portion of patients with lutd ( . %) have low grade vur. in detection of vur in patients with lutd, hydronephrosis is a good indicator of the presence of reflux, while utis and urodynamic findings were not found to be significant indicators. the overall spontaneous resolution rates of vur in patients with lutd and stable bladder following treatment was found to be . % and . %, respectively. - g) were grouped: group (n: ) was the sham group. group , and (n: for each) received mg/kg twice daily ptx intraperitoneally (i.p.), mg/kg/day gen i.p. and both ptx and gen at the same dosages for consecutive days, respectively. the rats were weighed at the beginning and than weekly during the study. after the last dose -hour urines were collected. then, rats were sacrificed and blood samples were obtained from the abdominal aorta. bun, serum creatinine (scr), creatinine clearance (ccr), renal superoxide dysmutase (sod), catalase (cat) and thiobarbituric acid reactive substances (tbars) levels were determined. all the parameters were compared between the groups. results: body weights were not different between the groups either at the beginning or during the study. bun levels were significantly higher in group than the other groups (p< . ). scr and ccr levels were similar between the groups and , but the levels were higher than those of groups and (p< . ). sod and tbars levels were similar between all groups. the levels of tubular cell apoptosis and caspase- expression were significantly higher in group than the other groups (p< . ). conclusion: we may conclude that ptx administration significantly reduced the apoptosis in gentoxicity, but we could not demonstrate any evidence of ptx-related reduced oxidative stress. the lack of evidence for the widespread use of antimuscarinics and holding exercises in mne prompted us to design a randomized controlled trial comparing interventions in four groups of children with mne: placebo (a) or oxybutynin chloride (b) in combination with a daily regimen of standardized fluid intake and holding exercises or as monotherapy (c) and (d). a fifth group, to be treated with alarm only, was planned as control. randomization was stratified for participating hospital, sex, age, tanner stage, family history of mne, previous treatment, and bladder capacity class, being the largest from either the maximum voided volume (mvv) from a h frequency volume chart or the volume after baseline holding exercises (hev). after weeks intervention with holding exercise (a and b) , hev had increased, both with oxybutynin ( ± (sd) ml to ± (sd) ml, p< . ) and placebo ( ± (sd) ml to ± (sd) ml, p< . ). without holding exercises, only oxybutynin (d) increased hev ( ± (sd) ml to ± (sd) ml (p< . ). mvv increased also in groups a and b (holding exercises), not c and d. cure rate (less than wet night in the last for weeks) was low: a / , b / , c / and d / . control group with alarm had / cure. cure was not related to hev, mvv or delta hev and mvv. this questions the relevance of increasing bladder capacity in mne. background: sickle cell disease (scd) is an inherited disorder of beta-globulin synthesis of haemoglobin, resulting in a tendency for haemoglobin polymerisation and consequent vasoocclusion, tissue hypoxia, and ensuing organ damage. the kidney is a particularly sensitive to hypoxia and renal failure is a major cause of morbidity and mortality in scd. children with scd commonly hyperfiltrate, the glomerular filtration rate (gfr) then typically falls back towards normal in adulthood. routine estimation of gfr in children is primarily derived from the height and plasma creatinine (pcr) measurements using k a constant dependent on the creatinine analytical method. this formula has reduced accuracy in children with a gfr > ml/min/ . m . it has never been validated in hyperfiltration or children with scd. recently, new gfr markers have been proposed including symmetrical dimethylarginine (sdma) that may be independent of body size. in this pilot study we tested the hypothesis that estimated gfr and/or sdma allow a reliable estimation of gfr in scd. methods: hbss patients, age range - yrs (mean age yrs) attending the evelina children's hospital were studied. the patients were on regular blood transfusions for stroke management and undertook a formal gfr measurement using plasma clearance of inutest. the plasma samples were also used for the measurement of pcr and sdma by stable isotope dilution mass spectrometry. egfr was calculated using k= . results: inutest gfr ranged from - ml/min/ . m . there was significant inverse correlation between sdma and inutest gfr (p< . )). there was no significant correlation between either pcr or egfr and inutest gfr. conclusions: this early data suggests that sdma might prove valuable in monitoring gfr in children with scd. introduction: the aim of this study was to identify the risk factors for renal scarring in children with lower urinary tract dysfunction (lutd) by using data available at the time of patient admission to the interdisciplinary management program of lutd at hospital das clínicas. material and methods: medical records of patients were assessed retrospectively concerning gender, presence of vesicoureteric reflux (vur), bladder capacity, detrusor overactivity, residual urine, urinary tract infection (uti), asymptomatic bacteriuria, constipation, detrusor-sphincteruncodination (dsu), high detrusor pressure at maximal cystometric capacity, low compliance, thickness and trabeculation of the bladder wall. renal scarring was diagnosed by dmsa scan. statistical analysis was performed by univariate and multivariate analysis. a p value < . , % confidence interval was considered significant. results: renal scarring was detected in patients ( %). abnormal bladder capacity, detrusor overactivity, residual urine, asymptomatic bacteriuria, constipation, dsu, high detrusor pressure and low compliance were not associated with renal sccaring. vur, uti, decreased bladder capacity, urinary residue, trabeculated and thick bladder wall were associated with scarring at univariate analysis. multivariate analysis showed vur (p< . ) and female gender (p= . ) as independent risk factors for renal scarring. thickness of the bladder wall was a marginal risk factor (p= . ). conclusion: urodynamic parameters didn´t predict renal damage in this study. uti was not a risk factor for renal scarring; however, it was associated with vur (p= . ). although vur was the main risk factor in our analysis, renal scarring was probably due to multifatorial causes as vur was associated with itu. results: comparison of test a and b demonstrates that a mild fluid load h before the administration of ddavp nasal spray ( puffs) results in major significant differences. ). maximal concentrating capacity (cc) is reached later than h after administration (p< . ). in / % cc at sleeping time is < % of max, thereby resulting in a persistent np in the first hour of the night. ) uosmol is significantly ( %) lower in the overnight collection (u ), correlating with a higher diuresis-rate ( %) ). the duration of the ddavp effect is shorter leading to an increase in diuresis-rate and to a decrease in the u osmolality in / children in the urine-collection between - h in the morning. this proves that in up to % of the patients the ddavp-effect does not cover the full night. conclusion: test b demonstrate sthat fluid intake prior to the ddavp-administration influences significantly the antidiuretic effect of ddavp (onset, maximum and duration). this might explain the partial response, suggestive for insufficient pd (and pk) effect of the spray. test a proves that fluid restriction h before ddavp administration, significantly reduces the nocturnal diuresisvolume. m. schmidts, c. schnakenburg, k. häffner, c. jacobi, k. schwab, m. pohl university hospital, center for pediatrics and adolescent medicine, freiburg, germany background: enteropathic hemolytic uremic syndrome (d+hus) is responsible for % of all hus cases. in addition to the nephrological and neurological complications, pancreatic damage resulting in diabetes mellitus is also possible and appears to be associated with more severe cases and elevated mortality. case report: a -year-old girl suffering from d+hus with severe colitis, acute renal failure, dyskinesia, dysarthria and agitation provoked by shiga-like toxin positive ehec infection in july, . the severe affection was characterized by partial thalamic infarction, prolonged leukocytosis (max. g/l) and the necessity of weeks of dialysis. days after the disease onset, hyperglycemia (max. mg/dl glucose) was noted. c-peptide was found to be low indicating reduced insulin secretion. months after hus the patient continues to be insulin dependent. clinically apparent exocrine pancreatic insufficiency has resolved spontaneously. gfr had recovered to ml/h/ , m , but then kidney function deteriorated and dialysis had to be resumed after months. kidney histology at this time showed severe nephron loss compatible with chronic changes after hus and ruled out other unrelated kidney disease. conclusion: in addition to the kidney damage, chronic pancreatic damage can occur in hus. therefore blood glucose levels should be monitored in all hus patients. it is tempting to speculate that patients after childhood hus might be at risk for diabetes mellitus later in life. objective: childhood nephrotic syndrome (ns) is characterised by a relapsing course resulting in significant corticosteroid burden or prescription of cytotoxic immunosupressive therapy. this randomised controlled study was carried out over years at a single centre in sri lanka to compare the efficacy and safety in children with steroid dependant ns treated with intravenous cyclophosphamide or intravenous vincristine therapy. methods: thirty-nine sequential children with steroid dependant ns with evidence of steroid toxicity were randomly allocated to receive either intravenous cyclophosphamide ( mg/m monthly for months) or vincristine ( . mg/m weekly doses followed by doses monthly). both groups received an identical tapering regimen of oral prednisolone for months. all children were reviewed on monthly basis for one year focusing on recurrence of proteinuria and side effects of therapy. finding of +++ proteinuria for consecutive days was diagnostic of relapse. results: there were ( m: f) children in the cyclophosphamide group (mean age . years) and ( m: f) in the vincristine group (mean age . years). during one year of follow-up / ( %) in the cyclophosphamide group suffered a relapse while / ( %) suffered a relapse in the vincristine group. p= . (comparison of proportions using standard error. ci . to . ). no serious adverse effects were encountered in either group. conclusion: in steroid dependant ns, intravenous cyclophosphamide therapy is superior to intravenous vincristine therapy in maintaining sustained remission. we present the clinical and biochemical features of a patient with antenatal bartter syndrome who was found to have a novel romk mutation. the patient presented antenatally with severe polyhydramnios. polyuria, hyponatraemia and hyperkalaemia were evident soon after birth. she had marked hypercalciuria and developed medullary nephrocalcinosis in early infancy. failure to thrive was evident from months. hypokalaemia was a late feature, developing gradually from months. serum chloride levels were consistently - mmol/l whilst urinary chloride levels were consistently < mmol/l, only reaching higher levels after treatment was commenced. alkalosis was not present and the patient did demonstrate some response to furosemide implying some functional capability of na-k- cl. renin and aldosterone levels were persistently elevated. treatment with indomethacin, nacl and kcl produced a good clinical response. mutational analysis revealed compound heterozygous mutations in kcnj , the gene encoding romk. both mutations, m t and l r are in the terminus of the protein thought to have a role in channel gating. similarities and differences from the classically described presenting features of antenatal bartter syndrome highlight the clinical heterogeneity in this condition. this relates to the different identified kcnj mutations which are likely to affect romk function in different ways. the m t mutation has been described, but past electrophysiological studies in sf cells transfected with the m t mutant have not identified any differences in k + conductivity from wild type romk. given that the mutation appears to be clinically relevant in this case, further functional studies are indicated. l r is to our knowledge a novel mutation. expression of these mutations in oocytes is now planned to enable evaluation their effects on channel function and regulation. a -year-old boy was admitted because of nephrotic syndrome. renal biopsy, performed after weeks of prednisone ( mg/m od) + methylprednisolone pulses ( mg/kg each), showed focal segmental glomerulosclerosis. prednisone was tapered (to mg/m od) and enalapril was introduced, without any significant improvement. two weeks later, the patient had transient hypoperfusive acute renal failure which required acei discontinuation. due to the persistence of proteinuria, cyclosporine was started ( mg/kg/day). proteinuria gradually decreased and ceased within the subsequent two weeks. in the meantime the boy had started to complain of low-grade fever without other symptoms and with normal physical examination. laboratory tests only showed leucocytosis (wbc x /ml) and increased c-reactive protein ( mg/l). a chest x-ray revealed an upper mediastinal enlargement and a total body ct scan confirmed the presence of several enlarged mediastinal lymph nodes, whose biopsy led to the diagnosis of hodgkin disease (hd) nodular sclerosis subtype, cd +; stage was iia. cyclosporine and the residual steroid treatment were discontinued and the patient was given six cycles of abvd (doxorubicin, bleomycin, vinblastine, dacarbazine), followed by radiation therapy. presently, months after stopping chemotherapy, both hd and nephrotic syndrome are still in remission. once again, this case points out both that fsg can be secondary to a lymphoproliferative disease and that chemotherapy for hd might have been effective to keep fsgs in long-lasting remission. several treatment methods including increased fluid intake and dietary modification, medical therapies such as potassium citrate and use of extracorporeal shockwave lithotripsy (eswl) and finally surgery methods are used for treatment of urolithiasis. the aim of this study was to evaluate the etiological and clinical characteristics and level of response to medical therapy with polycitra in children with urolithiasis. one hundred thirty-four patients had urolithiasis of which cases followed thetreatment instructions and fulfilled the inclusion criteria for this study. struvite stone were excluded from the study. all other patients who had an initial ultrasonography showing stone inurinary tract were treated with polycitra-k (potassium citrate grams, citric acid . grams in liter of distilled water) irrespective of the cause of the stone. at the end, complete resolution or passage or a decrease in the size of stone in later sonography was defined as response to treatment. hypercalciuria and hyperuricosuria were found to be etiological factor in % and % of patients respectively. the stone analysis was found that % of them were ca-oxalate. stone disease was more common between the age of - years. the most common complaint was hematuria ( %). eswl was performed in % of patients who did not respond to polycitra and had surgically active stones. calcium-oxalate stones were the most frequent stone which responded to polycitra. the response rate in girls and boys was equal and in different age groups the response rate was almost equal. methods: mmcs were expanded in culture and immunocytochemistry was used to characterize the cells. after gentamicin-induced atn, fluorescently-labeled cells were transplanted and traced in kidney tissues by fluorescence microscopy. kidney pathology was studied by hematoxylin-eosin staining, apoptosis was examined by the tunel assay, and ki- and bcl- expression were examined by immunohistochemistry and reverse transcription-polymerase chain reaction, respectively. results: ( ) mmcs (rimm- cells) were successfully expanded in culture. the phenotype of the cultured cells were vimentin-positive and kreatin-negative by immunocytochemistry. ( ) in the mmcs-treated group: the mortality rate decreased; renal function clearly improved; damage to the cell-treated kidneys was reduced and histopathologic lesion scores were lower; proliferation of renal tubular epithelial cells was improved; the apoptosis of renal tubular epithelial cells was reeuced; and the expression of bc - mrna and protein was upregulated. the subcapsular transplantation of mmcs could ameliorate renal function and repair kidney injury. atn is the most common reason for arf, and there is still an absence of effective therapies. this study was done to observe the effect of mobilizing bone marrow cells with stem cell stimulating factor (scf) and gm-csf on recovery from gentamicin-induced acute tubular necrosis (atn) in rats. atn was included in male sprague-dawley rats with five daily high dose intraperitoneal injections of gentamicin. subcutaneous injections of scf and gm-csf were administered simultaneously and these cytokines was observed at day , , , , and . leukocyte numbers, percent venous blood cd + cells, mortality rate, and concentration of the urine proteins, urine nag, bun, scr, and ccr, histopathogic lesion scores were determined. twelve hours after bone marrow ablation (bma) by lethal x-ray radiation, gentamicin-induced spf atn rats were given five daily injections of scf and gm-csf. bun, scr, and histopathogic lesion scores were evaluated at day , and . the effects and mechanism of scf and gm-csf on atn was observed. the number of leukocytes and the cd + cell percentage increased significantly in atn rats between and days after scf and gm-csf injection. in addition, mortality rates dropped, the peak value of renal function increased, renal function were rapid ameliorated and histopathologic lesions were reduced. there was no significant effect on atn rats after bma. this study demonstrates that scf and gm-csf effectively mobilized bone marrow stem cells in atn rats. rapidly improving renal function and decreasing mortality rate. these results suggest that bone marrow stem cell mobilization may be an effective therapy for atn. key words: acute tubular necrosis, bone marrow stem cells, stem cell factor, granulocytemacrophage colony stimulating factor, irradiation. objective of the study: the response to recombinant human erythropoietin (rhuepo), unit/kg twice weekly was studied prospectively in children and adolescents with end stage renal failure who were either transfusion dependent or had hematocrits (hct) < %. methods: rhuepo was given to haemodialysis (hd) patients and patients on conservative treatment, with mean age ( . ± . ) years, males and females with mean hct ( . ± . ). blood pressure, haematocrit, iron-indices, serum potassium, calcium, phosphorus, alkaline phosphatase, urea nitrogen and intact parathyroid hormone (ipth) were monitored serially. results: serum aluminum was measured randomly in patients, results were normal ranging from - ug/l. when serum ferritin was < ng/ml during therapy, they received iron supplementation. according to the response, patients were divided into groups, the non-responders group with hct< , mean age ( . ± . ) years, males and females with mean ipth ( . ± . pg/ml) and group of responders with hct > with mean age ( . ± . years), males and females with mean ipth ( increase of fatty acids such as nonesterified fatty acid (nefa) and triglyceride (tg) with oxidative stress and production of cytokine/chemokine occured during cisplatin (cp) toxicity. statin ( hydroxy- -mthylglutaryl coenzyme a reductase inhibitors) have been postulated to have pleiotrophic effects. we examined whether statin, pravastatin, would ameliorate renal damage induced by cp. male wistar rats (weight - g) fed standard chow were divided into groups: control-rats received tap water alone for days; cp treatment-rats that received cp ( mg/kg, i.v.) on the th day of the study; cp+pravastatin treatment-rats that received pravastatin ( mg/kg/day) in their drinking water for days and cp injection as indicated in the preceeding group. blood and urine samples were collected and the kidney were removed days after cp treatment. urinary excretions of protein and -hydroxy-deoxyguanosine ( -ohdg), serum levels of creatinine and fatty acids were measured. histology was evaluated by light microscopy with immunohistochemistry for pentosidine, n-carboxymethyllysine (cml), and heme oxygenase (ho)- . expression of ho- mrna in the kidney was also measured. pravastatin decreased urinary excretions of protein and -ohdg and ameliorated renal function diminishing areas of tubular damage and positive staining of pentosidine and cml compared with those of cp treatment alone. however, positive staining area and mrna expression of ho- were not significantly changed by pravastatin treatment. although pravastatin did not influence serum levels of total and low-density lipoprotein cholesterol, serum tg level decreased and was equivalent to that of control group. these findings suggest that pravastatin treatment partially protects against cp-induced nephrotoxicity in rats, through its antioxidant as well as lipid-lowering effect. n. bresolin, v. fernandes, f. carvalho, j. goes, l. araujo, m. simon, g. gamborgi, m. zanin hospital infantil joana de gusmo, nephrology pediatric department, florianópolis, brazil objectives: the objective is a report case of acute renal failure (arf) in a child contact with lonomia obliqua caterpillar in southern brazil. the accidents with lonomia oblique has increased in south of brazil in recent years. this increase can be related with reduction of caterpillar natural predators and deflorestation. the venom of lonomia caterpillar provokes hemorrhagic syndrome resembling disseminated intravascular coagulation (dic) and hemolytic anemia. arf could be an important complication of hemoglobinuria that has been recently described in adults. methods: a case report. results: the present is a first case described of arf in a child after contact with lonomia obliqua caterpillar. conclusions: the arf can occur in any age, however, the contributing factor to the development of arf remains obscure. there are mechanisms pointed out: fibrin deposition in glomerular microcirculation, ischemia in hemorrhagc shock with hypotension and venom direct action. the present article related a case of lonomia obliqua accident in a child who revealed coagulation disorder, hemolytic anemia, arf and always, she was hemodynamic stable. the treatment included antilonom serum, urine alkalinization, hyperhydration and peritoneal dialysis for four days. she was treated and followed per year when she recovered her normal renal function. introduction: secondary hyperparathyroidism develops in chronic kidney disease as a consequence of impaired phosphate, calcium and vitamin d homeostasis. the treatment includes phosphate binders and vitamin d analogues, but sometimes ineffective. we report two cases of refractory secondary hyperparathyroidism treated successfully with cinacalcet. case : a -month-old boy with end stage renal disease (esrd) due to posterior urethral valve started on peritoneal dialysis at months of age. he developed secondary hyperparathyroidism with serum parathyroid hormone (pth) level reaching pg/ml. serum calcium had been in the range of . to . mg/dl and serum phosphorus in the range of . to . mg/dl. despite treatment with phosphate binders and vitamin d analogues, pth levels kept increasing to pg/ml. x-ray showed the cupping and fraying of the distal ends of radius and ulna. we started cinacalcet mg daily and increased the dosage up to mg daily. eight months later, pth level decreased to pg/ml and bone changes resolved. case : a -year-old boy with esrd due to primary hyperoxaluria started on peritoneal dialysis at years of age. he developed secondary hyperparathyroidism with serum pth level of pg/ml. serum calcium had been in the range of . to . mg/dl and serum phosphorus in the range of . to . mg/dl. despite treatment with phosphate binders and vitamin d analogues, pth level kept increasing to pg/ml. x-ray showed the distal radius and ulnar fracture of left arm and right femur fracture. we started cinacalcet mg daily. five months later, pth levels decreased to pg/ml. conclusion: cinacalcet is effective in the secondary hyperparathyroidism resistant to phosphate binders and vitamin d analogues in children with chronic renal failure. rota virus (r) is a common pathogen as the cause of gastroenteritis in childhood. we experienced some cases with r infection who had the renal failure induced by uroammoniac calculi as well as dehydration. we examined the clinical feature and laboratory findings of the cases with viral acute gastroenteritis in r and non-rota virus (nr) groups for - . with rapid diagnosis test, we checked the patients that needed the hospitarization medical treatment from newborn to five-years old. in the cases of r group and cases of nr group, we campared the clinical findings, blood chemistry test and urinalysis of r groups in acute and convalescent a tage with those of nr group. r group had significantly (p< . ) lower in ph (vein blood gas test) and higher in blood uric acid (bua) compared with those of nr group. these findings suggest that the elevation of bua and acidosis in r group may induce the formation of renal calculus resulting in postrenal failure. our patient is white male y/o. at year of age, he was dx. with acute lymphocytic leukemia and was induced to remission on pog ; he presented tumor lysis syndrome during induction, acute renal failure with no recovery in renal function and rrt was started (ccpd) and continue on the same therapy. during the last years, he presented chronic pancreatitis, ards, sepsis. he had episodes of major vessel thrombosis probably due to central lines (several femoral lines and vascath placed in his thorax) and l-asparaginase. our patient did receive years of chemotherapy and radiation; and he is on complete remission. on / , , for pre-kidney transplant evaluation, a mri test was requested using gadolinium ml/kg for evaluating his vascular system (abdomen and pelvis) with inconclusive results. another mri test was requested months later using gadolinium . ml/kg. weeks later, his mother noticed brawny hyperpigmented, shiny, tightly bound-down, indurate plaques of his bilateral lower extremities, (more significantly on his lateral and posterior calves, and in his anterior and lateral thighs) a punch skin biopsy showed increasing number of fibroblastic cells and widened space between septa in the deep reticularis dermis compatible with nfd. nfd is a fibrosing disorder identified among patients with renal disease with cutaneous finding of skin thickening in extremities and trunk, very similar to those of systemic sclerosis. etiology, pathogenesis and clinical course remain unknown. the majority of cases have been reported in dialysis or kt patients and gadolinium has been identified as a trigger of nfd. in our case, there appears to be a link between the use of gadolinium and the developed of nfd. background: chronic renal failure (crf) is an independent cardiovascular risk factor. changes in calcium-phosphate homeostasis not only affect the quality of bones but also constitute the biochemical base for vascular calcification. aim: to find a method better describing factors of calcification using routine laboratory examinations and computed evaluation of complex equilibria. methods, patients: data of crf and of transplanted (tx) children were compared to a healthy control group of . tx children's parameters were taken before and and month following transplantation. three different strategies were used to analyse factors of calcification: ca x p product, ca-p activity value and the concentration of cahpo . the ca x p product and the ca-p activity value were not informative, because they didn't represent the direction of change in the complex chemical equilibrium. the cahpo concentration was increased in the crf and the tx group (before transplantation) ( . ± . mmol/l) compared to the healthy control group ( . ± . mmol/l) (p< . ). after and months to transplantation the cahpo concentration was in the normal range in the tx group. a negative correlation was found between the concentration of ica + (ionic calcium) and pth (parathyroid hormone) in the dialysed children (r= . ), but not in the transplanted group (r= . ). conclusion: according our findings the force driving calcification is better represented by the concentration of cahpo , the base compound of all primary calcification, than by measuring ca and p separately. follow-up study is needed to establish the predictive value of determination of cahpo . this study was supported by grants otka-t and ett / , the national office for research and technology (nkth) and szentágothai j. knowledge centre. introduction: acute renal failure is a rare complication of nephrotic syndrome and its cause is still unknown. several investigators reported that the most important factor for renal failure was acute tubular necrosis (atn); however, some cases did not have laboratory findings of tubular dysfunction paradoxically. patients and methods: we reviewed cases of nephrotic syndrome with acute renal failure (nsarf) since at metropolitan kiyose children's hospital. seven of cases had calcium deposition in the distal tubules predominantly. we analyzed the clinicopathological findings in these cases. results: the pathological diagnoses of these cases were as follows: minor glomerular abnormalities, mesangial proliferative glomerulonephritis (without iga deposition), and focal segmental glomerulosclerosis. interstitial nephritis was not documented in any case. the common characteristics of these cases were calcium deposits in the distal tubules. some cases had focal simplification of tubular epithelium. all cases were an initial episode of nephrotic syndrome, and cases were steroid resistant. almost all cases had hypertension. in addition, the range of urinary β microglobulin and fena were to and . to . %, respectively. discussion: in these cases, there was enhanced na reabsorption and urinary β microglobulin was only mildly elevated at the time of renal failure. these findings were not consistent with atn. additionally, pathological finding of severe tubular damages was not found on biopsy. contrarily, tubular obstructions due to ca depositions were consistent with these clinicopathological findings. conclusion: our findings suggest that tubular obstruction due to calcium deposition plays an important role in the etiology of nsarf except for atn. background: natriuretic factor was found in urine of chronic uremia for more than years. n-terminal pro-b-type natriuretic peptide (prontbnp) is postulated to be the natriuretic factor owing to its elevation in chronic kidney disease (ckd). however, salt wasting and non-saltwasting chronic kidney disease haven't been partitioned as different entities before. this study is designed to clarify whether prontbnp is different in salt wasting and non-salt wasting ckd and if it is the main causative factor of natriuresis. methods: patients with salt wasting ckd, which are mainly composed of congenital renal structure abnormalities, and patients with non-salt wasting ckd, which are mainly composed of glomerulonephritis, were collected. all of them are non-dialysis-dependent and without heart failure. serum prontbnp in these two groups and normal controls were sampled. fractional excretion of sodium (fena) and estimated clearance of creatinine (ccr) were also checked. results: prontbnp was elevated in salt wasting group compared to normal controls (p= . ). moreover, prontbnp was even significantly higher in non-salt wasting group than in salt wasting one (p< . ). in salt wasting ckd, prontbnp and fena were correlated (r= . , p= . ), but the same result was not observed in non-salt wasting group. prontbnp was significantly correlated to ccr and age using multiple regression analysis (p< . ). conclusion: prontbnp elevation was different between salt wasting and non-salt wasting ckd. volume expansion explained the difference and prontbnp elevation in salt wasting ckd resulted from other mechanisms. since salt wasting ckd, in which the influence of volume expansion was eliminated, had a good correlation between prontbnp and fena, prontbnp may be one of the major contributing natriuretic factor in chronic uremia. background: cidofovir is a new antiviral drug that has a broad spectrum of activity against a number of dna viruses. several observations reported its efficacy as topical treatment of resistant warts. we herein report a systemic complication of acute renal failure associated with such topical therapy. casereport: girl aged , received a renal transplant in and for end-stage renal failure secondary to haemolytic uremic syndrome. her initial immunosuppressive regimen consisted of prednisone, tacrolimusand mycophenolate. five years post transplant she developed chronic allograft nephropathy with mild renal impairment. as a consequence of long standing immunosuppression she also developed invalidating, widespread periungueal warts. a well conducted, aggressive, conventional management of her warts including reduction of immunosuppression failed to improve the symptoms. she subsequently received an intralesional injection of a mg/ml cidofovir solution. forty eight hours after the treatment she developed local swelling, inflammation and pain along with acute alteration of renal function. although cidofovir seric dosages performed on day , , and postinjection were negative we attributed this acute renal failure to a potential nephrotoxic side effect of cidofovir. renal biopsy showed no evidence of rejection but mild alterations of the tubes compatible with tubulo-interstitial nephritis. spontaneous recovery of renal function occurred within months. conclusion: we describe an acute renal failure as a consequence of topical cidofovir treatment of warts in the context of renal transplant with mild preexisting renal failure. topical administration of cidofovir needs as carefull use and monitoring as its parenteral administration, especially in patients with altered renal function. the hemolytic uremic syndrome (hus) is a disease characterized by microangiopathic hemolytic anemia and variable organ impairment with a predominat feature of renal failure in children. the aim of this study was to investigate the presence of plasma lipid peroxidation products in the acute phase of hus. we have analyzed the levels of lipid peroxidation, determined fluorometrically as thiobarbituric acid-reactive substances (tbars), in the plasma of patients (aged - months with a median of ) diagnosed with the shiga toxin-associated form of the disease. in all cases, tbars determinations were performed at hospital admission, during treatment and upon discharge. tbars values averaged . ± . and . ± . mm sem at admission and discharge respectively (reference value < . mm). of the patients examined, presented conserved diuresis during the course of the syndrome, while the other were anuric and required dialysis. maximum tbars values resulted significantly higher (p< . by anova followed by newman-keuls test) in the dialysis-requiring patients as compared to those that had conserved diuresis ( . ± . vs . ± . mm respectively) we also investigated a possible correlation between tbars and plasma creatinine, urea, lactate dehidrogenase (ldh) and platelet count. positive and highly significant correlations (r= . and . , p< . ) were observed when tbars values were plotted as a function of plasma creatinine and urea values respectively. no significant correlations were detected for tbars and plasma ldh values or platelet count. thus, patients affected by shiga toxin-associated hus exhibit increased levels of oxidative stress. also, there is a positive correlation between the magnitude of oxidative stress and the severity of renal failure. c. soares, j. diniz, e. lima, g. oliveira, c. camargos, b. sousa, e. oliveira objective of the study: the purpose of this retrospective cohort study was to report the clinical course of children and adolescents with chronic kidney disease (ckd) enrolled in a pre-dialysis program. methods: the records of patients with ckd admitted to an interdisciplinary pre-dialysis program from to were retrospectively analyzed. the program consisted of conservative management of children and adolescents with ckd and was conducted by an interdisciplinary team including pediatric nephrologists, pediatricians, nurses, psychologists, nutritionists, and social workers. the patients were admitted with a glomerular filtration rate (gfr) equal to or below % of the value expected for their age according to normal reference data. demographic, clinical and laboratory data at entry and at the end of the follow-up were analyzed. renal survival analysis was performed using the kaplan-meier method. results: the median age at admission was . years (interquartile range: . - . yr). the most frequent primary renal disease was congenital urological anomaly in patients ( %), following by glomerular diseases in ( %), cystic diseases in ( %), and others in children ( %). at admission, patients ( %) had ckd stage , ( %) had ckd stage , and ( %) presented ckd stage . median follow-up time was . years (iq range, . - . ). at the end of the follow-up, children presented ckd stage or ( %), patients were in stage ( . %), in stage ( %), and children were in stage ( %). it was estimated by survival analysis that the probability of ckd stage was % at years, % at years, and %at years after admission to the pre-dialysis program. conclusion: the long-term overall renal survival is relatively poor in a cohort of children and adolescents with ckd. objective: characterize the association between proteinuria and gfr in a cross-sectional study of children with mild to moderate chronic kidney disease (ckd). methods: first morning urine protein to creatinine ratios (up/c) and gfr (measured by iohexol blood-disappearance) for children enrolled in the ckid cohort study were examined using loglinear regression of proteinuria and gfr, adjusted for age, sex, body surface area (bsa), and ckd cause. conclusions: in children with mild to moderate ckd, there was a log-linear relation between proteinuria and gfr. the prospective cohort design of ckid will assess the risk of gfr decline associated with level of proteinuria in children with glomerular vs non-gn causes of ckd. objective: to study the clinical characteristics of chronic renal failure (crf) in children. the clinical data of children with crf in the last fifteen years were retrospectively analyzed. results: the first main causes of crf in children were still glomerular disease, and congenital deformities of urinary system and hereditary renal disorders were the second main causes. the initial age of children with crf which were caused by congenital deformities of urinary system and hereditary renal disorders were relatively younger than children with crf which were caused by glomerular disease. the symptoms of some crf in children were not typical. conclusions: glomerular disease were still the first main causes of crf in children. urine screening test, early renal function examination and kidney b-mode ultrasonic were attribute to early diagnosis and proper management of crf in children. the aim of the study was the evaluation of influence of clinical and biochemical parameters upon degree of impairment of cardiac function in dialysed children. methodology: chronically dialysed ( hd, pd) children participated in the study ( m, f), aged - , yrs (x= , ± . yrs). echocardiography examinations were carried out with a hp device. diastolic and systolic left ventricular (lv) dimension, ejection fraction (ef) and lv mass index (lvmi) were evaluated. mean values of estimated parameters in months preceeding echo were calculated. results: on the basis of echo examinations groups were singled out: a (n= ) of normal heart function, b (n= ) of impaired systolic and diastolic heart function and c (n= ) of normal systolic and impaired diastolic heart function. no differences between groups according age, bmi, dialysis and renal insufficiency duration were found. in group of children with severe cardiac lesion (b group) a higher lv mass (a vs b vs c: , vs , vs , g/m) and statistically significant lower ejection fraction ( , vs. , vs. , %) were ascertained. these children were anuric ( vs. vs. ml/d), their systolic ( , vs. , vs. , ) and diastolic ( , vs. , vs. , ) blood pressure were significantly higher, so was the number or hipotensive medications ( , vs. , vs. , ) . bioimpedance analysis showed overhydration in group b (tbw% vs vs . ; ecw/icw . vs . vs . ). conclusions: the vast majority of chronically dialysed children demonstrate an impairment of cardiac function mainly of diastolic parameters. anemia, malnutrition, hypervolemia, anuria and hypertension stand for a significant risk factors of cardiac impairment in dialysed children. we report here the clinical findings and prognosis of patients ( girls, boys) with infantile oxalosis diagnosed between june and december in order to remind this rare autosomal recessive metabolic disorder as the potential cause of acute renal failure in infancy. the mean age of the patients was . months (range: . - months). all patients had the complaint of vomiting since birth, had irritability, and had convulsions. seven of them had parental consanguinity ( %) and family histories revealed urolithiasis in four patients and infantile deaths in one. two patients were cousins without any other family history. all patients presented with anemia (hemoglobin: . - . g/dl), renal failure (creatinine levels: . - . mg/dl) and metabolic acidosis. abdominal x-rays showed bilateral nephrocalcinosis, renal ultrasonographies revealed normal sized kidneys with diffuse and intensive hyperechogenity and loss of corticomedullary differentiation in all patients. crystal deposition was demonstrated in fundoscopic examination of patients, bone marrow aspiration of patients, and renal tissues of patients that underwent renal biopsy. besides supportive therapy, peritoneal dialysis was performed on patients, but only one patient accepted to continue the therapy. four patients died within few months and were lost to follow-up, probably died. two patients have been followed up for months one on continuous ambulatory peritoneal dialysis. in conclusion, this rare disease with fatal outcome should be remembered and investigated in infants with renal failure and bilateral nephrocalcinosis since early combined renal and liver transplantation may be life saving if it can be performed. acute renal failure following halothane anesthesia in young child? case report we present here the case of renal failure and hepatocellular lysis that developed h after the exposure of halothane anesthesia during eye examination. previously a healthy months old boy had a cardiac arrest, during the above mentioned diagnostic procedure, therefore cpr was applied which all happened in another hospital. after a few hours he was transferred to icu at our hospital, consciousness, hemodinamic stabile. in the following hours he developed acute non-oliguric renal failure (maximal level of urea mmol/l, creatinine mmol/l), as well as hepatocellular lysis (alt u/l, ast u/l). plasmaferesis and continuous venovenous hemodiafiltration were immediately applied followed by conservative measures. the level of serum transaminase returned to the normal values within a week and the level of creatinine and urea within two weeks. fully recovered boy was released home. toxic effects of halothane anesthesia in children are reported in only few cases in the literature. objective of study: many cases of chronic aristolochic acid nephropathy (caan) in adults had been reported, but it had rarely been described in children. we reported children with caan to investigate its clinical and pathological characteristics. methods: three cases were studied retrospectively and relevant literatures were reviewed. results: three children received traditional chinese herb medicine containing aristolochic acid to months for different basal diseases including chronic aggressive hepatitis b, secondary hydrocephalus and purpura nephritis and suffered from caan from mouths to years after they began receiving the chinese medication. the main manifestations were renal failure of various degree accompanied with proximal and distal tubular dysfunctions. two of them began with anemia and suffered from serious renal failure. the onset of another case was glucosuria with renal function impaired mildly, and she presented secondary fanconi's syndrome simultaneously. their pathological characteristics were diffuse paucicellular interstitial fibrosis and marked tubular atrophy with mild glomerular impairment. after withdrawal of the chinese herb medicine, renal failure in two patients attenuated progressively. the clinical features of caan in children are progressive renal failure and renal tubular disfunction. its pathological characteristics are diffuse paucicellular interstitial fibrosis and marked tubular atrophy. therefore, we emphasize the recognition of the nephrotoxicity of traditional chinese herb medicine and prevent caan from happening in children. objective of study: recombinant human erythropoietin (rhuepo) treatment may cause pure red cell aplasia (prca), but it had been rarely described in children. in order to acquaint ourselves with this disease, we reported a boy with chronic renal failure developed prca following rhuepo treatment. methods: one case was studied retrospectively and relevant literature was reviewed. results: a -year-old boy suffered from chronic renal failure combining with renal anemia and received rhuepo treatment. two weeks later, his hemoglobin (hb) increased from to g/l, and maintained to g/l for weeks. subsequently his hb declined suddenly at a rate of g/l/day, despite rhuepo increased in dose. his reticulocyte count reduced to . /l without other cytopenias in peripheral blood. a series of laboratory examinations were performed, including bone marrow cell smear and culture to confirm his prca. because various of other factors such as parvovirus etc. induced prca was excluded, we considered the boy's prca was due to rhuepo treatment, although we didn't detect anti-epo antibodies for lacking of the reagent. the boy received erythrocyte suspension transfusion to correct his anemia and was waiting for renal transplant in the following period. conclusions: during the treatment of rhuepo, sudden and rapid reducing of hb might be a hint of rhuepo induced prca. the diagnosis should be based on the clinical presentation, the absence of red cell precursors in bone marrow and the detection of anti-epo antibodies. renal transplant and immunosuppressive therapy might be effective. m. zaniew, b. mroziñski, a. warzywoda, e. stefaniak, a. siwiñska, j. zachwieja among ambulatory blood pressure monitoring (abpm) parameters, pulse pressure (pp) provide an information on cardiovascular (cv) status. recently, a novel parameter i.e. ambulatory arterial stiffness index (aasi) has been proposed. aim: to investigate pp and aasi in relation to left ventricular (lv) geometry and carotid intima-media thickness (cimt) in children with chronic renal failure (crf). subjects: children ( f/ m; median age: yrs) with crf treated conservatively (n= ) and with dialysis (hd; n= /pd; n= ). methods: we studied demographic data, echocardiography data [left ventricular mass (lvm), left ventricular mass index (lvmi), interventricular septum (ivs), left ventricular posterior wall (lvpw), left ventricular end diastolic diameter (lvedd), relative wall thickness (rwt)], cimt and abpm. from abpm, we calculated pp [difference between systolic blood pressure (sbp) and diastolic blood pressure (dbp)] and plotted dbp against sbp (regression slope). aasi was defined as minus this regression slope. results: a positive correlation was found between aasi and pp (r= . , p< . ). aasi was correlated to lvedd (r= . , p< . ) and rwt (r=- . , p< . ). pp was related to: weight (r= . , p< . ), body surface area (r= . , p< . ), body mass index (r= . , p< . ), and lvm (r= . , p< . ), lvmi (r= . , p< . ), lvpw (r= . , p< . ), lvedd (r= . , p< . ), rwt (r=- . , p< . ). neither aasi nor pp was associated to cimt. children with lv hypertrophy had higher pp than without this alteration (p< . ). when data analyzed across quartiles of pp, children in the upper quartile showed higher lvm (inter-group comparisons p< . ), lvmi (p< . ), lvpw (p< . ) and lvedd (p< . ). conclusions: pp is a stronger predictor than aasi of lv geometry in children with crf.. acute renal failure in newborn period may be caused by prenatal, natal and postnatal factors. among them, obstructive lesions of the genital tract (e.g. imperforate hymen and vaginal atresia) are very rare. children with hydrometrocolpos due to distal vaginal atresia may present with severe obstructive uropathy and its consequences. hydrometrocolpos is the result of vaginal obstruction and can become an emergency in newborn period. acute renal failure associated with distal vaginal atresia appears to be rare, with only one report in the paediatric literature. here we report a -dayold infant with a hydrometrocolpos causing life-threatening renal failure. percutaneous drainage did result in dramatically improved clinical and laboratory findings of the patient. objectives of study: sympathetic overactivity is currently considered as an important mechanism of both development and progression of chronic renal failure. however, this statement was mostly based on the researches in which the participants were adult patients with terminal renal failure. little information is available on autonomic changes in pediatric patients with mild renal insufficiency. our aim was to determine whether there is sympathetic activation in children with chronic pyelonephritis in a stage of mild renal insufficiency. methods: patients met the inclusive criteria were selected and assigned into two groups according to the creatinine clearance. group i had patients with creatinine clearance between and ml/min/ . m while group ii have patients with normal creatinine clearance. baseline of age (from - years old), gender and diagnosis between the groups are comparable. time domain analysis of heart rate variability in short-term recordings of minutes was performed in both groups. as well vain questionnaire for assessment of autonomic state was performed in all participants with their parents help. results: the outcomes of heart rate variability analysis showed sympathetic overactivity of . % patients in group i vs . % in group ii, and the difference is statistically significant (t= . , p< . ). significant difference was also found in results of vain questionnaire: . % of patients in group i were estimated as "sympathetic", while only . % in group ii (t= . , p< . ). conclusions: based on the consistent findings of the two methods used in this study, we conclude that sympathetic overactivity may be found in children with even mild renal insufficiency, and it should be considered as an early event in the development of pediatric renal failure. the aim of this study was to describe the prevalence of myocardiopathy in pediatric patients with different stages of ckd (stages to ).methodology: inclusion criteria -gfr < ml/ . m , ckd treatment > months, age < years old. echocardiograms were performed using standard techniques. left ventricular mass (lvm) was measured by two-dimensional directed m-mode echocardiography according to the american society of echocardiography criteria. lvm index was assessed and when > g/m . it was considered severe hypertrophy. the relative wall thickness (rwt) was measured to assess the lv geometric pattern. age, high blood pressure (hbp), anemia, time and type of treatment were compared to the echocardiographic findings. results: we evaluated patients, mean age years old, % on pre-dialysis, % on hemodialysis (hd) and % on peritoneal dialysis (pd). patients on hd were evaluated in the interdyalitic period. twenty-seven patients ( %) had myocardiopathy, clvh in ( %), elvh in ( . %) and cr in ( %). severe hypertrophy ocurred in pacients ( . %). there was no significant difference in relation to age and high blood pressure. patients with clvh were on hd for longer time and had a lower hematocrite when compared to the patients without clvh ( ± vs ± months; p< . ) and ( ± vs ± ; p< . ) respectively. there was a significant correlation between hematocrite and left ventricular mass (r = . ). conclusion: we observed a high prevalence of myocardiopathy in this study population. the risk factors associated to clvh were anemia and time on hd. larger and prospective studies are needed to analyze the impact of myocardiopathy in the cardiovascular mortality in children as well as the results of interventions applied to correct these risk factors. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . urological problems such as vesicoureteral reflux ( , %), obstructive uropathy ( , %) and neurogenic bladder ( , %) were the leading underlying conditions causing cri with a total of , %. while majority of the patients were having gfr levels less than ( , %) or between to ml/min/ , m ( , %), gfr level was between - in only . %of the patients. patients with pth levels between - and more than pg/ml comprised the majority ( , and % respectively). the gfr levels correlated positively with hemoglobin/hematocrit and calcium levels and negatively with phosphorus and pth levels (p< . ). renal replacement therapies were initiated in , % of the patients. the most striking result of this study is the predominance of vur or related urological problems that are relatively preventable as the underlying causes of cri in children. early diagnosis and appropriate medical or surgical management of these conditions should be emphasized together with achieving broader coverage of the pediatric cri population in terms of supportive treatment. twin-twin transfusion syndrome (ttts) complicates up to % of monochorionic twin pregnancies. shunting of blood between twins through common placental blood vessels can cause growth restriction, oligohydramnios and anaemia in the donor twin. renal impairment in the donor twin has been reported as a transient phenomenon with full recovery. we describe a case series of three children with chronic renal failure due to ttts. all cases were monochorionic diamniotic twins. in cases and , growth discrepancy was noted on prenatal scanning. in the case anomaly scans were normal. gestation at birth ranged between and weeks. in all cases there was a significant birth weight discrepancy between twins. post-natal ultrasound appearances were variable: case had normal scans within the first month but echogenic kidneys at months; case had initial increased echogenicity but features consistent with cortical necrosis at weeks; case had small kidneys with no cortico-medullary differentiation. all children became dialysis dependent within the first year of life. age of commencement ranged from days to months. case was successfully transplanted at years. case had an unsuccessful transplant at years and remains on dialysis at years. case remains on dialysis at years. cases and are now at mainstream school with only mild learning difficulties; case has some gross motor delay but other wise normal development. with advances in neonatal intensive care and improved survival of low birth weight babies, this presentation may become increasingly common. even severe renal involvement can occur in the absence of other significant hypoperfusion injury. the management of survivors of ttts with established renal failure may present unique challenges and opportunities. introduction: endothelial heparan sulfate proteoglycans (hspg) play an important role in various biological processes in the renal glomeruli. it is involved in the inflammatory process by acting as a ligand for l-selectin. furthermore, leukocytes are able to interact with chemokines bound to hspg (examples are il- , rantes and mcp- ). this will lead to activation of the integrins on leukocytes and result in more stable leukocyte-endothelial wall adhesion. in this work, we have studied the effect of a subtoxic dose of shiga-like toxin (stx) and on the hspg and the possible implications on the pathogenesis of the hemolytic uremic syndrome (hus). methods: to study this effect, primary human umbilical venous endothelial cells (huvec) and primary human glomerular microvascular endothelial cells (gmvec) were incubated for hours with a subtoxic dose of stx or . then, cells were treated with the enzyme heparinase (which cleaves off hspg). non-treated cells were used as controls. after treatment with the enzyme, the endothelial cells were exposed to flowing human leukocytes in a parallel plate flow chamber. the amount of adherent leukocytes was calculated. -: not treated with heparinase , +: treated with heparinase conclusion: stx and cause an upregulation of the amount of adhering leukocytes on both endothelial cell types. treatment of the endothelial cells with heparinase decreases markedly this upregulation. the effect can not be detected without stx-incubation. this can be explained by a possible upregulation of hspg on endothelial cells by stx, resulting in a higher level of bound chemokines or an increased binding of released chemokines to hspg. this will lead to an increased adhesion of leukocytes and will induce a more severe inflammatory process in the renal endothelium. this effect will contribute to the devastating pathogenesis of the hus. c. soares, j. diniz, e. lima, g. oliveira, c. camargos, b. sousa, m. almeida, e. oliveira objective of thestudy: the purpose of this study was to identify clinical, nutritional and laboratory factors associated with the rate of progression of chronic kidney disease (ckd) among the children and adolescents admitted to a pre-dialysis interdisciplinary program. methods: one hundred eight children and adolescents aged months to years with ckd in conservative management were prospectively followed up from to . renal survival was analyzed by the kaplan-meier method and cox's regression model. a multivariate model was developed from the admission until occurrence of ckd stage (glomerular filtration rate < ml/min). the following data were obtained at admission: gender, race, age at admission, weight z score, renal primary disease, blood pressure, and laboratory data (serum creatinine, serum urea, glomerular filtration rate, hr urinary protein excretion, hematuria). results: median follow-up time was . years (iq range, . - . ) and patients ( %) progressed to ckd stage . in the univariate analysis the following variables were significantly associated with the event: non-white race (p= . ), age > years (p= . ), ckd stage at baseline (p= . ), renal primary disease (p< . ), severe proteinuria (p< . ). after adjustment, variables remained as independent predictors of ckd stage : severe proteinuria (rr= . , % ci= . ± . ), glomerular disease as renal primary disease (rr= . , % ci= . ± . ), and ckd stage at baseline (rr= . , % ci, . ± . ). conclusion: the combination of three factors -severe proteinuria, glomerular disease, and ckd stage at admission -was an independent indicator of adverse outcome in children and adolescents in a pre-dialysis interdisciplinary program. background: allogenic hematopoetic stem cell transplantation (allo-hsct) has gained world wide acceptance as a treatment for various diseases. renal dysfunction is one of the major complications that influences transplant related mortality (trm) rates following hsct. in this prospective study, we aimed to investigate the effect of allo-hsct on renal function in children. methods: renal ultrasonography, dmsa scintigraphy, analysis of renal and tubular function tests were performed before, shortly and -year after hsct. acute renal toxicity (art) was classified according to bearman criteria. grade =increase in creatinine up to twice the baseline; grade =increase in creatinine above twice baseline; grade =increase in creatinine above twice baseline and need for dialysis. chronic renal insufficiency (cri) was defined as gfr< ml/min/ . m and failure (crf) as need for dialysis. results: between april and june , children (median age: . years) underwent allo-hsct because of hematologic disorders (malignancy, ; hemoglobinopathy, ; aplastic anemia, ). all patients except one received nontbi conditioning regimen. six patients ( . %) were died because of trm but none of these patients had primary art. during the first days, patients ( . %) had grade art (csa nephrotoxicity in , vod in patients). grade art was defined in patients ( . %) (vod in , sepsis in , csa nephrotoxicity in patient). eleven patients had structural renal abnormalities before hsct, of them persisted and new patients had pathologic results one year after hsct. in long term period, ( . %) of evaluable children had cri and no patient had crf requiring dialysis. conclusion: renal dysfunction was found to be a frequent complication after allo-hsct in children. therefore, renal functions should be followed carefully in these patients. . years and at the end of follow-up, and compared between the three groups. there were no significant differences between groups in so far as gender, underlying disease, age at diagnosis, proteinuria, hypertension, hyperparathyroidism, use of ace inhibitors or renal size. erithropoietin use was significantly higher (p< . ) in group . gfr improved in all three groups during their first two years of life. the cut-off point on the roc curve indicating worse gfr long term evolution was ml/min/ . m at two years of life (sensitivity %, specificity %). g. zilleruelo, am. onder, j. chandar, o. nwobi, c. abitbol background: catheter-related bacteremia (crb) is a common complication of tunneled-cuffed hemodialysis catheters. our objective was to investigate the effectiveness of tissue-plasminogen activator-tobramycin locks (tpa-abl) in preventing crb in pediatric patients. methods: a retrospective analysis of pediatric hemodialysis patients was performed. patients with > crb/ catheter days (cd) were designated as high risk. those with < crb/ cd were of average risk. three eras of consecutive months were studied. in era , high risk patients were detected. during era , the high-risk group was placed on times weekly prophylactic tpa-abl. in era the high-risk group was given once weekly tpa-abl. results: there was a significant decrease in the rate of crb with prophylactic tpa-abl which was more pronounced when given three times/week. conclusions: the use of prophylactic tpa-abl times weekly significantly reduces the rate of crb in patients at high risk. prophylaxis once weekly may be less effective than thrice a week. l. was born after a normal pregnancy without a special personal or familial history, was seen at the age of years, after a days long ordinary oro-pharyngeal viral infection treated by symptomatic treatments. he presented with inflammation of the left cheek with slight fever ( °) and a sole purpuric lesion of the left leg ( cm) and some petechiae on the thorax. blood count showed haemolytic anemia (haemoglobin= g/dl, schizocyte= %, increased ldh), white cells ( % neutrophils) and platelets. no germs were found in hemoculture, lumbar punction, stools or urines cultures. creatininemia was μmol/l. in the following hours, despite immediate antibiotics administration and without any shock sign, several purpuric extensive necrotic lesions appeared, renal insufficiency increased (creatininemia= μmol/l), platelets count decreased to and markers of diffuse intravascular coagulation dramatically increased. in the following days, proteinuria, macroscopic hematuria and hypertension appeared. after days on anticoagulation therapy, renal function remained stable while anemia, thrombopenia and coagulation disorders persisted. coagulation factor tests demonstrated a heterozygote deficiency of factor v leiden (also found in the father) and an acquired protein s deficiency secondary to streptococcal infection. after protein s infusion and plasma exchanges, his state improved and necrotic lesions ceased. this initial hematologic and renal presentation could have suggest a hus but the large purpuric lesions remain unusual in such pathology. a in children on chronic peritoneal dialysis malnutrition is being diagnosed with an objective combined nutritional score (abn score) based on anthropometry and bioimpedance analysis indices (nephrol dial transpl ; : - ) . aim of this study was to investigate the prevalence of malnutrition and the main factors associated with it in children with ckd - . we planned a cross-sectional study of children with ckd - , mean age . ± . years, who underwent controls in our institution between september and december , . the data of abn score, age, primary renal disease, standard blood and urinary tests, and estimated gfr (schwartz formula) were collected.the prevalence of malnutrition (abn score < . ) in the whole population was %. the abn score was positively correlated with age, height sds, serum hemoglobin, total protein and albumin (p value from < . to < . ), while a negative correlation was found with serum phosphate and proteinuria (p< . ). patients with steroid-resistant nephrotic syndrome had lower abn score values than those with other primary renal diseases ( . ± . vs . ± . ; p< . ). the percentage of children with malnutrition in the different stages of ckd increased in parallel with the decrease of gfr, from % in the ckd group to . % in the ckd group. in conclusion, the prevalence of malnutrition in children with ckd - is not negligible. low hemoglobin, total protein and albumin levels and high serum phosphate and urinary protein excretion, particularly in small children with growth impairment, strongly suggest the need for an in depth nutritional assessment, in order to diagnose malnutrition and treat it accordingly. e.c. developed atypical hus at months of age. a heterozygous factor h gene mutation was found. despite plasma-exchange treatment numerous relapses led the child to ckd stage : creatinine clearance (ccr) . ml/min/ . sqm according to schwartz formula. at yrs we started a programme of fresh frozen plasma (ffp) infusions, - ml/kg bw. the child was poliuric and hypertensive, notwithstanding the treatment with ramipril, amlodipine, clonidine and furosemide. in the first months he received ffp every days. mean ccr during this period was . ± . ml/min/ . sqm. haptoglobin (hap) was still < mg/dl in / tests ( . %), ldh was increased ( . ± . u/l), hemoglobin and platelet count were always in the normal range. the treatment schedule was then changed to ffp every days for the next months. during this period, ccr was significantly higher ( . ± . ; p< . ) and ldh significantly lower than in the first months ( . ± . ; p< . ); haptoglobin was always > mg/dl. no differences between the two periods were found for hemoglobin, platelet count, proteinuria, microalbuminuria and blood pressure values. both in the first and the second period, ccr was negatively correlated with ldh (r . , p< . ) and with the bioimpedance analysis (bia) measure of resistance, which is an index of body hydration. in conclusion: . the only signs of disease activity in atypical hus can be minor abnormalities in laboratory tests, such as increased ldh and decreased haptoglobin levels; . ffp infusions are useful in maintaining hus remission and preserving kidney function, provided that the treatment schedule is optimized; . bia is useful in monitoring hydration status of children with ckd, especially those with poliuria and under ace-inhibitors, as it allows for the correct interpretation of serum cr values. analgesic-antipyretic agents are commonly used medications worldwide for the treatment of pain and fever in children. acute renal failure is commonly seen in adults after treatment with analgesicantipyretic agents. this complication has rarely been reported in children. two patients, ages and years were admitted with a diagnosis of acute, non-oliguric renal failure. one had symptoms of upper respiratory tract infection, and the other had been suffering from vomiting and abdominal pain. appropriate evaluations including detailed history especially the history of drug ingestion, physical examination, and measurement of serum creatinine concentrations were performed in the emergency department. both patient had ingested analgesic-antipyretic agents (mefenamic acid, and paracetamol) before the onset of acute renal failure. none of the patients had previous history of renal disease or concomitant treatment with other drugs. none had oliguria or anuria, dehydration, abnormal serum electrolyte concentrations, or evidence of glomerulonephritis. microscopic hematuria and leukocyturia were found in one patient. serum creatinine was . and . mg/dl at presentation. both of them recovered completely within a week. we emphasize that clinicians must be aware of renal toxicity of analgesic-antipyretic drugs with low doses. with the increasing use of over-the-counter analgesic-antipyretic agents, this association may become more prevalent. cardiovascular disease is a main cause of morbidity and mortallty in patients with chronic kidney disease (ckd). the pathophysiology of cardiovascular disease (cvd) in ckd remains uncertain but nowadays sympathetic hyperactivity is recognized as an important mechanism involved. this observational and transversal study of patients from five to years old, submitted to dialysis or at least four months after kidney transplantation (ktx), without signs of transplantations rejections, with definite ckd and creatinine clearance of ml/min or less. the subject (median age= years; . % female) were classified accordingly with treatment modality: conservative (n= ), peritoneal dialysis (capd) (n= ), hemodyalisis (n= ) and renal transplantation (n= ) submitted to l-metaiodobenzilguanidine ( l-mibg) planar and tomography scintigraphy and heart rate variability (hrv). comparisons among groups were made using anova and the association between variables was assessed using spearman's correlation coefficients and bonferroni correction was used during multiple comparisons testes. a p value < . was considered significant. hemodialysis patients presented increased cardiac washout (p= . ), heterogeneous pattern of l-mibg distribution (p= . ) and lower values of low frequency component of hrv (p= . ). capd subjects had reduced lung washout (p= . ). the cardiac washout had positive correlation with pth and negatives correlation with creatinine clearance. there was a significant negatives association between the rr interval in low frequency (lf) and cardiac washout. the uremic cardiac disautonomia might be characterized by decreased low frequency component of hrv and increased l-mibg washout and heterogeneous distribution pattern by left ventricular walls; these abnormalities subsided after ktx. d+hus is the main cause of acute renal failure in children. extrarenal manifestations are associated in more than % of the cases. hus causes toxin mediated endothelial cell damage, resulting in thrombotic microangiopathy and intraluminal thrombosis of small vessels, with subsequent tissue ischemia and necrosis of involved organs. a -year-old boy has been admitted for d+hus associated with escherichia coli o diarrhea. he presented with renal failure and hypertension requiring hemodialysis for days, hemolytic anemia ( g/dl, schizocytes %) requiring blood transfusions, severe thrombopenia ( g/l) and hyperleucocytosis ( /mm ). severe hemorragic colitis with duodenitis required prolonged parenteral nutrition. at days after onset, the child presented with confusion, slurred speech followed by loss of consciousness associated with major hyperglycemia ( mmol/l) and elevated corrected natremia ( mmol/l) without ketosis requiring transfer in intensive care unit (icu). continuous hemofiltration associated with insulin therapy ( . ui/kg) was then established with slow decrease of natremia and serum glucose within hours. neurologic condition rapidly improved. serum amylase and lipase were normal. insulinemia at the same time as the highest hyperglycemia was low ( , ui/ml), and search for human insulin, islet cell and glutamic acid decarboxylase antibodies were negative. insulin therapy could be discontinued within days. at the last follow-up, months later, neurologic examination, serum glucose and glomerular filtration rate were normal. in conclusion: / hyperglycemic hyperosmolar coma is a severe complication yet never reported in d+hus; / continuous hemofiltration with constant monitoring of biologic parameters could avoid permanent lesions due to rapid correction of this major metabolic unbalance. chronic renal failure (crf) can interfere with the regulation and time dependent secretion of multiple hormones. adrenocortical function in children with crf is examined in a few studies with a limited number of patients, and the results are controversial. in this study our aim is to evaluate adrenocortical function in basal and stimulated conditions, and to determine the relationship with the glomerular filtration rate (gfr), etiology and duration of crf in a larger group of patients. sixty-one patients with crf ( f, m; mean age . ± . years) were studied. the patients were grouped according to etiology [structural abnormalities (n: ), glomerulonephritis (n: ), others (n: )], duration of crf [ - (n: ) , - (n: ) and > months ( )] and gfr [ - (n: ), - (n: ), < ml/min/ . m (n: )]. cortisol levels were measured at : a.m. (basal cortisol) and : p.m. low dose acth test ( . micg/m synacthen iv) was performed. delta cortisol was calculated as peak cortisol minus basal cortisol during the acth test. diurnal rhythm is accepted to be preserved if : a.m. cortisol/ : p.m. cortisol is greater than two. basal cortisol levels and peak cortisol response to low dose acth is similar in all groups. median levels of delta cortisol found to be higher in the gfr< ml/min/ . m group; p= . . diurnal rhythm seems to be more preserved in the gfr - ml/min/ . m group (% ) compared to gfr< group (% ); p= . . no correlation was found between the basal, peak and delta cortisol, gfr and duration of crf. our preliminary results have shown that there is no difference in the basal and peak cortisol levels between all groups. this is the first study in children showing that adrenocortical function is preserved in groups with gfr levels between - ml/min/ . m . objective: this study was we evaluated bk virus and jc virus in urinary after renal transplantation. methods: because these polyoma viruses are excreted in urine, these patients ( females and males, . ± . years old) was analyzed by polymerase chain reaction. all patients were living donor renal transplantation from a parent. results: two patients have detected bk virus in urine. as the type of immunosuppressive treatment, one had tacrolimus and mycophenolate mofetil, and one more had methylprednisolone and tacrolimus. seventeen percent of the patients had quantifiable bk virus-dna in urine. thirty-three percent of the patients had quantifiable jc virus-dna in urine. there was non significant relationship between these polyoma viruses in urine and the type of immunosuppressive treatment. no patients developed interstitial nephritis during the study. conclusions: the activation of bk virus and jc virus does not seem to be related to the type of immunosuppressive treatment. the pathogenetic role of polyoma virus infection in renal transplantation recipients further researches are needed. background: urinary tract infection (uti) due to neurogenic bladder, secondary to large spina bifida as myelomeningocele, is well known, but the association of small occult spina bifida (sbo), having normal physical examination, with that of infection has not been reported. we studied the frequency of spina bifida occulta in children with urinary tract infection. method: the kub of voiding cystouretrography in patients ( f, m) with average of age year (± . sd), who referred to radiology department of ali asgar children hospital for uti, were observed for sbo. all patients had normal physical examination. chi were used to find the frequency of the level of sbo and the differences respectively. p< . was considered significant. result: out of patients had sbo. the order of frequency of the level of sbo was s ( %), l ( , %), s s ( , %), l s ( , %), and l s s ( %). patients had vesicoureteral reflux (bilateral in cases, at left and at right side). the severity of vur was % grade (g) ii, , % g iii, . % g iv, and . % g i. spina bifida occulta was detected in out of patients with vur. this difference was not statistically significant (p= . ): conclusion: the high frequency of lumbosacral sbo in the patients with urinary complaint may imply some lower urinary tract dysfunction in these patients although we need a control study in normal children. we evaluated interleukin- and interleukin- levels in the urine of children with renal scarring, with vesicoureteral reflux ( / , group a ) and without vesicoureteral reflux ( / , group a ) and in the urine of healthy children (group b). none of the children had urinary tract infection for the last ten months. interleukin- and interleukin- were determined using a commercially available human enzyme-linked immunosorbent assay kit. results: urinary interleukin- levels were below the lower detection limit in all samples. interleukin- levels were detectable in all urine samples of children with renal scarring and below the detection limits in the urine samples of healthy children. there were no statistically significant differences between urinary interleukin- levels in children with and without vesicoureteral reflux. there is a relationship between the grade of renal scars, the time past from their development and the urinary levels of il- . the introduction of mycophenolate mophetil (mmf) was an important advance in immunosuppressive therapy but its use is associated with gastrointestinal intolerability (gi) requiring dose reductions or drug interruptions. enteric coated mycophenolate sodium (ec-msp) was designed to improve mycophenolic acid (mpa)-related gi by delaying the release of mpa until reaching the small intestine. at present, its immunosuppressive activity in pediatric renal transplant with gi has not been clarified. we studied trough levels of active metabolite mpa (c ), changes in kidney function, mixed lymphocyte culture, cytotoxic antibodies as well as cytotoxic response before and after months of the conversion from mmf to ec-mps in renal transplant recipients with gi. in the immunosuppressive protocol used: mmf, tacrolimus and corticosteroid, mmf ± mg/m /day was replaced by ec-mpa ± mg/m /day. after months of treatment with ec-mpa, the incidence of gi decrease to . %. the levels of mpa were about % higher on ec-mps ( . ± . ug/ml) compared to mmf administration ( . ± . ug/ml). serum creatinine, creatinine clearance and urinary protein excretion did not change ( . ± . to . ± . mg/dl, . ± . to . ± . ml/min/ . m and . ± . to . ± . gr/ hr, respectively). also, during ec-mpa, proliferative response and cytotoxic antibodies showed no significant change. the release of il- was striking augmented with mmf or ec-mps therapy, but interferon-γ and tnf were low under both treatments. our data indicate that conversion from mmf to ec-mps leads to an improvement in gi without altering key elements of immunosuppression. however, the monitoring of mpa before and after conversion should be appropriated to the optimization of therapy efficacy. re. munarriz, ju. arakaki, ce. munarriz pediatric clinic, pediatric nephrology, buenos aires, peru objective: to describe the results of a program of chronic ambulatory peritoneal dialysis (capd) in children in peru by means of conventional indicators. methods: children ( , % male) were included in a longitudinal descriptive study. the average age was , ± , years (rank of , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . % were from lima (the capital city) and % came from other cities of the country. primary glomerulonephritis ( , %) was the main cause of the renal insufficiency. we evaluated the program from to . results: the average weekly kt/v was , ± , . the average dose of erythropoietin (epo) was ui/kg/week. % of the patients had average annual albumin of more than , gr./dl. the average annual protein catabolism index (icp) was , ± , gr/kg/d. the weight/age, height/age, weight/height z scores at the beginning and at the end were . / . , - . / . , - . / , - . / . , . / . - . / . , respectively. the average hematocrit was . ± . %. the rate of peritonitis adjusted for the period was , episodes/patients-year ( episode every months) and the mortality for the same period were %. conclusions: the indicators evaluated in our patients are according to the results of the international literature. is repeated urine culture essential after antibiotic therapy in uti in thai children? background: in , the american academy of pediatrics recommended for uti treatment, that urine culture be repeated only in children < years with fever > hours, since the chance of a positive urine culture in other children is very low. objective: to evaluate the cost-effectiveness of repeated urine culture after antibiotic therapy in childhood uti. patients and methods: a retrospective review of the records of children diagnosed with uti in songklanagarind hospital from jan -dec , . results: there were patients total, of which were excluded due to no repeated urine culture. patients with uti episodes were analyzed ( boys and girls). ( . %), ( . %) and ( . %) patients aged < , - and > years respectively. ( . %) had a repeated urine culture with significant growth. multivariate analysis showed that age < year, etiologic agents psuedomonas aeroginosa or enterococci spp., fever > hours and kub anomalies were the most significant risk factors for positive repeated culture, while vur and recurrent uti episodes were not significant risk factors. if we consider that a child who has at least one of the above risk factors should have a repeat urine culture, then cases ( . %) will require repeating urine culture and x . =$us . will be saved and ( . %) positive repeated urine culture will be missed. conclusion: our study in a group of thai children indicates that repeated urine culture after antibiotic therapy is still recommended. our aim was to find out if there are any signs of renal scarring and reduced renal function without recurrent uti in patients with obstructive pyelonephritis. there were investigated children ( - y) with - years passed after diagnosis of obstructive pyelonephritis. these patients were investigated during years long period without uti. all the children had a treatment with nitrofurantoin during season viral infections. we investigated excretion with urine of the collagen product (hydroxyproline) and activity of lisosomal enzymes (b n-acetilglutamase, elastase, pseudocholiesterase). as a control group, healthy children of the same age were investigated. our result demonstrates the decrease of the level in urine of collagen product and lisosomal enzymes and normalization of tubular and glomerular functions during years remission of pyelonephritis. prevention of recurrent uti and maintenance of the remission of pyelonephritis leads to the decrease of sclerosing processes on kidney. regular dialysis induces insecurity and special psychological problems associated with staff-, machine-and artificial material-dependence. the more severe the child's physical problems are the more probable is developing of emotional disorders, a sense of loneliness and an exaggerated dependence on the parents and staff. a psychological and social study of children on regular dialysis was performed. there were girls and boys, aged - (mean: ) ys. two children ( %) are exclusively treated with haemodialysis, ( %) are on peritoneal dialysis and in ( %) both methods interchanged. somatic concomitant disorders are present in ( %) of children. among psychological disorders, an inclination to unsociability, autoaggression or aggression towards the immediate environment has developed in children ( %), ( %) do not like talking about disease while ( %) are communicative and sociable. psychosocial characteristics showed: emotional difficulties (anxiety, mild depression) in %, feeling of being physically different from peers (short stature, less physical ability) in %, lowered self-esteem and social isolation as a result of school absenteeism in %. overprotection of parents was presented in %. different psychological changes were present in some children. of the children are of school age: ( %) attend special schools and the remaining follow regular education programs. with the help from their teachers, children on dialysis can master regular school programs, in spite of the time spent on dialysis. a good and continuing co-operation of dialysis staff and sick children and their parents as well as a more intensive co-operation with psychologists and teachers are necessary to reduce psychological disorders and promote a better adaptation to the life of their healthy coevals. we report a -year-old girl with syndrome frasier who developed b cell lymphoma within nine month after live related kidney transplantation. in induction therapy we applied atg up to days, mycophenolate mofetil and cyclosporine. routine abdominal ultrasound revealed multifocal hypoechogenic changes in liver and spleen. computed tomography showed diffuse focuses of changed liver tissue in length up to . cm, precontrast density of - hu and postcontrast of - hu. in spleen there were three similar changes (up to . cm). after surgical biopsy of liver, patohistological examination confirmed diffuse large cell b lymphoma (cd positive, moderate risk). pcr ebv was positive. we immediately started with ganciclovir intra venously and decreased cyclosporin and mmf (within two weeks) up to completely exclusion from therapy. in the same time we increased prednisolon on mg daily. after weeks from beginning ganciclovir she treated with rituximab, one dose of mg every week (five weeks). repeated abdominal ultrasound and two controls computed tomography showed markedly regression of tumorous lesions. after . months of last rituximab doses scan showed normal spleen and liver findings. all lesions were resolved. in two occasions she developed severe leucopenia without any infection complication. she still has got moderate lymphopenia due to continual ganciclovir therapy. during this period ( months) of illness course she treated with ganciclovir intravenously due to repeated ebv reactivation (positive pcr). despite enormous reduction in immunosupressive therapy renal function remain stabile without episodes of acute rejection. - . years) . the most of them, % ( patients) received graft from live related donor. % of patients had preoperative dialysis and % were preemptive. the mean waiting period for transplantation was months (range to months). congenital anomalies of kidney and urinary tract were the most common underlying diseases ( patients), then nephrotyc syndrome ( patients), hereditary nephritis ( patients), polycystic kidney disease ( patients) and others. daclizumab was the most commonly used as immunosuppressive induction agent and the maintenance immunosuppressive therapy consisted of azathioprine or mycophenolate mofetil (mmf), cyclosporine or tacrolimus and prednisone. two patients had immediate postoperative surgical complication and graft loss due to thrombosis of a. renalis and donor tubular necrosis respectively. three patients had delayed graft function; two of them underwent cadaveric transplantation. one patient had recurrence of primary kidney disease only few days after transplantation and graft loss after one year. other patient lost the graft after years due to noncompliance and chronic cellular rejection. after one year of follow-up graft survival rate is % and patient survival rate %. at the end of follow-up (mean range . months), patients had normal, patients slightly decreased renal graft function. catch-up growth was seen during the first year after transplantation from mean height sds of - . to . . the mean goal of our further intention is improvement of cadaver renal transplantation. j. lee, y. shim, s. lee objectives; although the variable risk factors of urinary tract infection (uti) in children such as virulence factors of the pathogenic bacteria and vesicoureteral reflux are already well known, the role of normal flora clononizing the intestinal tract and genitourinary tract is not fully understood. the change in colony forming units (cfu) of lactobacillus in chidren with uti is primarily investigated to explore the role of lactobacillus, one of the human normal flora, in development of uti. methods; lactobacillus was cultured from stool, urine, and periurethral or vaginal discharge of febrile infants with uti. those with confirmed uti by the suprapubic urine culture were classified to uti group (n=- ), and those with negative urine culture and confirmed viral illness were classified to control group (n= ). lactobacillus was anaerobically cultured in dico rogosa sl agar (becton, dickinson and company, usa) for hours at °c. results: the cfu of lactobacillus in stool was correlated with those in periurethra, vagina and urine (p< . ). the cfu of lactobacillus in stool was significantly lower in uti group than in control group ( , ± , vs , , ± , , , p< . ) . the cfu of lactobacillus in periurethra or vagina was significantly lower in uti group than in control group ( , ± , vs , ± , , p< . ). the cfu of lactobacillus in urine was significantly lower in uti group than in control group ( ± vs , ± , , p< . ). the cfu was distributed mostly at low level in uti group, which was significantly different from that in control group (p< . ) conclusions; the cfu of lactobacillus in stool, periurethra, vagina and urine is low in infants with uti. it is suggested that lactobacillus has a role in the development of uti. pediatric small bowel transplantations are associated with pronounced electrolyte inbalances in the posttransplant period. we investigated the sources of possible electrolyte losses. our hypothesis was that electrolyte inbalances after intestinal transplantation might be augmented by fk (tacrolimus) mediated renal toxicity rather than short bowel syndrome alone. we retrospectively reviewed eleven living-related small bowel transplantations between october and december . the data collected included frequent serum and urine electrolyte profiles, renal function parameters, enterostoma electrolytes, and fk levels in the postoperative period up until either discharge or graft loss. we analyzed pearson's correlations between fk levels, serum electrolytes, renal function parameters, and also fractional excretions (fe). in order to investigate possible delayed nephrotoxic effects of fk , we correlated all values of the same day as well as with fk levels of , , and hours earlier. furthermore, we analyzed our data stratified by fk dosing ranges. our results show decreased gfr and prominent increase of renal sodium, phosphorus, and magnesium losses along with rising fk levels, suggesting this pathway as a major contributor to their imbalances. furthermore, fk levels were associated with serum calcium and phosphorus decline, though urinary calcium excretion was not significantly changed. signs of renal toxicity are apparent within the first hours of fk challenge. our data suggest that fk mediated nephrotoxiticy is a significant contributor to electrolyte imbalances observed after small bowel transplantation. objectives of study: urinary tract infections (uti) are common in children and c-reactive protein (crp) in serum is often used to evaluate the severity of the renal inflammation. recently it was demonstrated that crp can be produced locally in the kidney. we therefore measured the crp concentration in both serum (s-crp) and urine (u-crp) from children with uti to evaluate the extent of local production and the usefulness of measuring u-crp for diagnosis of inflammatory kidney disease. methods: children ( boys) with uti were studied (median age . years, range days- years). children had fever . °c or more. the uti was caused by e.coli in patients. all children were examined within a few days of diagnosis by dmsa scan for evaluation of renal function. as controls were used children with respiratory infection (pneumonia in most) and elevated s-crp in whom uti was ruled out by negative urine culture. u-crp was measured in a commercial hscrp elisa. normal value was < mg/l results: in the uti patients, the median s-crp was mg/l (range - ) and u-crp mg/l (range - ). there was a significant correlation between the s-crp and u-crp concentrations (< . ). dmsa scans were abnormal in ( %) uti patients. the proportion of abnormal scans increased significantly with the crp concentration in both serum (< . ) and urine (< . ). all control patients had increased s-crp concentrations (median mg/l, range - ) but the median u-crp was . mg/l (range - ). the u-crp in the patients with uti was significantly higher than in the controls with other infections (< . ). conclusions: our data strengthens the concept that crp can be produced locally in the kidney during uti. the usefulness of measuring u-crp to evaluate inflammatory kidney disease needs to be tested further. s. paunova, a. kucherenko, i. smirnov, g. serova, i. donin, l. revenkova, n. goltsova in order to reveal the role of cytokines in renal tissue damage in infants with urinary tract infection (uti) patients aged from to months were examined. in all of them inflammatory markers (esr, crp, leukocyte count), urine concentration of tumor necrosis factor-α (utnf-α) and transforming growth factor-β (utgf-β) standardized to urinary creatinine concentrations were evaluated. two groups of patients were determined: ) with uti and normal urodynamics (n= ), ) with uti and urodynamic disorders (vur, hydronephrosis) (n= ). healthy infants were used as controls. as a result, all the patients demonstrated significantly elevated utnf-α, utgf-β creatinine ratio in comparison with controls (p< , ) with no difference between groups. but children with normal urodynamics (from the st group) presented with severe uti ( st -a) showed urine tnf-α tgf-β creatinine ratio in , times higher than other patients of st gr and close to nd gr. data ( st gr.-utnf-α/ucr= , ± , , utgf-β/ucr= , ± , , st gr.-utnf-α/ucr= , ± , , utgf-β/ucr= , ± , ; nd gr -utnf-α/ucr= , ± , , utgf-β/ucr= , ± , , p , - < , ) . to conclude, tnf-α and tgf-β are responsive for renal tissue impairement in infants with uti. elevated tnf-α tgf-β creatinine ratio in a part of infants with normal urodynamics suggests that renal damage begins early in infection mostly due to inflammation. one may suspect a predisposition of that subgroup of patients to fibrogenic process and subsequent scar formation. prompt diagnosis and localization of pyelonephritis are of great importance in treatment and prognosis of the patients. the urinary excretion of enzymes, in particular n-acetyl-beta-dglucosaminidase (nag), is considered a relatively simple and non-invasive method in the detection of renal tubular function under various conditions such as pyelonephritis. this study was performed to determine the diagnostic value of urinary nag in acute pyelonephritis and to compare it with other indices traditionally used for this purpose in children. this is a quasi experimental study conducted from april to may on children with pyelonephritis. diagnosis of pyelonephritis has been based on standard criteria. seventy-two patients between month and years were recruited. fresh random urine samples were obtained on the admission time and at th hour of treatment and were tested for nag and creatinine. there was a significant difference in pre and post-treatment urinary nag/creat ratio (p< . ) and the sensitivity and specificity of urinary nag in diagnosis of pyelonephritis were % and % respectively. there was a significant correlation between urinary nag level and kidney ultrasonography results. patients whose ultrasonography showed hydronephrosis, had the highest level of urinary nag and patients who showed urinary stone in their ultrasonography had the lowest level of urinary nag. in addition, there was a reverse correlation between urine culture results and urinary nag level; patients who had negative urine culture had higher level of urinary nag in comparison with patients with positive urine culture. we conclude that urinary nag is elevated in children with pyelonephritis especially in the presence of urinary tract abnormality and the absence of renal stone. type- hyperoxaluria (ph- ) is an autosomal recessive disorder caused by the impaired activity of the hepatic peroxisomal alanine-glyoxilate aminotransferase. the disease leads to end stage renal disease (esrd) and combined liver-kidney transplantation (clkt) is required. we report cases diagnosed with ph- who received clkt. case- : she had attacks of dark urine without any pain and renal stones were determined on sonography when she was . years old. she was diagnosed with ph- and received peritoneal dialysis (pd) at the end of the first year and cadaveric clkt was performed when she was yearsold. at the age of , she had chronic allograft nephropathy and began to have hemodialysis (hd). recently, . year after hd, cadaveric renal transplantation (tx) was performed. she is well after the second tx. case- : he was admitted with polyuria, polydypsia, stomachache and renal stones were determined on sonographic examination. he had esrd and pd was started when he was years old. at the age of , cklt was performed from his mother. his liver and renal functional tests are well months after cklt. case- : he was evaluated because of having an older brother diagnosed with ph- when he was . years old. he had no complain, but sonography showed multiple calculi. within years he experienced flank ache, hematuria attacks and anuric phases due to obstruction and esrd appeared and he received hd and clkt was performed from his full-match sister at the age of . . he is doing well years after tx. here, we present the favourable clinical outcomes of our patients with cklt to indicate the validity of this treatment of choice in ph- . tenascin (tn) is a glycoprotein component of extracellular matrix (ecm) which is not present in the normal kidney tissue. tissue plasminogen activator inhibitor- (pai- ) regulates fibrinolysis and the plasmin mediated matrix metalloproteinase activation and it is also not expressed in the normal kidney. recent studies focus on the pathogenesis of advanced renal diseases. in this study we evaluated tn and pai- staining in the renal tissues of pyelonephritic rats using immunohistochemistry (ihc) as to understand if these markers may be served as histological parameters of pyelonephritis like fibrosis, tubularatrophy or vascular changes. seven rats were injected . ml solution containing e. coli atcc cfu/ml into left renal medullae. seven rats were designed as sham group and were given . % nacl. rats were sacrificed days after injections. renal tissues were studied histopathologically by hematoxylin and eosinand scored for the parameters of pyelonephritis. tn and pai- expressions were studied semiquantatively by ihc by tenascin novocastra (ncc-tenas-c) and pai- (h- ) santa cruz biotechnology. both tn and pai- expressions increased in the pyelonephritic groups. we observed acorrelation between tenascin and fibrosis, vascular changes and tubular atrophy and pai- expression showed a correlation with only fibrosis. we conclude that increase in renal tn and pai- expression shown in experimental pyelonephritis are the responsible factors for the fibrotic changes of persistent renal damage. introduction: urinary beta microglobulin (β mg) urinary excretion is a good index of proximal tubular cell dysfunction. objective: to determine β mg excretion significance in determining the outcome in respect to scar and renal insufficiency. patients and methods: urinary β mg and creatinine (cr) was measured in urine samples of whom proceed to do dmsa renal scan at the time of admission and months later to detect scar. β mg was measured using radioimmunoassay method using β mg -test kit (radim company). twenty children had various grades of renal scars. results were compared with ratios of children with low uptake and normal scanning and normal children. student t test, anova, and unpaired t-test was used for analysis and differences considered significant if p< . . results: the mean urinary β mg/cr was significantly higher in the scarring group ( . ± . ) than in the normal group ( . ± . ) and in low uptake group ( . ± . ) (p< . ). patients with grade iii had higher values ( . ± . ) than grades i ( . ± . ) and ii ( . ± . ) (p< . ). patients without renal scar had β mg/cr ratio below . microgram/mg. the mean β mg/cr was higher in patients with vur grades and ( . ± . ) than patients with vur grades to ( . ± . ) (p= . ). maximum β mg/cr was detected in patients with grade vur ( . ) and the minimum was zero in non-refluxing patients and normal children. two patients with high grade vur and the highest levels of β mg/cr ratio ( . and ) progressed to renal failure in years time, the first patient was treated by hemodialysis and the second underwent renal transplantation. conclusion: measurement of urinary β mg is useful in the early detection of tubular damage in patients with renal scars. introduction: chronic allograft nephropathy refer to the progressive decline of renal function seen in some renal transplant recipients in association with alloantigen-dependent and alloantigenindependen factors. hyperlipidemia is a risk factor for chronic allograft nephropathy in adult pts, where no data exist in pediatric transplant population. methods: in this cross sectional study, patients ( can/ non-can) that aged - yr and - mo (mean: mo) after transplantation, were evaluated for lipid profile and renal function tests. results: hyperlipidemia has high prevalence in our patients both pre and posttransplantation and hypercholesterolemia and increased ldl had significant correlation with chronic allograft nephropathy (p= . ) and p= . respectively. conclusion: in pediatric patient as in adults hyperlipidemia and particularly hypercholesterolemia has significant correlation with chronic allograft nephropathy and as adults may need specific therapy. results: pre-transplantation renal replacement therapy time ranged from to months. eleven children underwent pre-emptiverenal transplantation. / transplants were from living related donors. donor age ranged from days to years. grafts were from donors < year of age and of these grafts were transplanted en-block. hla mismatches ranged from to antigens. primary disease was: focal segmental glomerulosclerosis in , rapidly progressive glomeluronephritis in , reflux nephropathy in , nephronophthisis in , iga nephropathy in , congenital nephrotic syndrome in , dysplasia-hypoplasia in , idiopathic membranous glomerulonephritis in , henoch-schönlein purpura in , hemolytic-uremic syndrome in , nephroblastoma in , polycystic kidney disease in and of unknown origin in children. patient survival at five years was %. allograft survival with living related transplants at one, two and five years was %, % and % respectively and with cadaveric transplants at the same periods was %, % and % respectively (p< . ). regarding en-block grafts, they functioned immediately and satisfactory and presented excellent graft function years later. most kidneys were lost due to acute or chronic rejection (n= ). other causes were renal artery thrombosis (n= ), infections (n= ), withdrawal of immunosupressive regime (n= ). conclusions: results of this single center series of pediatric renal transplants are encouraging from the standpoint of patient and allograft survival. conclusion: in infants with hn, the incidence of uti was higher especially in those with ou, hn of higher sfu grade or hun. the antibiotic prophylaxis may be recommended during year after birth in infant with hn because the incidence of uti was high in these period. results: the underlying diseases were: sepsis with mods ( . %), septic shock ( . %), severe intoxication ( . %), trauma with sirs ( . %), drowning ( . %), abdominal compartment syndrom ( . %) and inborn metabolic disorders ( . %). children ( %) had acute renal failure, ( %) patients met non-renal crrt criteria. cvvh was performed in ( %) children, cvvhdf in ( %) children. crrt duration was to hours (median . hours). dynamics of blood urea, creatinine, c-reactive proteine (crp) and white blood cells (wbc) were evaluated. significant decline (p< . ) of creatinine along the treatment with cvvh as well as during cvvhdf was observed. blood urea levels showed significant decrease only in children treated with cvvhdf (p< . ). significant decrease of wbc and crp was observed only using cvvh. children from the study group survived (overall mortality . %). in non-survivors was time from crrt initiation to its termination compared to time interval from crrt initiation to the death of children with - organs failure significant (p< . ) where as in non-survivors with - failured organs it was not. conclusion: cvvh is efficient at removing urea and creatinine as well as inflammatory mediators (crp, wbc). cvvhdf is more potent to blood urea elimination. authors suggest preferring cvvh to cvvhdf in critically ill children to affect basic inflammatory parameters. to analyse hd and pd prescription (pr) adopted in chronic dialysis children, were viewed data of pd regimens in patients ( . - years) and hd regimes in patients (age . - years) treated in pediatric centres in . pd patients were on automated pd: -nightly intermittent pd (nipd; pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dwell volume (dv) ± ( - ) ml/m bsa; -tidal pd ( pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dv ± ( - ) ml/m ; tidal volume . ± . ( - )%; -continuous cycling pd (ccpd; pr): . ± . ( - ) hrs; . ± . ( - ) cycles/night; dv ± ( - ) ml/m ; daytime dv ± ( - )% of night dv. in % of pr dialysis fluid (df) glucose concentration was > . %, and in % buffer was bicarbonate. df of daytime dwell was . % glucose ( pr) or icodextrin ( pr). patients with residual diuresis were . % of those on nipd, % on tidal pd, and . % on ccpd. hd was performed as bicarbonate hd ( %), hemodial filtration ( %) and acetate-free biofiltration( %). patients received sessions/week in % of cases, /week in %, and /week in % of cases; oxalosis patients were on daily hd. session duration was hrs in pr, hrs in , and . hrs in . dialyser membrane was: polysulfone ( %); hemophane ( %); polyamide s ( %); cellulose acetate ( %); polyacrylonitrile ( %); cellulosediacetate ( %); cellulose triacetate ( %); polymethylmetacrylate ( %); polyether/carbonate ( %). ratio between dialyser surface area and patient bsa was . ± . ( . - . ) and was - . in %, . - in %, > . in %, and < . in % of cases. isoniazid (inh) is widely used in most prophylactic and therapeutic anti-tuberculosis regimens because of its effectiveness and low cost. acute intoxication by isoniazid is known to cause symptoms of seizures, metabolic acidosis, coma, and even death. we present a case of acute isoniazid poisoning in a seven years old patient who ingested tablets ( mg) of isoniazid. she was admitted unconscious, with ventilatory insufficiency and convulsions. renal and liver function tests were in normal ranges. she was intubated and mechanically ventilated. despite parenteral midazolamand pyridoxine (vitamine b ) treatments convulsions went on. then hemodialysis was performed and after hemodialysis convulsions and ventilatory insufficiency were disappeared and the patient was conscious and she was extubated. hemodialysis may be an effective treatment alternative for the patients who doesn't respond pyridoxine treatment. the aim of this study is to analyse children under two years of age, with their first febrile urinary tract infection (uti), identifying bacteriological etiology, antimicrobial resistance, urologicalabnormalities and renal damage. this is a prospective study including children ( % girls) with their first febrile uti. mean age was months ( - ), ( %) patients were younger than months ( % of them were boys). urine was obtained by suprapubic aspiration ( . %) or transurethral catheterization ( . %). % had positive nitrite on urinalysis and . % had leukocyturia. they were submitted to ultrasonography (usg), dmsa scan (within months) and voiding cystourethrography (vcug). the most frequent microorganism found in urine culture was escherichia coli, ( . %). in this study high bacterial resistance to antimicrobials was observed in relation to the following antibiotics: ampicillin ( . %), first generation cephalosporyn ( . %), sulfamethoxazole/ trimethopin ( . %). resistance to second generation cephalosporyn, aminoglycoside, nitrofurantoin and nalidixic acid was lower than . %. renal ultrasound was abnormal in . % of the infants. vesico-ureteral reflux (vur) was observed in . %, although only . % had vur grade iii or more. the dmsa scan showed that ( %) patients had renal parenchymal damage. fourteen of these ( . %) had normal esr. there were ( . %) reinfections within a months period, even under prophylactic treatment, and the presence of vur grade iii or more was the only one with a significant relationship. conclusion: there were high levels of bacterial resistance to frequent used antimicrobials. this finding points toward a need for reviewing criteria of choosing initial blind therapy. investigation with dmsa scan is important in the detection of renal parenchymal scars, irrespective of the reflux grade. purpose: urinary tract infection (uti) has a risk of renal damage and is associated with vur. vur is investigated only by vcu. however, vcu is an invasive, painful study and many patients hesitate to be taken the study. we studied the correlation of vur in vcu and defect of dmsa scan and investigated the possibility of substitution of vcu by dmsa scan. material and methods: from to , the medical records were searched for children admitted to cheongju st.mary's hospital with the first uti who had been evaluated with both dmsa scan and vcu within months of the infection. the value of several clinical signs, laboratory findings, the resultsof dmsa scan and vcu were investigated. bacteriuria was defined as , or greater colony-forming units in urine from a bag, midstream or catheter sample. results: there were patients underwent both studied at the first uti. mean age of the patients was months old. the male patients were ( %). the vur was found in of the patients ( %), grade i-ii in and grade iii-v in patients. there was no significant correlation with the presence of vur in sex, fever duration, blood white cell count and the level of serum creactive protein (crp). but the patients with vur grade iii-v were significantly older than the patients with grade i-ii reflux or without vur. there were abnormal dmsa scan findings in of ( %). of these patients, were without vur, with vur grade i-ii and with vur grade iii-v. the abnormal dmsa scan was correlated with the presence and severity of vur. but vur was found in % of patients with normal dmsa scan. conclusions: abnormal dmsa scan is correlated with the presence of vur, so the patients with abnormal dmsa scan require vcu. in order to prevent missing a quarter of patients with vur shown normal dmsa, vcu should be recommended in all children with first febrile uti. cuba is the largest of the carribean islands with its , millions inhabitants. cuba is considered as a developing country and is classified in the group of: "lower middle income countries and territories". despite low financial resources, cuba has succeeded to develop an efficacious health care system with comparable results to those of west europe and usa (who data) ccl: ) hd is the most prominent form of pediatric dialysis (automated night pd is in progress); ) the no of transplantations is relatively low because of no participation to an international transplantation network; ) high no of pediatric nephrologists; ) high quality of patients care. background: inborn errors of metabolism in neonates are often characterised by hyperammonaemic coma within the first days of life and require prompt diagnosis and specific treatment such as toxin removal and nutritional support. cvvhd seems to be the optimal modality for extracorporal ammonium detoxification, however, little experience with small numbers of children has been accumulated. patients and methods: from to , patients with hyperammonaemia ( male, female) were admitted for dialysis treatment: neonates (mean age . ± . days, range - days) with a mean birth weight of ± g and infants (mean age . ± . years, range to years). in neonates and infants we inserted venous double lumen shaldon catheters (predominately femoral or jugular vein) for cvvhd treatment while neonates and infant underwent capd treatment. results: plasma ammonia levels (range - μg/dl before dialysis and - μg/dl after dialysis) were reduced by % within . ± . h by cvvhd and within . ± . h by capd (p< . ). total dialysis time was . ± . h for cvvhd patients. no major mechanical complications were observed with cvvhd and stable blood flows ( - ml/min) and dialysate flows ( - ml/m /h) were achieved. due to severity of underlying disease, out of neonates ( %) undergoing cvvhd died on day - while out of neonatal capd patients ( %) died on day and one infant patient died after days of capd treatment. twelve out of neonates ( %) survived with no or moderate mental retardation. conclusions: cvvhd is an effective modality to eliminate plasma ammonia within few hours. however, vascular access and blood flows are critical restrictions. mental retardation has to be evaluated in larger scale studies. r. vilalta, e. lara, a. madrid, s. chocron, j. nieto hospital materno-infantil vall de hebron, nefrologia pediatrica, barcelona, spain background: transplant nephropathy is the main cause of renal failure in kidney transplanted children. until this situation is proved by biopsy, sometimes the progressive raise of creatinine leads to raise the anticalcineurinic (cni) drugs with added nephrotoxicity. sirolimus (sir) plus an anticalcineurinicin less dose and mycophenolate (mmf) could offer in kidney-transplanted children an immunosuppressive regime with less toxicity and even an improvement of renal function. methods and patients: paediatric kidney-transplanted patients developed biopsy-proved chronic allograft nephropathy (age - y, mean ) a follow-up post-transplant of y and exhibit also tubular involvement and acute cni toxicity. sir was added in all patients as a rescue therapy at . mg/kg/d. results: after a follow-up period of months, creatinine level diminished (p< . ) in patients ( in group tac, in group cya, with no significant differences). creatinine level did not show a significant change in the other patients ( group tac, group cya, basal creatinine . mg/dl. serum cholesterol changed from ± mg/ ml to ± (ns) and serum tryglicerides from ± mg/ ml to ± (ns). proteinuria also did not show changes ( ± to ± mg/m /h (ns). conclusions: a poly-drug approach with less dose of anticalcineurinic added to the antiproliferative effect of sirolimus and the inhibition of purine synthesis based on mycophenolate mofetil could suppose an improvement of the renal function in children graft nephropathy an even in the graft survival. steroids have been a cornerstone in renal transplant immunosuppression. several strategies have been used to minimize their side effects. new immunosuppressive drugs have allowed steroid withdrawal or total avoidance. aim: to evaluate a new protocol with steroid-free maintenance immunosuppression in pediatric renal transplant. patients and methods: a prospective, non-randomized study in consecutive first renal allograft recipients, followed-up to months. patients received prednisone the first days, two-dose basiliximab induction and maintenance therapy with tacrolimus (tac) and mycophenolate mofetil (mmf). no steroids were given after d posttransplant. controls were historical-matched steroid-based children receiving basiliximab, tac and mmf. all patients gave informed consent. anthropometric, biochemical variables, acute rejection and cmv infection were compared using student-t test and regression analysis. results: a better growth pattern was seen in steroid-free maintenance group reaching a normal growth at months. gfr and serum glucose were similar in both groups. total cholesterol levels were significantly lower in the study group. the incidence of acute rejection was . % in steroidfree maintenance vs . % in steroid-based group, no differences in cmv infection and blood pressure were observed. hematocrit levels were lower during the first months after transplant in the steroid-free group, increased after months post-transplant. patient and graft survival was % at two-yr post transplant in the two groups. conclusions: this steroid-free maintenance immunosuppressive protocol was efficacious, safe, with a lower incidence of acute rejection, not increased risk of infection, preserving optimal growth, renal function and reducing cardiovascular risk factors. objectives of study: to evaluate the lipid profile and its possible implications in children with end stage renal disease (esrd) or renal transplantation. methods: children ( boys, girls) aged from . to years, on peritoneal dialysis (group i) and with renal transplantation (group ii) were studied. in all children were examined: serum creatinine, total cholesterol, triglycerides, high density lipoproteins (hdl) and low density lipoproteins (ldl). a cardiac and liver ultrasonography were also performed. the body mass index (bmi) and blood pressure were evaluated in all children. / children received also a triplex carotid study. the median values of blood creatinine, cholesterol, triglycerides, hdl, ldl as well as the number of children with bmi over th percentile in both groups were shown in table i . all children had normal findings in triplex carotid study. cardiac ultrasonography was abnormal in child of group i and in children of group ii. only child presented lipoid invasion in liver ultrasound. / children of group i and / children of group ii presented hypertension, well controlled, with antihypertensive therapy. conclusions: frequent evaluation of lipid profile is recommended in all children with esrd or renal transplantation independently their bmi. in our study, children with renal transplantation presented better lipid profile compared with children on peritoneal dialysis. group i with < months (n= ; , ± , months) and group ii > months (n= ; , ± , months). results: serum albumin, serum lipids values and the distribution of the categories of the peritoneal membrane did not present significant differences between the groups. hypertension, renal residual function (p= , ), the renal urea kt/v (p= , ) and the weekly renal ccr (p= , ) were significantly higher in group i, while the weekly peritoneal ccr (p= , ) and the total weekly ccr (p= , ) were significantly higher in group ii. catch-up was not observed in any group. control of the cholesterolemia, trigliceridemia and albuminemia were maintained with the dialysis time in both groups. the goals of adequacy of the doqi for kt/v and ccr were gotten respectively in , % and , % of the group i and in , % and , % of the group ii. the longer time in dialysis was associated with the lowest values of renal residual function, renal kt/v and renal ccr. the capacity of transport of the membrane was similar in both groups. objectives of study: to explore the characterize of peritoneal transport in chinese children with chronic peritoneal dialysis. methords: pet was carried out times for six children (mean ages . ± . , aged from to years) who were maintained by capd, and the infusion volume of dialysate was ± ml ( ml/m ). the peritoneal solution transport rate was evaluated by the standards of twardowski's and ppdsc's criteria. results: in our study, the initial pet was performed at . ± . days following initiation of pd, the -hours of peritoneal creatinine clearance ( h-d/p) and glucose absorption ( h-d/d ) was . ± . and . ± . , respectively. according to the standards of twardowski's and ppdsc 's criteria, the peritoneal transport categories were divided into high transport (h) ( / ), high average transport (ha) ( / ), low average (la) ( / ) for peritoneal solution transport, and h ( / ), ha ( / ), la ( / ), low transport ( / ) for glucose absorption. no low transport type of solution was uesd in our patients. the coincidence rate of peritoneal creatinine and glucose transport types were % and % between the twardowski's and ppdsc's criteria, respectively. the different changes of peritoneal transport type were found in two patients with continuous pet. the value of h-d/p increased after peritonitis episodes. our results showed that the pet in % of capd children fall into high and high average transport categories elevated by ppdsc's and adult standards. the peritoneal solute clearance was adequacy in the children, but net water ultrafiltration was lower. standard pediatric pet and its criterie are consistent with the adult criteria. the capability of peritoneal solute transport increased after peritonitis episodes. verapamil (vp) is known to alter cyclosporine (csa) bioavailability. the impact on immunoregulators (il- , tgf-β , and tgf-β ) in allograft recipients remains unresolved. a prospective open study to examine the impact of vp on peripheral blood cell mrna encoding il- , tgf-β , and tgf-β and serum il- , tgf-β , tgf-β protein levels was performed. parental written informed consent was obtained in all cases. children with stable renal allograft function (< months), and receiving immunosuppression (csa, pdn, either with aza or mmf) were included. in the first visit, a clinical examination, two-point ( and h) csa pharmacokinetic profile, serum creatinine, serum for il- , tgf-β , and tgf-β protein levels (by elisa) were obtained; peripheral mononuclear cells were collected for measurement of transcripts for s rrna (house keeping gene) and mrna for il- , tgf-β , and tgf-β (by real time quantitative pcr assay). after the visit one, patients were either withdrawn of vp (if the subject was already receiving vp) or started on vp mg/kg/day (if the subject was not receiving vp). two weeks after, a repeat clinical evaluation and blood collection, as in the first visit, were performed. pediatric recipients of renal allografts were included ( were from ld, mean post-transplant time . years, mean csa dose . mg/kg/day). the c h and calculated auc - h were significantly higher in those receiving vp, but there was no difference in csa trough levels. protein and mrna levels of il- tgf-β , and tgf-β were not different. were previously seen by a nephrologist. logistic regression was performed on anemia (hgb< . g/dl) and showed relative risk in blacks was . vs. whites. relative risk in those who did not receive epo was . vs. those who did. of black patients, were anemic and previously seen by a nephrologist. of white patients, were anemic and previously seen by a nephrologist. in summary, blacks and patients not receiving epo at the time of dialysis initation were more likely to be anemic. despite being seen previously by a nephrologist, nearly % of patients were anemic when starting dialysis. further analysis is needed to determine causality to improve anemia control in incident dialysis patients. of the avf were in whites with in a black patient. the avg was in a black patient, with a cvc distribution of whites and blacks. patients with cvc had been previously followed by a nephrologist and of these had been followed for > months. in summary, incident pediatric hemodialysis patients are primarily having cvc as initial access type. with . % having been previously seen by a nephrologist and % of these for greater than months, the reasons behind not having an avf or avg as primary access need to be explored and improved upon. this high incident cvc use is consistent with data reported in the united states, but not with other european and asian countries. an effort to have a permanent avf or avg in incident pediatric hemodialysis patients needs to be made by the patient's nephrologist. to find the preventive measures for recurrent uti in infants with first febrile uti and normal urinary tract (ut), the incidence of recurrent uti and its risk factors were investigated. method: from june, to june, under months of age (- mon: , - mon: ), who were diagnosed as the first febrile uti and proved to have normal ut, were enrolled to the retrospective study. for all infants with nonretractile prepuce, topical application of hydrocortisone for - weeks and physiotherapy was recommended. during the following year, the incidence of recurrent uti and the well-known risk factors such as female, young age, phimosis, vaginal reflux, and initial mtc-dmsa(+) pyelonephritis were evaluated. result: the incidence of recurrent uti in infants with normal ut was . % and recurrent uti episode was . /patient-year. the recurrent incidence in male infants was . %, which was not significantly different from . % in female infants (p= . ). the recurrent incidence in younger infants was significantly higher than in older infants [- mon: . %, - mon: . %, p= . ]. this age-related difference was significant in male infants [- mon: . %, - mon: . %, p= . ], but not in female infants (p= . ). in infants with persistent nonretractile prepuces, recurrent uti developed in . %, which was higher than . % in infants with retractile prepuces (p= . ). the presence of the vaginal reflux (p= . ) or initial mtc-dmsa(+) pyelonephritis (p= . ) showed no significant difference in the incidence of recurrent uti. conclusion: in uti infants with normal ut, younger infants under months of age and nonretractile prepuces of male infants were the risk factors for recurrent uti. objective: vascular endothelial growth factor (vegf) appears to play a central role in the process leading to peritoneal angionesis and increased level of vegf may conrtibute to high peritoneal small-solute transport rate (ptsr) in continuous ambulatory peritoneal dialysis (capd) patients in adult. vegf-c is related to lymphogenesis, but its role in peritoneal solute transport rate is not known. in this study, we evaluated possible relationship between dialysate vegf and vegf-c levels and pstr in children. method: twelve children with no apparent inflammation process or disease, who had been on capd, were enrolled. standard peritoneal equilibration test (pet) was done to evaluate pstr. d/pcreat and d/d gluc were calcualted at hr of pet. overnight dialysate levels of vegf and vegf-c were measured using commercial elisa kit. correlation between dialysatevegf (or vefg-c) and d/pcreat (d/d glu) was analyzed. results: mean peritoneal dialysis duration was . ± . months. mean overnight dialysate vegf and vegf-c level were . ± . pg/ml and . ± . pg/ml, respectively. a significant correlation was noted between the dialysate vegf-c and vegf level (r= . , p= . ). dialysate vegf level had negative correlation with d/d glu of hr pet (r=- . , p= . ). vegf-c had no correlation with d/d glu or d/p creat. conclusion: there was significant relationship between dialysate vegf and vegf-c levels in children and significant correlation was also noted between dialysate vegf and ptsr. it seems that vegf contribute to high ptsr also in children on capd. m. feldkötter, l. stapenhorst, b. beck, u. bangen, b. hoppe we currently use sirolimus as a second line medication in transplanted patients with a distinct nephrotoxicity of calcineurin-inhibitors. as our short term experiences were not as positive as expected, we performed a short term meta-analysis in our renal transplant recipients under sirolimus treatment: we give an account of seven kidney transplant patients who were either directly started or were switched to a medication with sirolimus during september to february . the reasons for this action taken were calcineurin-inhibitor side effects like severe arteriolopathy with lossof gfr, atypical haemolytic-uraemic-syndrome, seizures after the first dosages of cya and a tacrolimus induced exanthema. in four of seven patients switched to sirolimus we observed severe side effects, exaggerating those of the calcineurin-inhibitor and hence, in three patients the latter treatment was installed again. findings were distinct proteinuria in two patients, hyperlipidemia in three patients, wound healing disorders and, most strikingly, treatment resistant severe pancytopenia in one patient and severe interstitial pulmonary fibrosis in another patient, both with amelioration after termination of the medication, but still the need of oxygen therapy in the latter patient. in addition we noticed a slightly faster reduction of the gfr calculated with the schwartz formula in five patients compared to the previous immunosuppressive regimen. based on these findings we strongly feel that a more critical discussion of each case is necessary before changing the immunosuppressive medication. also, the question arises on whether sirolimus can really be valued as an equivalent alternative to a calcineurin-inhibitor based immunosuppressive regimen in pediatric kidney transplantation. y. kovalski, r. cleper, i. krause, m. davidovits schneider children's medical center of israel, nephrology and dialysis unit, petah tiqwa, israel background: despite significant technical improvements, haemodialysis in infants with end-stage renal disease (esrd) is still associated with significant morbidity and mortality. methods: the files of patients weighing less than kg with esrd who were treated with haemodialysis at our institute between and were reviewed for background and treatment characteristics, morbidity and outcome. results: the study group included patients aged - months (mean . months) weighing . - . kg (mean . kg). mean duration of dialysis was . months. vascular access posed the major problem. ten patients were dialysed through a central venous cuffed catheter and one through an arteriovenous fistula. an average of three different vascular accesses was required per patient (range - ). mechanical difficulties were the most common cause of central line removal ( . %), followed by infections ( . %). major complications causing significant morbidity were intradialytic haemodynamic instability, hyperkalemia, coagulation within the dialysis set, anaemia, hypertension, inadequate fluid removal and recurrent hospitalisations. analysis of outcome revealed that patients underwent successful transplantation, one returned for haemodialysis after . years due to graft failure, and died. conclusion: haemodialysis is a suitable option for low-weight paediatric patients with esrd awaiting transplantation, when performed in highly qualified centers. the importance of antibiotic prophylaxis in management of vur vesicoureteral reflux (vur) cause urinary tract infection (uti) and renal scarring is a common condition in children. the detection and treatment of vur before renal scarring is vital. recently, optimal management of low grade vur is controversial. the aim was to explore the kidney outcome in a cohort of patients with vur. the patients were divided into five subgroups according to vur grades. all of them were treated with low dose prophylactic antibiotics until the age of years. urine culture was repeated monthly. background: anemia is a common complication in patients on hemodialysis. treatment of anemia with recombinant human erythropoietin (rhuepo) may lead to iron deficiency. intravenous sodium ferric gluconate complex (sfgc) therapy improves iron stores. objectives of study: aim of our study was to assess effects of maintenance sodium ferric gluconate therapy in pediatric patients on hemodialysis on mean hemoglobin (hb), hematocrit (hct), transferrin saturation (tsat), serum ferritin and rhuepo dose, as well as safety of therapy with sfgc. methods: intravenous sfgc therapy was administered for months in mean dose of . mg/kg/week to eight pediatric patients on hemodialysis. patients were from to years old ( males and females, aged . ± years). all patients were prescribed rhuepo before start of study. results: sfgc therapy was successful in maintenance of mean hb (increased from . to . g/dl), mean hct (improved from % to %), mean tsat (from to %) and mean ferritin level (from to ng/ml). high ferritin levels in two patients were due to inflammatory disease rather than the sign of iron overload. the mean weekly rhuepo dose decreased from to iu. no significant adverse event due to intravenous sfgc therapy occurred. conclusions: intravenous maintenance sfgc use in pediatric patients on hemodialysis was safe and successful in maintenance of iron indices, thus allowing reduced use of rhuepo. the the viral hepatitis b still remains a serious problem, especially actual in patients with end-stage renal disease (esrd) on renal replacement therapy (rrt). the high frequency of hbv infection transmission in hemodialysis units and immunodeficiency modify hepatitis clinical course and outcomes and worsening vaccination results and renal graft survival. we have analyzed the results and influence on transmission of hb -infection of hepatitis b vaccination in children aged from to years with esrd on chronic hemodialysis. majority of children were boys ( . %) older than years ( . %). an assessment of hbs-ag has been conducted prior and during the vaccination (engerixb) by scheme - - months. after first vaccination hbv infection was detected there after in . % of children, after second vaccination in . %. in all patients ( ) which have received three tours of vaccination, an active immune response was developed. thus, vaccination against viral hepatitis b is effective and prevents hbv infection in children with end stage renal disease on chronic hemodialysis. renal transplantation (tx) represents the best treatment for the patient with crf. scientific advance has been able to optimize the immunosuppressive treatment however the adherence to treatment has been not maintained. aims: to identify the factors that influence in non-adherent behavior with the purpose of designing effective educational strategies. methods: the qualitative focus was carried out through patients and tutors interviews. the quantitative aspect applies for epidemic variables, time post-tx, percentages and frequency of the sentences coming from the analysis of the interviews. nurse, psychologist and a social worker were incorporated with the purpose of elaborating an instrument based on seven questions related to the transplantation, risk and/or loss of the graft; besides the events happened as consequence of this, allowing that interviewed manifested with freedom their opinions. the interview was recorded in a microcassette and later transcribed. analysis was determined by categories containing the answers of each question granting the agreement sentences according to the frequency which was repeated in each interview. informed consent was obtained. results: tx ( - ; non-adherent, % of them were interviewed. mean age: . ys. loss the graft: %, time post-tx: . months, dd: % ld: %. the lack of supervision in the taking of medications, numbers/schedules medications, family conflicts and the poor communication with the parents/medical team seem to be the main factors for non-adherence. conclusion: it is necessary to modify the pattern of the patient's attention transplanted under the pattern of chronic suffering that allows the sick person's and their family active incorporation to the process in an integral way to the multidisciplinary group. infantile results: patients ( females, males) < kg, / -< kg at pd start were treated. they consisted % of our center's pd patients ( pts). age at pd start: . ± months (median ), / pts < mo. pd therapy duration: - mo (median ), pts > mo. esrf cause: congenital nephrotic syndrome pts, dysplastic kidneys , cortical necrosis . pts were fed by gastrostomy, pts received gh (growth hormone). / pts had hypertension (ht) treated with > drugs and - cv events. pd type: / cycler-assisted, / capd (continuous ambulatory pd), / both. pd adequacy targets (kt/v> . ) were reached in / . peritonitis: . episodes/patient-month, pts had > episodes. / pts had > pd catheters and / > pd-related surgery. outcome: / -kidney transplantation, / switched to hd for infections or uncontrolled ht. height ±sds median , weight ±sds median + . . conclusions: small infants with esrf can be successfully treated by pd despite high rate of infectious, cv and surgical complications. pd therapy main target is optimal growth towards kidney transplantation. hyperlipidemia is a well recognised complication of renal transplantation. it is a fairly common problem in the paediatric renal transplant population. its prevalence ranges from % to % though the mechanism is not clear. steroids, calcineurin inhibitors and rapamycin are the main culprits in inducing hyperlipidemia, which is a potential risk factor for cardiovascular heart disease and graft dysfunction. long term effects of these immunosuppressive drugs in children have not been adequately studied. of the calcineurin inhibitors cyclosporine (csa) was found to induce hyperlipidemia compared to tacrolimus (tac). post-ransplant hyperlipidemia is well described in adults; the same cannot be said in children. in adults, post-transplant hyperlipidemia increases risk of cardiovascular disease to fold. screening and management of hyperlipidemia has therefore become an important part of current long term management of transplant patients. there is a limited data on prevalence of hyperlipidemia in renal transplant in children and even more so locally here in south africa. most of the known studies have been conducted in the first world, there was therefore need to determine prevalence locally. this information would ultimately assist in the overall management of our renal transplant recipients. majority of the patients had normal lipid profile. % of the patients had high cholesterol levels, while % of the patients had high tg levels. / ( %) of the patients on csa had hypercholesterolemia compared to only / ( %) on tac (p= . ). / ( %) of the patients on csa had high tg compared to / ( %) on tac (p= . ). the study concluded that the prevalence of hypercholesterolemia and hypertriglyceridemia in renal transplant pts is high, comparable to other studies and that there is a tendency towards having more lipid abnormalities in transplant pts on csa. grade vur in ( %) and . the incidence of abnormal findings was significantly higher in children with uti and vur than in those with uti without vur ( . % vs %; p< . ). in children with no vur, grades - vur, grade vur and grades - vur, renal scarring rates were %, %, % and %, respectively. the patients with higher grades vur tended to have more than scars on their dmsa scans (p< . ). our findings suggest that renal scarring resulting from uti is mostly related to vur, but sometimes is caused by the infection itself. we can conclude that vcu is essential for diagnosis of vur, but mtc-dmsa scan shouldn't be avoid in the management of children with uti. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] years. seventythree ( . %) of them were on triple immunosuppressive therapy, one on double therapy, and one didn't use any medication. overall, subjects ( %) had at least one episode of uti. twenty-four episodes of urinary tract infection occurred in children: episodes in two girls with neurogenic bladder (ngb), episodes in two boys with posterior urethral valve (puv), four episodes in an obese girl with laurence-moon-biedl syndrome, episode of uti in girl with unknown primary renal disease and episodes in girl, one with polycystic kidney disease and one nephronophthisis. conclusion: uti following kidney transplantation was more common in children with known lower urinary tract abnormalities. key words: urinary tract infection, kidney transplantation. background: in japan, the severe shortage of cadaveric kidneys led clinicians to attempt performing abo-incompatible living kidney transplantation (tx). some reports demonstrate successful results of the combination of plasmapheresis (pp), strict immunosuppression and splenectomy. however, we should concern about a great risk of surgical invasion and postoperative serious infection in younger patients who underwent splenectomy. recently, a few reports suggested anti-cd monoclonal antibody (rituximab) can be an alternative to splenectomy. patient and method: a years old boy with bilateral hypoplastic kidneys had been treated with peritoneal dialysis for years. since his blood type o was incompatible with paternal blood type a, we arranged to perform tx using pp and rituximab without splenectomy. a single pp was performed on days - , - , and - to reduce anti-a antibody (ab) titer. rituximab was administered in a single dose of mg/m on day - . basiliximab, tacrolimus, mycophenolate mofetil and methylprednisolone were used for immunosuppression. results: before tx, the anti-a ab titer was reduced from : to : , and cd level was suppressed from % to %. tx was performed without splenectomy and he had excellent initial graft function. we observed anti-a ab titer rose up to : on day + , but it decreased spontaneously to : . there were no side effects and severe infections during the perioperative period, but the neutropenia treated by gcsf appeared months after rituximab administration. the protocol biopsies were performed in month and months, which revealed no signs of rejection. conclusions: abo incompatible tx using pp and rituximab without splenectomy can be a therapeutic option in children to avoid a invasive surgery and infectious risks. further establishment of optimal protocol for children are necessary to obtain excellent outcomes safely. . . , . . , and . . , . . , in hivan, and od, p= . , p= . , respectively. serum p levels were . . , . . , and cap were . . , and . . , in hivan and od, p= . , p= . the aim of this study is to identify the outcome of the physically or socially handicapped children with end stage renal disease (esrd) receiving chronic peritoneal dialysis (cpd). among patients commenced on cpd, handicapped children with esrd receiving cpd were identified in our unit during the period between november and february . age at cpd initiation ranged from . to . years (median age: ; girls, boys). underlying diseases were neuropathic bladder and vesicoureteral reflux (in patients), chronic pyelonephritis (in patients), vesicoureteral reflux (in patients), amyloidosis (in patients), and alport syndrome (in patient). causes of handicapped status against cpd were inadequacies of indoor resources (in patients), cerebral palsy (in patients), down syndrome (in patient), inadequate psychosocial status (in patient), surgically corrected rectovesicale fistula and ectopic anus (in patient), blindness (in patient), ventriculoperitoneal shunt and paraplegia (in patient), colostomy (in patient). all catheters were implanted percutaneously by the same pediatric nephrologist. median duration of dialysis was (range - ) months. during a total of dialysis months, episodes of peritonitis ( episode/ . patient-month), episode of exit-site infection, and episode of tunnel infection occurred in of children. except for an inguinal hernia in patient, we did not observe any mechanical complication related to catheter. cpd was terminated in children (death in , renal transplantation in , switch to hemodialysis in ). before initiation of renal replacement therapy, some negative baseline factors may not be really contraindications for cpd. the socioeconomic and geographic factors greatly influence the prevalence and outcome of renal disease in children. the subspecialty of pediatric nephrology in sudan was established few years ago and the facilities for the management of renal problems are limited. the aim of this study is to review the demographic profile, complications and outcome of capd after nineteen months of treatment. all children who underwent capd from june to january were studied. there were children ( males), the mean age was years (range from months to years). the majority of children has undetermined cause of esrd ( children). the most common complication was peritonitis (peritonitis rate was / . patient/months. patients had refractory peritonitis that necessitate catheter removal, exit-site infection was documented in children and catheter block in children. there were drop out of the program were due to deaths, changed modality and one family withdraw treatment. in conclusion this analysis has stimulated improvement in nurses training and supervision as well as attempts to improve catheter survival and microbiology monitoring. the - ) , looking for symptoms of hypovolemia (cramps, abdominal pain or headache) during or at the end of hd treatment. bioimpedance measurements were performed at the end of each session according to the khz tetrapolar technique; resistance and reactance values were plotted on the age and gender specific th , th and th percentiles of the vector distribution in the healthy population (reference tolerance ellipses) as a resistance-reactance graph. hypovolemia (hv) was indicated by a vector shifted to the upper pole, out of the % tolerance ellipse; normovolemia (nv) by a vector inside the ° ellipse. patients complained of one or more of the above-mentioned symptoms in % of hd sessions, while biva suggested hv in . % of the sessions. symptoms were significantly more common (p< . ) in sessions with hv ( / cases; positive predictive value . %) than in those with nv ( / cases; negative predictive value . %). biva suggested hv in / sessions with symptoms (sensitivity . %) and nv in / sessions without symptoms (specificity %). no significant differences in the accuracy of biva were found between patients either younger vs older than years, or with height sds <- vs >- , or taking vs not taking antihypertensive drugs. in conclusion, biva can be useful in assessing dry weight in children and young adults on hd: since patients with a vector shifted to the upper pole, out of the reference % tolerance ellipse, are at high risk of hypovolemia during the next hd treatment, the increase of the dry weight is then indicated chronic antibody-mediated rejection can occur as a de novo complication in renal allograft recipients and is associated with c d deposition in peritubular capillaries in the renal graft and positive circulating anti-hla antibodies, although the sensitivity and specificity of positive c d staining for chronic humoral rejection requires further study. renal outcome appears to be worse in c d positive patients. current treatment strategies to manage c d-positive chronic humoral rejection are poorly defined. various protocols with enlarged doses of tacrolimus, mycophenolate mofetil, plasmapheresis, ivig and rituximab have been reported in adult patients. we investigated four pediatric patients (mean age . yrs; range to yrs) after renal transplantation that developed c d positive chronic rejection. in of patients, maintenance immunosuppression with calcineurin inhibitors had previously been minimized because of severe toxicity. in of patients, an elevated anti hla class ii antibody titre could be detected; donorspecific antibodies were positive in patients. all patients experienced a progressive deterioration of graft function. treatment with repeated intravenous immunoglobulin (ivig) ( g/kg body weight per week over four consecutive weeks) followed by a single dose of rituximab ( mg/m ) was therefore initiated. three of four patients showed an improvement of graft function with a mean increase of gfr by %. one patient with advanced chronic transplant nephropathy lost his graft after months. this pilot study demonstrates that the combination of high-dose ivig and rituximab can stabilize or improve transplant function in chronic antibody-mediated rejection without major side effects. the use of ivig and rituximab appears to reduce the active immunologic process, but larger trials are needed to support these observations. cardiovascular diseases are some of the most important causes of morbidity and mortality in children with end stage renal disease (esrd). chronic inflammation has been suggested to be a risk factor for cardiovascular diseases. the aim of this study was to investigate the relation between crp and cardiac changes in children on hemodialysis. this study was conducted on patients ( patients were hypertensive & were normotensive), males ( %) and females ( %) on regular hemodialysis due to esrd. their ages ranged from to years (mean . ± . ). sixty age-and sex-matched controls were also included. significantly higher velocity of circumferential fibre shortening (vcfs), tei index, interventricular septum thickness in diastole (ivsd), left ventricular mass index (lvmi) and isovolumetric relaxation time (ivrt) and significantly lower e/a ratio were found in all patients as well as in hypertensive & in normotensive groups as compared to the controls. significantly higher ivsd and lvmi were found in hypertensive patients than normotensive patients. significantly higher high sensitivity crp (hs-crp) & crp latex were found in all patients as well as in hypertensive & in normotensive groups when compared to the controls. crp was significantly higher in both study groups with cns symptoms and cardiac symptoms in comparison to those without. it was also significantly higher in patients with increased lvmi & than in those with abnormal e/a ratio. hdlc showed a significantly direct negative effect on crp. s. ca + , se. p and ca x p had a significantly direct positive effect on it. we can conclude that the cardiac affection in children with esrd appears in the form of lv hypertrophy with early diastolic affection. crp could be correlated to these changes and to cns symptoms and cardiac symptoms in these patients. is. lim, hs. lee, dw. kim, wh. choi chung-ang university, pediatrics, seoul, south korea purpose: urinary tract infections are common clinical problems occurring in infants and pediatric patient groups, most frequently caused by uropathogenic e. coli. urinary pathogens almost always infect the host through ascension from the rectum, vagina to the urethra and bladder. recurrent urinary tract infection is a disorder involving repeated or prolonged bacterial infection of the bladder or lower urinary tract. in this study, we examined the substitusion effect of probiotics in the high risk group of recurrent urinary tract infection. objectives & methods: patients diagnosed as recurrent urinary tract infection were administered probiotics for six months, and urine cultures were checked during the period. probiotics in this study were selected among the products commercially saled in korea, namely lactobacillus acidophillus, bacillus subtilis, and bifidobacterium infantis. single blind study was done for selection of probiotics for patients. result: the separated bacteria from the urinary tracts of the patients were the same as administered probiotics in some patients. conclusion: in recurrent urinary tract infection, there seemed to be a substitution effect of probiotics for uropathogenic bacteria, and it is reasonable to administer probiotics for long period in the high risk group of recurrent urinary tract infection. renal insufficiency therapy in children: quality assessment and improvement: the rich q study objectives: outcome studies in children on chronic renal replacement therapy (crrt) have revealed a -time increased mortality and % co-morbidity in adult survivors. information on the quality of care of treatment centers and on the impact of advised quality indicators on outcomes in children are lacking. no data exist on the impact on these outcomes of the different treatment modalities, peritoneal dialysis, hemodialysis & transplantation either. until now, no structural corporation and consensus on general guidelines with respect to crrt exist between the dutch (nl) and belgium (b) centers for pediatric crrt. aim of the study: . assessment of the current quality of treatment crrt in children (qt) in nl & b and of the effect of recurrent peer review of the achieved outcomes on the qt. . the assessment of the effect of different treatment modalities on outcomes. . the creation of a format for multicenter trials. methods: all prevalent patients on chronic dialysis aged < years at onset of the study & all incident patients during the study period with onset of crrt< years of age, from b & nl will be included. treatment characteristics and quality indicators of crrt with respect to physical and psychosocial outcomes will be collected of all patients. operational data collection and management will be performed by members of the dutch institute for quality care in dialysis patients (hans mak institute). each months, all data will be revealed and actively discussed by representatives of all centers (peer review). the effect of registration and peer review on the qt will be analyzed after & years. comparison will be made between the effects of cumulative periods of different rrt models on outcomes. the study will be performed between august & . on estimation, patients will be analyzed. renal renal transplantation in patients with lower urinary tract dysfunction (lutd) of different origin is a challenging issue in field of pediatric transplantation. we report our single centre experience to evaluate the patient and graft survival as well as risks of the surgery and immunosupressive therapy. among pediatric transplant patients patients had severe lower urinary tract dysfunction. videourodynamic test was performed in all patients preoperatively and postoperatively. the cause of urological disorders was secondary to neurogenic bladder (n: ) and valve bladder (n: ). clean intermittent cathatetization (cic) was needed in patients to empty the bladder. pretransplant augmentation ileocystoplasty was created in four patients and gastrocystoplasty in one patient to achieve low-pressure reservoir with adequate capacity. three of the patients received kidneys from cadaveric and of them from living donors. the mean age at transplantation was ± . years. the median duration of transplantation was months (range - months). at their last visit median creatinin levels were . mg/dl ( . - . ) . three patients had recurrent symptomatic urinary tract infections who had augmented bladder and on cic. one of them had creatinine levels of . mg/dl. one patient with ileocystoplasty who developed urinary leak and ureteral stricture in early postoperative period was treated by antegrade j stent. severe lutd reserves high risks for graft kidney. however our data suggests that renal transplantation is safe and effective treatment modality if the underlying urologic disease properly managed during the whole course of transplantation period. since surgery and follow-up of these patients is more complicated, patient compliance and experience of transplantation team will have significant impact on the outcome. r. meneses, l. sylvestre, j. sousa, d. ribeiro hospital pequeno principe, pediatric nephrology, curitiba, brazil introduction: in july , we started a systematic evaluation program of each patient on chronic pd. the aim of this study was to analyze the long-term outcome of children on pd program. material and methods: we evaluated all the patients on pd between july and may , who performed complete protocols, with a minimal interval of months between them, consisting of: anthropometric measurements, blood pressure and cardiological status, standardized laboratorial evaluations, pet test, clearance and kt/v, measurement of the intra-peritoneal pressure (ipp), occurrence of infections, hernias or constipation and need to change the catheter. we then compared all the evaluations using the graphpad prism software, a p value < . was considered significant. results: out of patients were eligible, mean age ± years old at the first evaluation, % boys, primary renal disease: % uropathies, % glomerulopathies, % tubulopathies and % other causes. there was an improvement on bmi and weight/height z-scores and worsening of height/age z-score, but none was significant. there was also no significant decrease in residual renal function (p= . ), adequacy parameters remained stable: clearance (p= . ) and kt/v (p= . ). most patients were converted from capd to ccpd and nipd, and some had to increase daytime dwells (p= . ).constipation and the number of infections improved but not significantly. laboratorial evaluations, peritoneal membrane characteristics, ipp, need to change the catheter and occurrence of hernias did not change over the time. conclusion: a long-term maintenance of children in peritoneal dialysis program is possible, but reaching a satisfactory clinical condition is a great challenge. several points need to be checked for planning a better adequacy and survival of dialysis technique in children waiting for a graft. a rigorous follow-up protocol seems helpful in precocity of prescription strategy modifications. we observed a stable long-term outcome observing these adequacy tools. outcome the recurrence of primary disease in transplants is a well-known problem. we report our single centre experience to assess the frequency of the recurrence of primary glomerulonephritis in children after renal transplantation. medical reports after of children with primary glomerular disease were evaluated. the grafts were nine from living related and four from cadaveric donors. eight of them were diagnosed as fsgs, of them mpgn and of them pan. the mean age was . ± . years. however the median transplantation duration was months, one of the fsgs patient had hyperacute rejection. five years later she had second graft with the serum creatinine . mg/dl at th year of second transplantation. and all recipients were immunosuppressed with either cyclosporin a or tacrolimus, azothioprine or mmf and steroid based regimens. mutational analysis was available in two patients, they had homozygous podocin mutations. post transplant recurrence of fsgs was confirmed in one patient. glomerular tip lesion was the only histologic abnormality on graft biopsy. he has treated with plasmapheresis with no improvement of proteinuria. two of the fsgs patients had thromboses after transplantation. one of them had cardiac thrombosis with heterozygote mthfr mutation and one of them had renal artery thrombosis and loss of graft with prothrombin a mutation. both of them have had additional risk factors for thrombosis. they have all functioning grafts except one. we have not observed any recurrence in patients with pan and mpgn. although the number of our patients quite small, renal and patient survival seems to be more favourable in our experience but we strongly recommend the evaluation of all risk factors of thrombosis and give appropriate anticoagulation. skin involvement in factor h deficiency (fhd) associated to hemolytic uremic syndrome (hus) has never been reported. we describe the case of a young adult on regular hemodialysis (hd) for fhd-hus who developed microangiopatic skin lesions and was successfully treated with plasma exchange (pe). the patient developed end stage renal disease secondary to fhd-hus (scr ) in , when she was . after one year of hd she complained of severe night pain in the perimalleolar areas, followed by skin lesions which evolved into superficial ulcers (fig ). in august , due to the worsening of the skin lesions, the patient started hd and pe ( litres of fresh frozen plasma per session twice a wk) based on the hypothesis that skin lesions were expression of thrombotic microangiopathy. after wks of pe there was a skin improvement (fig. ) and a pain relief. pe was discontinued. wks later she started to complain of the usual pain in the right foot. pe program combined to hd was restarted and the symptoms ceased again. pe was gradually discontinued and she was addressed to regular plasma infusion of . litre per wk. so far, after months the pain and the skin lesions did not show up again. m. belingheri, s. cristino, p. basile, v. bianchi, a. leoni, s. testa, l. ghio, a. edefonti, g. ardissino ospedale maggiore policlinico irccs, mangiagalli e regina elena, pediatric nephrology, milan, italy background: in rapidly growing children on hemodialysis (hd), the determination of dry weight still remains troublesome. bioimpedance analysis (bia) is potentially helpful in quantifying the fluid to be removed but its specific role, in routine clinical practice, is not yet clearly set. the aim of the present study was to test the feasibility of prescribing ultrafiltration (uf) exclusively based on bia parameters. methods: differences in body weight, resitance (rx) and reactance (x-c) between pre-and post-hd were calculated in order to derive the equivalence between uf and bia parameters in a years old girl over a period of months. for consecutive hd sessions, uf was prescribed exclusively based on the derived uf-bia equivalence. this period was compared with hd sessions where uf was prescribed by the conventional approach. results. xc correlated with ultrafiltration better (r: . ) than rx (r: . ). bia-based compared with weight-based uf prescription showed a significantly lower number of hd sessions complicated by hypotension ( % vs. %), need of fluid reinfusion ( % vs. %) and a better quality of the hd sessions ( % vs. %). conclusion. prescription of uf solely based on xc is feasible and provides a better outcome compared to the conventional modality of uf prescription. we believe that this approach could be useful for any patients with low tolerance to uf or with problems in setting the correct dry weight. aim: the aim of the present prospective study was to determine the incidence of urinary tract infection (uti) and related abnormalities in children ages between - years. material and methods: all children between - years old whose admitting to first step health offices (routine controls and immunization) was screened for uti with urine dipstick test after education of minimum two persons from first step health offices according to protocol with two tertiary child care center and health directorate of izmir province in turkey between july and july . all patients with urine dipstick test abnormalities were referred to tertiary child care centers for evaluation. urine microscopic evaluation and urine cultures and other further investigations were performed in tertiary care centers after obtaining urine with urinary catheterization. results: . children ( % boys) were screened with urine dipstick test. the children's mean age was . ± . mo (median mo). screening test was found normal in . ( %) children. of ( %) of referred child were admitted to tertiary care centers and evaluated for uti. uti was demonstrated in children ( . % of screened and % of evaluated children's). uti incidence was found . % in girls and . % in boys. urinary tract abnormalities were found in children ( . % of screened and . % of evaluated children's). the most common urinary abnormality was vesicoureteral reflux ( patients). conclusion: the uti incidence was . % in children ages between - years, uti more common in girls than boys in this age group and only small group of children has urinary tract abnormality which is determined with routine urine screening. knowledgement: thank you for this opportunity to health directorate of izmir province. we describe ds post-peldrt in children with no known neurologic problems and discuss potential predisposing factors. a . kg girl with renal dysplasia was started on a calcineurin inhibitor (cni) one week pre-t and when her blood urea nitrogen (bun) was mg/dl. on admission for t, the bun had increased to , and her serum sodium (na) was mmol/l. post-t, she remained intubated and paralyzed to permit generous volume supplementation, including : replacement of her vigorous urine output (uop), initially with . % nacl in water. five hours post-t, her bun was and her na . after modification of uop replacement, her na normalized. on the morning of post-t day , paralysis was discontinued, but she did not awaken and had sluggish pupillary reactions. computed tomography of the head (cth) revealed diffuse cerebral edema, and brain death occurred. a kg adoloescent with polycystic kidneys was started on a cni days before peldrt. his bun and na then were and , respectively, and had not changed on the day of t. post-t, the patient was immediately extubated. with uop replacements as described above, his bun and na decreased from to and to , respectively, over hours despite adjustments in the na content of his intravenous fluids based on urine na levels. the patient then had a -second tonic-clonic seizure, followed by a -hour post-ictal state. cth was negative, and the patient recovered completely. we conclude that ds, caused by a rapid decrease in serum bun and thus osmolality, may complicate peldrt in settings even with older pediatric recipients or without excessive elevation of pre-t bun. other factors contributing to this ds may include relatively mild hyponatremia and cni effects on both pre-t uremia and seizure threshold. results: patients, predominantly males, ages between months and years old. the mean incidence of peritonitis was . episodes/patient months. fifty-seven patients ( %) had at least one episode of peritonitis.there were peritonitis, % percent from all episodes began at home, % caused by gram negatives, % by gram positives, % by fungus, % had a negative culture and in less than % it was not performed. the mean treatment time was days, % had a good response to initial empiric antibiotics (cefazoline and amicacine). the interval between the beginning of dialysis and the first peritonitis episode varied from to days, occurring in the first months in % of the patients. successful treatment occurred in % of the cases, % were transfered to hemodialysis, % had a consecutive peritonitis episode, and patient died due to mesenteric artery trombosis. conclusion: peritonitis occurred early in our patients. even though most of them have a good initial response, there is still a great amount that have complications leading to technique failure. continuous education for the patients and health team, aiming early diagnosis and treatment, are useful to preserve the technique and decrease morbidity and mortality associated to peritonitis. d. davis, j. emancipator, x. zhu, c. rosen objective: to assess for sd in p chronic kidney disease (ckd) patients before and after rtx. methods: we assessed symptom (sx) domains of sleep disorders: ) sleep-disordered breathing (sdb); ) insufficient sleep (is) (shortened sleep time or nap); ) excessive daytime sleepiness (eds); and ) restless leg syndrome (rls) using a set of standardized questionnaires in patients with ckd (age - yrs) including non-d non-tx (ndntx) (n= ), d (n= ), rtx (at least months post-tx) (n= ), and age-matched sibling controls (c) without known ckd. the presence of an overall sd was defined by positive responses in any of the sx domains. results: mean age (se) ranged from . ( . ) to . ( . ) in the pt groups (p> . ) without significant differences in gender, race, or congenital ckd. estimated mean gfr (ml/min/ . m ) (se) was significantly higher in the rtx group [ . ( . ) methods: in a prospective design, renal transplanted children, who had renal transplantation at least months before, at namazee hospital, were enrolled in our study. immunosuppressive regimen consisted of cyclosporine and prednisolone plus mycofenolat mofetil or azathropin. data regarding gfr, serum creatinine, electrolytes, lipids and c and c levels was collected at beginning, in one-month, and five-month intervals. cyclosporine was adjusted to - ng/ml based on c level. patients were divided into two c (< and > ng/ml) and two c (< and > ng/ml) subgroups. discussion: similar creatinine levels, drug dosage, and complications of c and c subgroups may be due to dependence of renal function to several factors other than cyclosporine dosage. regarding coefficient of variation, c was more accurate and reliable than c level. as there was no significant difference in mean c and c levels, and renal function at beginning and the end of the study, there seems to be no need to check c levels after renal transplantation. purpose: preparation is necessary in order to effectively meet the critical needs of the post-operative pediatric kidney transplant patient upon their arrival to the icu following transplantation. the increasing number of children requiring liver transplantation services has made it evident that it is important to have guidelines in place for their initial and often specialized post-operative care. methods: the main goal is to provide the child with appropriate post-operative care and to recognize and quickly address complications. therefore the icu nurse will: · monitor the patient continually and conduct full assessments a minimum of time/hour (airway, breathing, ventilation, perfusion, neurological status, etc) . · observe the incision for signs of bleeding, evisceration, and dehiscence. · treat post-operative pain. · update family with findings, etc. · see that appropriate post-operative studies (ultrasound, laboratory studies, etc) are completed. outcomes: nurses in the icu monitor the pediatric post-operative kidney transplant patients very closely as outlined. this allows for quick recognition of problems and immediate intervention. it is the practice of these nurses to be fully aware of the patient's status as well as any changes that might be problematic. conclusions: nurses are prepared to care for pediatric kidney transplant patients and very carefully follow established guidelines for assessment. following guidelines for assessing and caring for pediatric kidney transplant patients upon admission to the icu has proven to be affective in allowing nurses to quickly recognize complications and notify the appropriate clinician. background: uremia is an independent cardiovascular risk factor. transplantation increases life expectations of patients with crf, however there is still an increased risk of accelerated arteriosclerosis. the pulse wave velocity (pwv) is a non-invasive marker of arterial distensibility, it increases along with arterial stiffness, as an early indicator of arteriosclerosis. aim: to evaluate pwv values of transplanted (tx) children. patients, methods: pwv was measured with a pulsepen in tx (age , ± , years). two control groups were formed using a database of healthy children ( - years): one matched for age (a) and one adjusted for height and weight (h/w). blood pressure, heart rate, serum calcium (ca), phosphate (p) , and pth were also determined before transplantation and at the time of the pwv measurement. results: tx patients were smaller by , cm (p< , ) than a and younger by , years than h/w (p< , ). pwv in tx ( , ± , m/s) did not differ significantly from a ( , ± , ) , however it was elevated in comparison to h/w ( , ± , p< , ). serum p, caxp and pth was increased before transplantation, all the values returned into the normal range except for creatinine ( ± micromol/l) at the time of the study. there was no correlation between pwv and the actual values of ca, p and pth. conclusion: pwv is higher in transplanted children as a sign of increased arterial stiffness. controls matched for height and weight should be used in states of severe growth failure. although a number of established risk factors potentially responsible for arterial dysfunction were present before transplantation, they were normal at the time of the study. the long lasting effect of uremia before transplantation could be in part responsible for the increased pwv in children after transplantation. supported otka-t -fo -f and ett / . d. derakhshan , h. jalaeian , a. derakhshan department of pediatric nephrology, shiraz, iran shiraz organ transplantation center, nemazee hospital, shiraz, iran backgrounds: bartter syndrome is an inherited recessive autosomal tubulopathy characterized by hypochloremia, hypokalemia, metabolic alkalosis associated with potassium renal leakage, and normal blood pressure despite increased plasma renin activity. patients with this syndrome may have proteinuria or hematuria, but most of them have normal gfrs. here we report on a child with bartter syndrome who developed esrd (end stage renal disease) and underwent successful cadaveric kidney transplantation. case presentation: a -year-old girl presented to the pediatrics nephrologist with failure to thrive, severe hypokalemia, hypochloremia, metablolic alkalosis, and normal blood pressure and the diagnosis of bartter syndrome was considered for her. however, due to poor compliance, she did not receive any medications, did not give consent for kidney biopsy and did not attend her opd follow-up visits for about years, when she developed esrd and went on chronic hemodialysis ( /weeks) . her little sibling also was diagnosed to be suffering from bartter syndrome at this time. after months, she received a cadaveric renal allograft. afterwards, her kidney function, serum electrolytes, and growth have improved dramatically. discussion: in this case, we postulate that long-term hypokalemia due to bartter syndrome led to chronic interstitial nephritis and renal dysfunction. successful renal transplantation, even after the onset of esrd, for severe clinically bartter syndrome results in correction of metabolic abnormalities and excellent graft function. we propose that bartter syndrome should be considered as a possible cause of esrd and an indication for early renal transplantation, a procedure that results in a cure for the underlying disease and significant improvements in patient's quality of life. h. jalaeian , a. derakhshan , d. derakhshan , m. fallahzadeh , z. bazargani , m. basiratnia shiraz organ transplantation center, nemazee hospital, shiraz, nemazee hospital, shiraz, iran fasa university of medicine, pediatrics, fasa, iran shiraz university of medical sciences, pediatric nephrology, shiraz, iran background: obesity is a major issue in the end stage renal disease population. while studies evaluating the effect of obesity on transplant outcomes in adults have yielded varying results, this issue is even still more controversial in children. methods: in a cross-sectional design, pediatric recipients, aged - at transplantation and with normal graft function for at least months after transplantation, were evaluated. we grouped the data with regard to the body mass index (bmi) percentiles as group i (bmi > th), group ii (bmi < th), group iii (bmi > th), group iv (bmi < th). we compared the clinical and laboratory findings between groups i and ii and between groups iii and iv. obesity was defined as bmi > th and being overweight was defined as bmi > th. results: there were children ( males, females) with mean age at time of transplantation of . ± . years (range, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , and mean follow-up of . ± . years. . % of children were overweight and . % were obese. no difference was found regarding age, height, duration of pretransplantation dialysis, or age at transplantation between groups i and ii and between groups iii and iv. (p> . ). further more, no difference was found in regard to serum creatinine, bun, glomerular filtration rate, and -year graft survival rates among obese and/or overweight and other children. no correlation was found between bmi and gfr (p> . ). conclusion: obese and overweight recipients can have excellent graft function and survival rates that are comparable to their non-obese counterparts. denying patients access to renal transplantation on the basis of obesity per se does not appear to be justified. d. derakhshan , h. jalaeian , a. derakhshan , b. sabet , m. fallahzadeh nemazee hospital, shiraz, iran shiraz organ transplantation center, nemazee hospital, shiraz, iran introduction: tb is an important cause of morbidity and mortality in renal transplant recipients, especially in developing countries. this study was done to identify the incidence of tuberculin test positivity before transplantation as well as the influence on outcome of graft function and patient survival in children who receive renal allografts. methods: all children with esrd who received a renal allograft between and were evaluated. as a routine pre-operative measure, a tb test was administered, using ppd. the ppdpositive recipients were compared with ppd-negative subjects, regarding age, gender, graft function, graft outcomes and patient survival rates. patients were divided into < mm versus > mm induration. results: the mean age of recipients was . ± . years (range, - ) with a male/female ratio of . : . the majority of children were on chronic dialysis with mean duration on dialysis of . ± . months. the tuberculin test was positive in . % of children; all of them received isoniazide prophylaxis on diagnosis of latent tuberculosis. overall, the -year, -year, and -year survival rates were . ± . %, . ± . %, and . ± . %. three year survival rate was not different among ppd positive or ppd negative individuals. ( . ± . vs. ± . %; p> . ) in addition, no difference was found for -year or -year graft survival rates (p> . ). also serial serum creatinine levels at -month, -month, -year, -year, and - year interval after transplantation was not statistically different (p> . ). conclusions: detection of latent tuberculosis infection is an important step in the control of tuberculosis among asymptomatic pediatric kidney transplant. with proper management, latent tb does not affect transplantation outcome among children. h. xu, q. shen, ss. ruan, yl. bi, yq. lu, x. wang children's hospital of fudan university, department of nephrology, shanghai, people's republic of china objectives of study: we have started the first pediatric renal transplantation project in children hospital in china from . survival of patients and grafts for the patients are %. the clinical features were analysed and specific problems related to drugs and infections were reviewed. methods: children ( ~ years old) underwent rtx. the duration of follow-up was months to months (average of . months). results: all the patients were on automated peritoneal dialysis prior to rtx. the transplanted kidneys came from cadaveric donors (one were a -year-old brain-dead boy). patients received il- receptor antibodies as induction therapy and the other one with alg due to high level of population reactive antibody. after the rtx, all the patients were on triple immunosuppressive treatment (prednisolone, mmf, fk or csa) . no patient developed postoperative complication and delayed graft function occured. during the follow-up, case suffered from calcineurin inhibitor renal toxicity and changed to rapamycin treatment, from acute respiratory distress syndrome due to infection and from elevated liver enzymes owing to drugs. one had acute rejection at months after the operation. a severe anemia appeared on him after the rejection recovered. the cause of the anemia was found by the positive of serum anti-parvovirus b igm and completely recovered from the ivig treatment. at latest follow-up, the mean serum creatinine level of the patients was . ± . umol/l and egfr was . ± . ml/min/ . m . some patients received a support from "shanghai child renal failure trust fund". conclusions: the improvement of surgical technique, adequate dialysis prior to rtx, rational use of medicine, financial support and regular follow-up are all important for improving the outcome. h. bunker-wiersma , , j-c. davin the area under the curve (auc) of cyclosporine is strongly related to the efficacy and toxicity of the drug and its variability is mainly determined by the absorption phase. close therapeutic drug monitoring (tdm) is warranted to optimise therapy, using more appropriate methods to estimate the auc, than trough concentration measurement. from july we started auc guided monitoring of cyclosporine therapy based on two concentration measurements, c and c . the results of this method are reported. methods: all paediatric renal transplant recipients treated with cyclosporine were included in the analysis. bayesian, model based estimation of auc values was performed at each out-patient visit or during hospital admission. calculated pharmacokinetic parameters, treatment efficacy data and side effects were collected over the month period after introduction. target auc values were derived from previous studies in adult patients: ng/h/ml in the first three months after transplantation and ng/h/ml after three months. results: early or stable post renal transplant patients were evaluated, divided in two groups (group i: < months after transplantation; group ii: > months after transplantation). in patients with trough concentrations below the therapeutic range, more than % auc's were in the therapeutic range in both groups. conclusion: auc guided monitoring of cyclosporine after kidney transplantation in children using c and c is practically feasible and presents the major advantage that c has not to be determined precisely hours after csa administration. it is more closely related to the total drug exposure as compared with trough concentration monitoring and isolated c . this method may facilitate the use of lower doses of cyclosporine and by this way limitside-effects. objectives: there is no satisfying data about reproductive functions after kidney transplantation in adolescence who have end stage renal disease (esrd) during childhood. we analysed the reproductive functions of kidney transplanted male adolescences. patients and methods: nine patients who followed between - were enrolled in the study. except one preemptively transplanted patient, all were on hemodialysis/peritoneal dialysis before transplantation. mean dialysis duration was ( - ) months. their ages ranged between - years (mean . ) at transplantation. at the urologic examination, their mean age was years. all patients had normal renal functions. results: all patients had normal testicular volume, libido and erectil functions. except one all patients had normal serum levels of lh, fsh, total and free testosterone. seven of the patients semens were available for analysis. / patients had normal sperm parameters. transplantation had been performed before adolescence period in these patients. one of these patients had been treated with intensive cyclophosphamide before. oligospermia was detected in , defective morphology in , low sperm motility in / patients. conclusion: although adult transplanted patients mostly have normal semen profiles; male children with end stage renal failure would not have normal spermatogenesis at the adolescence period; even after successful renal transplantation. in our study only patients had normal semen profile, even hormon levels were normal. renal transplantation age seemed to be more crucial than the duration of esrd, of primary diagnosis or previous cyclophosphamide usage. r. vilalta, j. nieto, e. lara, a. madrid, s. chocron hospital materno-infantil vall de hebron, department of pediatric nephrology, barcelona, spain background: inhibition of il- receptors by basiliximab is irreversible and extended in time (mean days). basiliximab (anti cd receptor) is used usually in the induction regime in our first cadaveric-donor kidney transplants. its re-use when chronic allograft nephropathy (can) develops could be useful. however some concern could exist related to possible adverse reactions (anaphylactic shock) linked to re-exposure to this drug because is an heterologous protein. less adverse reactions as lymphokine release syndrome has been described with the use of other monoclonal antibodies as the anti-cd receptor rituximab. objective: to describe our experience in the treatment with basiliximab of seven children with banf ii can. patients: seven children ( - years old (means . y.), boys, girls) showed biopsy-proved banf ii can. its period post-transplant ranged from to years (mean . y.) and their creatininine level from to mg/ ml (mean . ). all of them had been received at the transplant time basiliximab, tacrolimus or cyclosporine, mycophenolate and tapered steroids to reach . mg/kg/day in the third month post-transplant. when can developed, sirolimus was used in two patients, but was withdrawn due to increase of proteinuria. results: one dose of basiliximab ( mg/ . m ) was administered after steriod pulses ( mg/kg/day) in all patients. their basal immunosuppression was not changed. plasma creatinine diminished by % in four patients in the second week post-treatment and this improvement was sustained in two patients after one year follow-up. proteinuria did not change in any patient. in the course of this treatment no adverse reactions were observed. conclusion: ) use of basiliximab in can is safe and possibly useful. ) exposure to different monoclonal antibodies in paediatric kidney transplantation could be usual in the future; in the induction time, in the treatment of humoral rejection if exists (rituximab) and in the treatment of can. ) it is necessary to establish that exposure and re-exposure to different antibodies is safe and without major adverse effects as our limited experience supports. r. vilalta, e. lara, a. madrid, s. chocron, j. nieto hospital materno-infantil vall de hebron, department of pediatric nephrology, barcelona, spain background: there are limited knowledge of kinetics and pharmacodynamic effect of sirolimus in paediatric renal transplantatation. provided that sirolimus is effective and safe in combination with tacrolimus and mycophenolate (mmf), the initial dose needed, the evolution of blood levels and the steady state should be studied in order to optimise its clinical use. objective: to establish a possible correlation between dose/level ratio of rapamune and other parameters as age, gender or puberal state. patients and methods: between and , paediatric patients ( girls, boys) received a cadaveric kidney transplant. age ranged from to years (mean y.), and all of them received mmf and steroids. sirolimus were used from . to . mg/kg/day, to obtain levels between to ng/ml. results: dose/level ratio obtained allowed us to describe three types of patients: an infant-type i dose-level patient (age - y), a prepuberal type ii (age - y) and an adult-type iii dose-level patient (age - y). type i needed sirolimus between . and . mg/kg/day (sd± . ), type ii between . and . mg/kg/day (sd± . ) and type iii between . and . mg/kg/day (sd± . ) to obtain all of them a constant blood levels between and ng/ml. the same positive correlation was obtained regarding the puberal status. no correlation were observed regarding the gender. introduction: developing of diabetes mellitus after renal transplantation is one of the determining factor in the survival of the patient and the graft. in present study we assessed the carbohydrate metabolism status of ntx. methods: we analyzed patients' data about recently developed carbohydrate metabolism failure after ntx. children underwent ntx between - were investigated. thirty-nine children ( girls/ boys) underwent ogtt, who had no ptdm. we analyzed the incidence of ptdm/igt, the combination of immunsuppressive therapy, the number of transplants, the proportion of cadaver/living donor, hcv, blood pressure, lipid metabolism, bmi, graft function parameters and the time since ntx. results: ptdm developed in children ( %). four of patients required insulin therapy. we diagnosed igt in of with ogtt investigated patients ( %). all ptdm/igt patient got tacrolimus and continous steroid therapy. the dose of steroid was . mg/day in the ptdm/igt group vs. . mg/day no ptdm/igt (p< . ). during ogtt the trough level of tacrolimus was higher in the ptdm/igt group . ng/ml vs. . ng/ml (p< . ). in the other parameters we did not find any significant differences between ptd/igt and no ptdm/igt patients. discussion: the most important reasons in the development of ptdm and igt after transplant are steroid therapy and higher tacrolimus trough level. in transplant children we recommend the regular fasting glucose and ogtt examimation, the reduction of steroid and tacrolimus in case of stable graft function. otka f- , otka-t , ett / , ett / the introduction: measurement of plasma bnp is a novel noninvasive approach in the assessment of cardiovascular status. in our study we investigated the role of bnp in the monitoring of cardiovascular status of children with crf or renal transplant (ntx). methods: we examined children with crf (n= , boys/ girls, age: , year ( , - )) or ntx (n= , boys/ girls, age: , ) ). patients underwent echocardiographic investigations (ivs, lvedd, lvesd, pw and fs) and their bnp levels were measured (age matched normal values were used). other cardiovascular risk factors, such as hgb, htk, ca, p, creatinine and blood pressure were also evaluated. a correlation between bnp and echocardiographic results was calculated. results: the values of lvesd, fs and bnp levels of renal transplant patients were significantly better than those of crf patients (p< , ). the other parameters did not show significant differences. bnp levels were significantly higher in all age groups of crf patients as compared to the normal levels. in younger ntx patients this value was within normal limits. in older ntx patients, and in those that had their transplants a long time ago we measured higher bnp levels, which correlated significantly with graft function as well (p< , ). bnp showed a significant positive correlation with lvesd and a significant negative correlation with fs only in crf patients. the elevated bnp levels showed the worsening of cardiac function even when the echocardiographic parameters were still normal. the hgb, htk, ca, p and creatinine values were significantly better in ntx patients and showed no correlation with bnp. summary: bnp is an early, easily usable marker in diagnosing and following decreased cardiac function of both crf patients and after ntx. otka f- , otka-t , ett / , ett / c. garcia , v. bittencourt , s. vitola , e. didone , e. guerra , f. pires , a. tumelero , d. malheiros , v. garcia department of pediatric nephrology, porto alegre, brazil complexo hospitalar santa casa, department of nephrology and kidney transplantation, porto alegre, brazil complexo hospitalar santa casa, department of surgery, porto alegre, brazil the objective is relate the results of consecutive kidney transplants carried out in children in a single center. patients and methods: analysis of kidney transplants performed in patients less than years old, carried out from may to december . results: kidney transplants were performed. % of the patients were female, % were caucasian and % were african-brazilian. the mean age at the transplant was . ± . years. the most frequent etiology of renal failure was vesico-ureteral reflux/obstructive uropathy ( %), followed by glomerulopathy ( %). the donor was deceased in % and living related in % (parents %). the initial immunosuppression was cya+aza+pred in . %, cya+mmf+pred in , %, tac+aza+pred in . %, tac+mf+pred in . %, tac + mf without pred in . %. sirolimus was employed initially in cases. induction with okt /atg occurred in patients and received anti-il receptor antibody. the graft losses during years of follow-up were secondary to chronic allograft nephropathy in ( %), vascular thrombosis in ( . %), acute rejection in ( . %), recurrence of original disease in ( . %). there were transplants in patients with focal segmental glomerulosclerosis, ( . ) had a recurrence after transplant. eight were treated with plasmapheresis and % obtained a total remission. the survival of graft in the first, fifth and tenth year was: %, % and % respectively. the graft survival in the th year according the immunosuppression was % using azathioprin and prednisone, % with cya/aza or mmf and % with tac/aza or mmf. the patient survival in the first, fifth and tenth year was: %, % and % respectively, infection was the main cause of death. j. feber , p. geier , b. chaudry , h. wong , g. filler children's hospital of eastern ontario, division of pediatric nephrology, ottawa, canada london health science center, departments of pediatrics, london, ontario, canada successful pediatric renal transplantation (tx) should fully correct the metabolic abnormalities of end-stage renal failure. however, ckd may persist because of only half of the normal nephron endowment and other factors (ischemia, nephrotoxocity etc). height, bmi and blood pressure (bp) z-scores, cystatin c-gfr, hemoglobin (hb), serum pth, hco , cholesterol, mycophenolic acid (mpa) and sirolimus (sir) levels were analyzed retrospectively in tx recipients ( males, age . ± . years) at months post tx (t ) and at . ± . years (median . ) post tx (t ). data are expressed as mean±sd. height z-scores remained significantly lower than controls (t : - . ± . ; t : - . ± . , ns), growth failure occurred in % of pts at t and % of pts at t . bp z-score did not change from t to t , but hypertension was diagnosed in % pts at t and % pts at t . gfr (ml/min/ . m ) was . ± . at t and . ± . at t (ns), mean decline of gfr was . ± . %/year. hb z-score remained below normal at - . ± . at t and - . ± . at t (ns) and anemia was diagnosed in % and % of pts at t and t respectively, despite trough levels of both mpa ( . ± . mg/ml, pts) and sir ( . ± . mg/ml, pts) that would be considered adequate. hypercholesterolemia was detected in . % pts at t and % pts at t , whereas only . % of pts at t and . % of pts at t were labeled as obese. bone disease was diagnosed in . % pts at t and . % pts at t . we observed suboptimal growth, hypertension, hypercholesterolemia, bone disease and persistent anemia in a significant proportion of tx children despite iron supplementation, adequate mpa and sir levels and good kidney function. these ckd complications require careful monitoring and intervention. a. al midani , g. koffman , j. john , s. stephen , s. suzanne , r. lord royal free hospital, transplantation, london, united kingdom great ormond street hospital for children nhs trust, transplantation, london, united kingdom objectives: to document factors predisposing towards surgical complications over years in a single pediatric renal transplant centre. methods: we retrospectively analysed consecutive renal transplants between jan and dec . patients were divided into group , without complications, and group , with complications. we compared variables previously identified as risks for surgical complications between the two groups: live/deceased donor, donor and recipient age, gender and weight, side of organ donation, cold ischaemia time, single/multiple vessels, intraperitoneal/extraperitoneal approach, anastomosis to aorta/iliac vessels, thrombosis prophylaxis (changed from heparin to aspirin in oct ). results: / ( %) were complication free; % patients developed one or more surgical complication: wound infection / ( . %), wound dehiscence ( . %), prolonged ileus ( . %), lymphocoele ( . %). patients were re-explored: ( . %) for bleeding, ( . %) for graft repositioning. we observed ( . %) cases of renal artery stenosis. overall, ( . %) graft loss occurred secondary to thrombosis, % ( / ) prior to changing our prophylaxis from heparin to aspirin ( . % on aspirin). urological complications occurred in ( . %): ureteric leaks and ureteric stenoses. the variables between group and group were as follows: under kg: % v %, less than yrs old: % v %, intraperitoneal approach: % v %, anastomosis onto the aorta: % v %, no aspirin prophylaxis: % v %, other variables were the same in both groups. conclusions: % of patients developed surgical complications. a higher rate of surgical complications was seen in recipients under , using the intraperitoneal approach onto the aorta. the introduction of aspirin prophylaxis reduced graft loss due to thrombosis from % to . %. other variables did not affect the complication rate. m. medeiros , v. sharma , r. ding , s. valverde , am. hernández , p. garcía , y. fuentes , m. suthanthiran hospital infantil de mexico federico gomez, departamento de nefrologia, mexico, mexico weill cornell medical college, immunogenetics and transplantation center, new york, ny, united states the forkhead transcription factor foxp is highly expressed in cd +cd + regulatory cells (tregs). the foxp +cd +cd + cells play a central role in immune tolerance and tgf-β is reported to induce foxp expression in vitro. whether there is an in-vivo association between foxp and tgf-β is not known. we investigated the hypothesis that there is a positive association between foxp and tgf-β in children with stable renal graft function. parental written informed consent was obtained before enrollment in all cases. children with stable renal allograft function for a minimum of months were studied. a complete clinical examination was performed; peripheral mononuclear cells were collected for measurement of transcripts for foxp , tgf-β , tgf-β , and s rrna (house keeping gene) using by real time quantitative pcr assay. correlation between transcript levels was performed using pearson r. results: pediatric recipients of renal allografts were studied. tgf-β and foxp were highly expressed in peripheral blood mononuclear cells, and there was a highly significant and positive correlation between levels of mrna for foxp and tgf-β (r= . , p< . )), whereas no significant correlation was found between tgf-β vs. tgf-β (and tgf-β vs. foxp ). conclusion: foxp expression in vivo is strongly correlated with tgf-β expression in peripheral mononuclear cells of stable renal transplant recipients. introduction: studies suggest that pre-emptive lamivudine therapy improves survival in hbv renal transplants. however, long-term outcome is not well established. method: four chinese adolescents with chronic hbv infection were transplanted. they were put on cyclosporin a, mycophenolate mofetil and prednisolone. prophylactic lamivudine was given just before transplantation and was continued afterwards. hbv status and liver enzymes were monitored serially. results: four patients were transplanted at the age of . ± . ( . - . ) yrs old. they were followed up for . ± ( - ) months and no mortality was reported. alanine transaminase (alt) was only transiently elevated in the first months post-transplant in all cases and became normal afterwards. there was no hepatitis flare and liver function was normal at the last follow-up. hbeag and hbv dna were positive in patient before transplantation and remained positive at the latest follow-up. mutation in the ymdd motif of the hbv genome was detected in the same patient and undeterminable in the other three due to low virus load. this patient remained clinically stable with normal liver function except there was a rise of viral load from baseline. all grafts were functioning and there was one late acute cellular rejection which responded to treatment and there was no hepatitis flare. latest mean serum creatinine was ± ( - ) umol/l. conclusion: ymdd mutation and resistance to lamivudine treatment may happen but appear to have little clinical significance. our long-term results showed that renal transplant seems feasible and safe in this population up to yrs follow-up. there are no studies in mexican children (mx) . the aim of the study was to determine tacrolimus pharmacokinetics (pk) in mexican renal transplant children and compare it wih reported pk in aa and ca. methods: a seven point pharmacokinetic profile ( , . , , , , and h) was performed in ten children receiving tacrolimus as part of the immunosuppressive therapy, mean age was . ± . years, mean post transplant time . ± months. c and cmax were obtained directly from experimental points, the auc and t / was obtained with a non-compartmental model using winnonlin version . . results: in cyclosporine (csa) is widely used for immunsuppression in transplant recipients and for treatment of srns. however, patients can develop csa associated cutaneous side effects, e. g. hypertrichosis, skin cancer, and viral warts due to human papillomavirus infection. here we report on a -yearold boy suffering from a microdeletion syndrome ( q-) and srns (histology: minimal change nephropathy) starting at the age of years. since the initial combination therapy with corticosteroids and cyclophosphamide was associated with severe side effects (sepsis, leukopenia) and did not lead to sustained remission csa therapy was initiated. csa-treatment resulted in rapid clinical remission. however, after months the patient developed viral warts (hands, trunk and head), although csa trough levels were kept below μg/l. therefore, immunosuppression was switched to mmf ( x mg/day) resulting in sustained remission of srns and rapid disappearance of viral warts within months. conclusion: conversion to mmf may be a usefull treatment strategy in srns showing csa associated side effects like viral warts. - . were live related (lrd) and the remaining cadaveric (cad). were pre-emptive(pet). all received basiliximab induction hrs prior to surgery. in addition, induction immunosuppression consisted of tacrolimus and methylprednisolone. in all but patients, basiliximab was re-administered at day . patients, aged and yrs (one cad and other lrd respectively) developed acute noncardiogenic pulmonary oedema - hrs after transplantation. both children had renal dysplasia as primary cause of renal failure. both required delayed ventilation and were ventilated for to days respectively. there was a rapid rise in c reactive protein in both patients. both grafts had primary function, but the cad transplant subsequently developed acute tubular necrosis, and was eventually lost within weeks due to thrombotic micro angiopathy and severe acute antibody mediated rejection despite immunosuppression with sirolimus, mycophenylate, steroids and plasma exchange therapy. conclusion: we report a rare but serious side effect of basiliximab. to our knowledge, this is the first report of basiliximab induced non-cardiogenic oedema so early post transplantation and in such young children. early recognition and aggressive appropriate supportive therapy is vital for patient and where possible, graft survival. ( ); cmv seroconversion ( ); seizures ( ); hypertension ( ), uti ( ), adverse reaction to basiliximab ( ), delayed graft function ( ), acute rejections ( ), chronic allograft nephropathy ( ). patients had well matched kidneys ( or less mismatches), were poorly matched. grafts were lost from latter group, both were cad, had acute tubulointerstitial nephritis and tacrolimus toxicity and the other thrombotic microangiopathy and eventually acute antibody mediated rejection. chronic allograft nephropathy (can) is a complex phenomenon caused by underlying kidney disease and superimposed by environmental and genetic factors. we investigated the association of polymorphism in the genee nos with the can. nitricoxide is synthesized from l-arginine in vascular endothelial cells by nitric oxide synthase. endothelial nitric oxide plays an important role in endothelial dysfunction and involved in the inflammation. the gene encoding enos maps to chromosome q q . . a missense variant of the enos gene in exon shows a transversion of g to t at nucleotide position (g t) that results in a replacement of glu by asp at amino acid residue (glu asp). the aim was to investigate the association between can and g t polymorphism of the endothelial nitric oxide synthase gene. the g t mutation at exon of the endothelial nitric oxide synthase gene, enos gene polymorphism, was analyzed in turkish children with renal transplantation. the g t polymorphism of the endothelial nitric oxide synthase gene was determined by polymerase chain reaction and restriction fragment length polymorphism. were grouped according to stages of chronic kidney disease (ckd) as estimated by the calculated glomerular filtration rate (gfr, schwartz formula). measurements of structural and functional surrogates for cardiovascular disease (cvd) included intima-media thickness (imt) of the common carotid artery (cca), pulse wave velocity (pwv) and augmentation index (aix). aix and pwv reflect the degree of arterial stiffness and were calculated from pulse wave recordings at the arteria carotis and arteria femoralis (sphygmocor device). results: patients and healthy control subjects had a mean age of years. imt was not significantly different in patients and controls. significant differences were found in the aix, which was increased by %: the mean aix was in healthy subjects was - , % and in transplanted subjects - , %. pwv was increased by % ( , m/s vs. , m/s). both aix and pwv increased in parallel with the degree of renal impairment (stages of ckd). table . discussion: weight gain post transplant is multifactorial, like cultural, psychological and associated to steroids. weight gain was observed in general, patients with overweight or in risk of overweight didn't loose weight postransplant even they were aware of the consequences. introduction: tacrolimus is metabolized by cytochrome p a and has a narrow therapeutic range. we report a kinetic interaction between tacrolimus and amlodipine, a potent cytochrome p inhibitor, resulting in anuric acute renal failure. case report: a -year-old male renal transplant recipient received amlodipine, a calcium channel blocker as antihypertensive treatment while he was on tacrolimus ( . mg/kg per day). he presented first with diarrhea and developed subsequently, dizziness and fatigue, related to acute anuric renal failure, requiring hemodialysis for days. tacrolimus trough levels were in the desired therapeutic range ( - ng/ml) until recently. three days after introduction of amlodipine, tacrolimus trough levels increased to a toxic level of . ng/ml. after discontinuation of amlodipine, tacrolimus levels returned to the normal range in seven days and renal function recovered progressively. no polymorphisms in the expression of cyp a and p-glycoprotein were detected. discussion: tacrolimus is known to be a substrate of p-glycoprotein, responsible for drug secretion into the intestinal lumen and metabolized by enterocytic cyp a. amlodipine is a competitive inhibitor of cyp a. as no abnormalities of cyp a and p-glycoprotein were found, we suspect that drug interaction due to competitive inhibition of tacrolimus metabolism by amlodipine was responsible for these toxic effects. concomitant diarrhea might have played an additional role for increased tacrolimus serum levels, presumably in relation to diarrhea associated dysfunction of enterocytic cyp a and p-glycoprotein. conclusions: amlodipine and diarrhea increase tacrolimus blood concentration by inhibiting its metabolism. amlodipine should not be used in patients on tacrolimus. careful monitoring of tacrolimus blood levels is recommended in case of concomitant diarrhea. urinary tract infection (uti) remains a significant cause of infectious complications in renal transplant recipients. the aim of the study was to determine the frequency of uti following renal transplantation in our center. the records of patients (f/m: / ) who underwent renal transplantation were evaluated retrospectively. among them patients (f/m: / ) were found to have at least one episode of uti during follow-up. the records were examined for the age, sex, primary disease, and duration of chronic renal failure, donors, posttransplant follow-up and recurrence of uti. biochemical analysis of blood for renal functions, complete blood count, creactive protein and sonographic examination of patients were also recorded and results were compared with renal transplanted patient who did not develop any episode of uti (group ). the mean age of the group was . ± . years, while it was . ± years in the group . mean duration of post-transplant follow-up was . ± . years for group and . ± . for group . four patients ( . %) in group and patients ( . %) in group had vesicoureteral reflux (p> . ). five patients had single uti while patients had more than one uti. though we did not find any difference between girls and boys in terms of presence of vesicoureteral reflux, frequency of uti in girls was found to be significantly higher than in boys (p= . ). ultrasonographic examination of patients during uti in group revealed pyelonephritis in and hydronephrosis in patients. the most frequent microorganism causing uti was e. coli. age, donor source and etiology of chronic renal failure did not influence the incidence of urinary tract infection. our data suggests that urinary tract infection remains a frequent but mostly benign complication in the pediatric transplant population, especially in female gender. the growing population of transplanted patients requires the consideration of the potential side effects of the different treatment regimens. experience of the last decade with calcineurin and nucleoside reverse transcriptase inhibitors revealed important renal side effects. we describe a years old girl who was known to have liver failure related to wilson's disease (wd). she had orthotopic liver transplantation from her mother years ago and treatment with tacrolimus and mmf was initiated. although she was known to have proximal renal tubular acidosis secondary to wd, renal tubular functions were found to be normal within the three months of transplantation. two years after the transplantation lamivudine was initiated because of de novo hepatitis b infection in transplanted liver. a couple of months later she developed renal fanconi syndrome with metabolic acidosis, hypophosphatemia, glycosuria and aminoaciduria. she needed high doses of sodium bicarbonate and phosphate supplementation. tacrolimus was suspected to be the cause of late post transplant renal acidosis and was replaced by sirolimus. however, months later, at the th month of lamivudine treatment, she was hospitalized because of metabolic acidosis, mild hyperglycemia and inability to walk. electromyographic examination revealed myopathic changes while liver biopsy was normal with a normal tissue copper level. renal biopsy showed findings of karyomegalic nephropathy which could be the result of the action of antimitotic agents. we suspect that our patient's tubular dysfunction, myopathy and hyperglycemia may have resulted from mitochondrial dysfunction which is triggered by tacrolimus and augmented by lamivudine. however, randomized and prospective studies with large groups of patients are needed for definite results about mithocondrial side effects of these drugs. recombinant factor viia (rfviia, novoseven) is a new hemostatic agent that was initially indicated in hemophiliac patients. recently it has been used successfully for the treatment of bleeding in patients with thrombocytopenia, and acquired and congenital platelet dysfunction. epstein syndrome, also known as alport-like syndrome, is a rare autosomal dominant disease characterized by proteinuria, chronic renal failure, hearing loss, and thrombocytopenia with giant platelets. our group previously reported functional alterations of giant platelets of boy with epstein syndrome, who rapidly progressed to end stage renal disease during adolescence. the first nonheartbeating kidney transplantation at age was failed because of the severe postoperativebleeding irresponsible for traditional therapy (packed red cells, platelets, and fresh frozen plasma), result in immediate graft failure and the need for transplant nephrectomy. the second kidney transplantation was years later, after a single intravenous bolus injection μg/kg body weight rfviia, which was repeated one and hours after the surgery. rfviia successfully controlled the bleeding in the peri-and postoperative phase and no side effect and thrombotic complication occurred and his graft function is still stable after years. recombinant factor viia may have a potential role in the treatment of phenotypic bleeding associated with chronic kidney disease. cyclosporin a (csa) and mycophenolic acid (mpa) have a wide interindividual variability in their pharmacokinetics (pk). among others, intestinal p-glycoprotein (p-gp) expression and cyp a activity have been held to be responsible for that variability. in adult kidney transplant (rtx) patients, an influence of these gene polymorphisms has not been shown; however, there are no data in pediatric patients. we reasoned that such an influence might be masked in adults by confounding environmental factors accumulating over the decades of life. we therefore investigated a possible influence of gene polymorphisms of p-gp and cyp a on defined dose-adjusted pk-parameters in children with rtx (age . ; range, . - . yrs). pk parameters (auc, c ) were assessed , , , and weeks after rtx. real-time, rapid-cycle pcr methods were used for genotyping. the allele frequencies for the mdr c t allele (expression and in vivo activity of p-gp) of % and for the cyp a -v allele of % were comparable to those reported for caucasian populations. dose-adjusted pk parameters of csa and mpa were not significantly different in patients with and without the cyp a -v allele or patients with different mdr c t genotypes. along with that finding, neither of the polymorphisms investigated into was associated with renal function or the incidence of acute rejection episodes. we studied how the il- r β-chain becomes enriched in lipid rafts of activated human t cells, isolated by ficoll gradient and sheep red cell rosetting, and how its tyrosine phosphorylation, which requires its heterodimerization with the common cytokine r β-chain (βc), occurs there. imunoblots (ibs) of sucrose gradient fractions of cell lysates obtained during a -hour activation with phytohemeagglutinine (pha) showed the gradual, largely selective, translocation of the β-chain into rafts. as dimerization or lipid modification can be mechanisms underlying raft enrichment, we assessed lysates of pha-activated cells in ibs under non-reducing versus reducing and crosslinking conditions but did not see evidence of β-chain dimerization. however, exposure to cycloheximide to interfere with post-translational acylation, or to the palmitic acid analogue -bromohexadecanoic acid substantially diminished raft enrichment of the il- r β-chain. we next performed ibs of il- r β-chainand βc-immunoprecipitates from raft and non-raft fractions of activated t cells before and after il- treatment. we found that il- exposure triggers the translocation of small amounts of βc, accompanied by il- r β-chains, into rafts, resulting in its heterodimerization with the il- r β-chain and their tyrosine phosphorylation. all of these processes were attenuated in the presence of the il- r β-chain-blocking antibody daclizumab. we conclude that the raft enrichment of the il- r β-chain requires palmitoylation and provides the focal point for the formation of the highaffinity il- r via il- r β-chain-mediated "chaperoning" of few βcs into these domains, establishing novel raft-dependent mechanisms underlying cytokine r specificity and selectivity in human t cells. iga nephropathy (igan) is an immunecomplex disease resulting from a defect in mucosal iga response. food antigens have been implicated in the pathogenesis. gut permeability to antigenic substances is immature at birth and its maturation is delayed by early administration of antigenic foods while breast feeding accelerates this process. we aimed to evaluate if exposure to antigenic foods in early life is associated with a predisposition for igan in childhood. three groups including children with igan (group , n= ), primary non-iga glomerulopathies (group . n= ) and healthy controls (group , n= ) were formed. their parents filled a questionnaire regarding the age at diagnosis, gestation time, birth weight, feeding by breast milk, formula, cow's milk and complementary foods. all groups were similar for age, sex, gestation period, birth weight and the rate and duration of breast feeding. in addition, the rate of formula feeding was also similar in all groups. however, cow's milk consumption rate was higher in group and than in group . introduction of formula was earlier in groups and than in group . in addition, the children in group were younger than the other groups at the onset of feeding by cow's milk and weaning. roc curves predicted . , . and . months as the best cut-off age values for formula feeding, cow's milk feeding and weaning for predicting the presence of igan, respectively. ors for igan with respect to these cutoff levels were ( % ci: - ), . ( % ci: . - . ) and . ( % ci: . - . ), respectively. the results of this preliminary study indicate that early introduction of antigenic foods might increase the risk of future primary igan. results: they were males and females, with a male: female ratio of : . their ages ranged from months to years (mean . years), with a peak age of - years. the common presenting complaints were generalised oedema ( %); oliguria ( %) and hypertension ( % we report nine patients (three males) with mesangiocapillary glomerulonephritis (mcgn) from a single paediatric nephrology centre. the average age at presentation was . years (range . to . ). all had nephrotic syndrome. seven had mcgn type and two had mcgn type ii. six of seven tested had positive c nephritic factor. three patients responded well to steroids and ace inhibitors and received no further therapy. five had a good response initially but relapsed when steroids were tapered and one patient had a poor response to steroids. these six patients received calcineurin inhibitor (ci) therapy. four responded well with resolution of proteinuria. one patient relapsed when tacrolimus was withdrawn after months of therapy but proteinuria resolved after re-introduction of therapy. two patients had a poor response to ci therapy. one remains stable but with heavy proteinuria. the second patient (with mcgn type ii) initially had a complete remission of proteinuria on steroids but relapsed months after presentation while on prednisolone mg on alternate days. repeat biopsy showed % crescents. treatment with pulsed intravenous steroids, cyclosporin and mycophenolate mofetil was ineffective and she progressed rapidly to end stage renal failure. we conclude that ci treatment might be useful in mesangiocapillary glomerulonephritis. prospective, randomised controled trials are required to determine their place in the management of this disease. iga nephropathy (igan) is caused by a primary defect in mucosal iga response leading to increased antigenic stimuli reaching to bone marrow. enteric flora is important for mucosal and systemic immunity, and probiotics regulate specific and innate immunity by maintaining microbial balance in the gut. saccharomyces boulardii (s.boulardii), a probiotic, increases intestinal siga production, protects enteric infections and also prevents atopic and immunoinflammatory diseases. we aimed to evaluate the effect of s.boulardii on experimental igan, induced by oral polio virus vaccine (opv) administration to the mice. four groups of male balb/c mice (n= for each) were formed. groups i and ii were immunized enterally by opv at the onset, nd and th weeks. group ii was also given s.boulardii in drinking water throughout the study. group iii was given only s.boulardii, while group iv received no treatment. two weeks after the last opv dose, all the animals were sacrificed to obtain their kidneys for histopathological evaluation and all four groups were compared with respect to the severity of histopathological changes. while there was mild to moderate mesengial proliferation and widening, tubular atrophy, interstitial inflammation and fibrosis in group i, no remarkable histological changes in the other groups were noted. immunofluorescence microscopy revealed universal deposition of iga and some c in group i, while there was no iga or c deposition in the other groups. electronmicroscopy revealed mesengial proliferation along with matrix expansion, focal basement membrane thickening and electron-dense deposits in the mesengial area in only opv group and the other groups were normal. in conclusion, enteral s.boulardii administration prevented experimental igan development in mice. the aim was to assess the correlation of renal histopathological findings with clinical diagnosis in order to recognize the pattern of kidney diseases in our pediatric population. methods: a total of renal biopsies performed on children who presented to the surgical kidney hospital in damascus during a period of years were retrospectively reviewed. results: nephrotic syndrome alone accounted for % of all cases, followed by hematuria in %, mild to moderate renal impairment including allograft dysfunction in %, nephritic syndrome in %, and hsp in %. the most common histologic lesion was mcd in ( %). fsgs was the second most common lesion ( %) followed by mesangial gn ( %), mpgn ( %), post-infectious gn ( %), iga nephropathy ( %), membranous gn ( %), cns of finnish type ( %), alport syndrome ( %), interstitial nephritis ( %), nephronophthisis ( %), hsp ( %), acute rejection ( %), chronic rejection ( %), nephrocalcinosis ( %), crescentic gn of undetermined origin ( %), and lastly, % were completely within normal limits. familial and inherited diseases were encountered in %. histopathologic diagnosis was mostly useful in nephrotic cases. while in hematuria cases, the usefulness of the histologic findings in terms of therapeutic and/or prognostic point of view was definitely less. one of the reason for that in our series is perhaps because we still do not have facilities to perform electron microscopic evaluation of the renal tissue. however, controversy about the usefulness of renal biopsy in such cases is still there. conclusion: this study provides an important data on the pattern of pediatric renal diseases in our center and highlights the usefulness histologic findings in guiding the therapeutic plan especially for nephrotic children. aim: the aim of this study was to determine the efficacy of tacrolimus in the management of sr fsgs in children. study design: this was a prospective study of children with sr fsgs treated with tacrolimus ( . - . mg/kg per day in divided doses over hours adjusted to a trough level between - ng/ml) for months in combination with low dose steroids. other therapies included angiotensin converting enzyme inhibitors, folic acid, multivitamins and lipid lowering agents. results: the mean age at study entry was . years (range . - . ). the mean duration of nephrotic syndrome before initiation of tacrolimus therapy was . years (range . - . ). at the end of the treatment period ( %) children were in complete remission, ( %) children were in partial remission and ( %) failed to respond. the average period of follow-up following cessation of tacrolimus treatment was . months (range . - . ). at last hospital follow-up ( %) of children were in complete remission, ( %) in partial remission and ( %) in relapse. children demised from dialysis related complications following cessation of tacrolimus treatment. adverse events included sepsis ( ), nausea ( ) diarrhea ( ), anaemia ( ) and worsening of hypertension ( ) . conclusion: tacrolimus is a safe and effective treatment for sr fsgs. however, like cyclosporine some children tend to relapse following cessation of treatment. it has been rarely reported in association with graves-disease. now we present a previously healthy -year-old japanese girl who had proteinuria due to stage i mn and graves disease. patient: she was found to have + proteinuria and a goiter at her school medical examination simultaneously. serum free thyroxine was . ng/dl (normal range . ~ . ), thyroid-stimulating hormone (tsh) less than . microu/ml ( . ~ . ), anti-microsomal antibody t (~ ), anti-thyroglobulin antibody t (~ ), and tsh-receptor antibody % (~ ) consistent with graves' disease. the electron microscopy finding of her renal biopsy specimen showed the presence of electoron-dense deposits located in the subepitherial and intramembranous spaces. with immunofluorescence microscopy, the bright granular staining of igg along the gromerular capillary wall was found. these findings were characteristic of mn. objectives of study: to investigate whether graves disease caused mn in this patient. methods: we examined the presence of thyroid microsome and thyrogrobulin in glomeruli by immunofluorescence study using anti-thyroid microsomal antibody and anti-thyrogrobulin antibody. result: glomerular granular staining of thyroid microsomal antigens was demonstrated corresponding to igg granular deposits, but that of thyrogulobulin was absent. conclusion: mn in this patient is presumed to be caused by immunecomplexes mediated by thyroid microsomal antigens. objective: to explore the role of oxidative stress reaction on the injury of glomerular podocyte slit diaphragm molecular barrier. methods: thirty-two male spraque-dawley (sd) rats were randomly divided into control, low dose ( . mg/kg), nephrotic ( . mg/kg), overdose ( . mg/kg) groups by the dosage of adriamycin (adr) injection.the levels of malondialdehyde (mda) glutathione peroxidase (gsh-px), hydroxy radical ( . oh) and superoxide dismutase (sod) in renal cortex were measured; the expression of podocin was measured with immunohistochemistry. results: ( ) compared with control group, the levels of mda in renal cortex and -hour urinary protein were increased, the levels of sod in renal cortex was decreased in adr-treated groups, especially in nephrotic group (p< . ). ( ) in control group, podocin staining was a sable linearlike pattern along the capillary loops of glomerulus; in nephrotic group, podocin staining was a light tan discontinuous punctiform or short linear-like pattern along the capillary loops of glomerulus. compared with control group, the score of podocin immunohistochemical staining was decreased in adr groups, especially in nephrotic group (p< . ). ( ) there were some significant negative correlations between the score of podocin immunohistochemical staining and the levels of mda in renal cortex. there were some significant positive correlations between the score of podocin immunohistochemical staining and the levels of sod in renal cortex. conclusion: ( ) there was close relationship between podocin and the development of proteinuria. ( ) there were significant correlations between the reduction of podocin in glomerular podocyte slit diaphragm and oxidative stress reaction, especially lipid peroxidation. lupus nephritis (ln) remains an important problem in patients with sle. to evaluate the clinical course, histopathology and the efficacy and safety of high-dose pulse cyclophosphamide (ctx) in children with ln. retrospectively, children with ln were studied; all patients underwent renal biopsy and were followed up for at least years. the clinical and serologic data at the time of renal biopsy were recorded. five of them were excluded because of short period of follow-up or defective laboratory data. based on renal biopsy (who classification for ln), patients were treated with the following regimens: one patient (class i) with low-dose prednisolone (pred), (class ii, iii) with high-dose of pred, (class iv) with high-dose pred and received intermittent intravenous (iv) ctx pulses (monthly for months, then every months) followed by mycophenolate mofetil (mmf) as maintenance therapy. there were girls and boys. the mean age at the time of diagnosis of sle was . years. eighteen patients were more than years old. sixty percent of the patients were presented as nephritic-nephrotic syndrome. there was with class i, with class ii, with class iii, with class iv and none with class v based on biopsy. eighty-five percent of cases went in remission, one was hemodialytic and died due to renal failure and cns involvement. among cases with class iv, responded to pred and iv ctx pulses. there was no evidence of side effects. it seems that iv pulse ctx does induce remission of clinical and renal disease in the majority of early diagnosed children with severe ln. furthermore, it appears that mmf is an appropriate drug for maintenance therapy. however, this study was based on a small number of subjects. further studies to confirm the long-term efficacy and safety of ctx pulse therapy on larger numbers of patients are needed. forming group i were compared with children on short course steroid therapy (iskdc regime) (group ii). children were examined for steroid side-effects and underwent blood tests, ophthalmologic evaluation and radiological examination. results: though remission was achieved in < weeks by % in group ii against % in group i, the total dose received ( - mg/kg) was lower in group i ( % vs %). forty-six % had - relapses, % had - relapses and % had - relapses. the proportion of children having > relapses was much higher in group ii ( % versus %). mean relapse/patient/ year was . (sd . ) in group i against . (sd . ) in group ii. delayed bone age ( %), radiological evidence of osteoporosis ( %). cushingoid facies ( %), posterior subcapsular cataract ( %), decreased growth velocity ( %) and hypertension ( %) were the side effects and were almost equally distributed in the two groups. more patients from group ii received a higher cumulative dose/ kg/year of > mg ( %versus % in group i) and these had higher risk for hypertension, delayed bone age and osteoporosis. conclusion: alternate day, prolonged therapy (soyka regime) compared to short course, daily therapy (iskdc) resulted in lower cumulative dose to the patient. acute side effects and severity of infections were less. mean relapse/patient/year were lower. group ii patients receiving higher cumulative dose had osteoporosis and delayed bone age. objetive: to assess urinary protein excretion decrease in patients with primary srns treated with ec-mps methods: cohort of patients, mean age: years with primary srns. inclusion criteria: primary sncr with of focal segmental glomerulosclerosis (fsgs). exclusion criteria: glomerular filtration rate (gfr) % than baseline level, leukopenia, absence of decrease of proteinuria excretion by month of treatment with ec-mps. mean time after the initial diagnosis of ns until the introduction of ec-mps was calculated in patients who decreased urinary protein excretion below nephrotic range and in non-responsive patients and the glomerular damage, interstitial fibrosis and tubular atrophy were classified as: absent, mild, moderate, severe ( to , risk grade> ). ec-mps dosing: - mg/m /day. complete response was considered a reduction in the urinary protein excretion lower than or equal to mg/m /hour; partial response: urinary protein excretion ranging from to mg/m /hour and absence of response: urinary protein excretion in the nephrotic range. laboratory monthly assessments: serum creatinine, urea, hemoglobin and blood cell counts, lipids, serum proteins, amilase, hours urinary protein excretion. . no significant differences in the frequency of both alleles were observed among patients with different grades of hypertension or proteinuria. in conclusion, drb * , and possibly alleles confer susceptibility to psagn. however the severity of the disease is not determined by these two alleles. methods: fifty children who diagnosed as biopsy-proven fsgs were studied retrospectively by medical records. response to treatment and pathologic slides, we compared normal renal function group (n= ) and decreased renal function group (n= ), assessed the factors affecting renal survival and progression to renal failure. results: the mean age at onset was / years, gender ratio m: f was . : and the mean duration of follow-up was / years. the overall renal survival rate was % at years, % at years. five-year survival rate was % in normal renal function group, but % in decreased renal functin group. between the two groups, there were no significant differences in age at onset, gender ratio, amount of proteinuria, incidence of hematuria, hypertension and mesangial hypercellularity. decreased renal function group showed higher serum creatinine level, poor response to treatment, higher percent of glomeruli with sclerosis, moderate to severe tubulointerstitial change and vascular change (p< . ). the prognostic factors of renal survival rate were same as above (p< . ). there were no significant factor has shown relations with the progression rate to renal failure. conclusion: we reviewed the factors affecting long-term outcome of fsgs. serum creatinine level, steroid responsiveness and the degree of glomerulosclerosis were significant prognostic factors. but, age at onset, gender, amount of proteinuria, incidence of hematuria and hypertension were not considered as a prognostic factor. a background: several studies have suggested that cyclosporine (csa) and methylprednisolone pulse therapy (mpt) may be effective for idiopathic steroid-resistant nephrotic syndrome (isrns) in children; however, the optimal regimen has yet to be established. the present study evaluated the efficacy and safety of years' treatment with csa (neoral) combined with mpt and prednisolone (psl) in such patients. methods: in this prospective study, children with biopsy-proved isrns were enrolled. all patients received csa and psl ( mg/kg every other day). patients who had focal segmental glomerular sclerosis (fsgs) additionally received mpt (methylprednisolone at a dose of mg/kg per day for consecutive days at weeks , , , , and ) . the dose of csa was adjusted to maintain a trough level from to ng/ml for the initial months, followed by to ng/ml for months to , and to ng/ml for months to . results: twenty-six patients were enrolled. their mean age was . ± . years. two-year follow-up was completed in patients. histological examination at study entry revealed minimal changes in patients, diffuse mesangial proliferation in , and fsgs in . at the end of the therapy, patients had complete remission, including who had occasional relapses of steroid-sensitive nephrotic syndrome, and had partial remission; the remission rate was . %. nephrosis persisted in patient. disease progressed to end stage renal failure in patient. serial renal biopsy at the end of the study showed mild signs of csa-related renal toxicity, including tubulointerstitial fibrosis in ( . %) of patients. conclusion: combination therapy with csa, mpt, and psl for years was clearly effective and produced a high remission rate without serious csa-related renal toxicity in children with isrns, in contrast to previous reports. objectives: patients with hemolytic uremic syndrome who do not require dialysis in acute stage usually have a good prognosis. however the spectrum of renal compromise is wide. we believed non-anuric patients with higher creatinine values in acute stage could have different evolution when compared to patients with lower values. aims: ) to analyze the outcome after a year and ) to determine if peak serum creatinine values in acute stage would be a prognostic marker. methods: patients, aged . months at hemolytic uremic syndrome, were analyzed. they were classified into groups: group i, complete recovery; group ii had subgroups: iia, microalbuminuria, and iib, proteinuria and/or high blood pressure, both with normal renal function; group iii, chronic renal failure; and group iv, end stage renal disease. peak creatinine value was definided as the highest value of at least determinations in acute stage. these data were available in patients and they were divided in those with creatinine equal to or higher than , mg/dl ( patients) and those with lower values ( patients). the relationship between creatinine and final outcome was analyzed. we applied fisher's test. results: after a mean follow-up of years, patients were in group i, in group iia, in group iib ( with hypertension, with proteinuria and with both) and in group iii. eight out of patients ( %) with creatinine equal to or higher than . mg/dl in acute stage and out of ( . %) with lower values were in groups iib and iii in the last visit (p= . ). conclusions: ) after years, % developed proteinuria, high blood pressure or chronic renal failure and % microalbuminuria. ) peak creatinine values in acute stage were a prognostic indicator. objective of study: the aim of this study was to assess the serum concentration of hs-crp in children with nephrotic syndrome (ns) treated with prednisone and cyclosporine a (cya). methods: patients were divided into groups: i - ns children ( - years) in relapse, examined twice: a -before treatment and b -after proteinuria regression (a - week course of prednisone therapy), ii - children with steroid-dependent or steroid-resistant ns, treated with cya, also examined twice: d -before treatment with cya, e - months after therapy. control group (c) consisted of healthy children. serum hs-crp level was determined using a nephelometric method with behring nephelometer analyzer, dade behring. results: it was shown that median hs-crp concentration was the highest in children with relapsing steroid-sensitive ns before treatment (ia). after proteinuria regression (ib), the hs-crp level decreased and did not differ from healthy controls (c) (p> . ). in group ii, before cya administration (iid) the level of hs-crp was normal, but increased after months of treatment (iie) up to a level six times higher that of the control group (p< , ). conclusions: in children with steroid-sensitive nephrotic syndrome in relapse, the serum hs-crp level is increased but returns to normal values after a - week glucocorticoid treatment course. in children chronically treated with cya due to ns, serum hs-crp level increases significantly during the therapy. slit diaphragm connecting adjacent foot processes of podocyte is the final barrier of glomerular capillary wall to prevent proteinuria. both podocytes and neuronal cells are terminally differential cells and they share many common features. nurexin is a presynaptic adhesion molecule that plays a role in synaptic differentiation, and they have been understood to be specifically expressed in neuronal tissue. we found that neurexins are expressed not only in neuronal cells but also in several organs including kidney. our immunofluorescence study shows that neurexins are restrictedly expressed in glomeruli in kidney. dual-labeling immunofluorescence studies show that neurexins are localized close to a cd ap. we also detected some portions of neurexin staining are coincident with that of rab a, a synaptic vesicle associated molecule. we found that a single splice variant of neurexin- is expressed in glomeruli. the staining intensity of neurexin in the glomeruli clearly reduced and their staining pattern shift to more discontinuous patchy pattern in puromycin aminonucleoside nephropathy and anti-nephrin antibody induced nephropathy. the alteration of neurexin in these models was detected more clearly and rapidly than nephrin. we confirmed that neurexin is expressed in podocyte also in human kidney section. these observations suggest that neurexin is involved in the development of proteinuria and that neurexin could be an early diagnostic marker of podocyte injury. to further elucidate the clinical relevance of t-cell abnormality in minimal change nephrotic syndrome (mcns), and to predict the consequences of mcns, we studied t-cell receptor (tcr) diversity by analizing cdr size distribution and the frequency of v repertoire usage. thirty-six pediatric patients with mcns were enrolled. eighteen were frequent relapsers and/or steroiddependent (fr/sd) and were non-frequent relapsers (nfr). the study was performed to analyze serial changes of tcr v repertoires in the two groups of patients. frequencies of v repertoire usage were determined by flowcytometry, and tcr cdr length distribution was analyzed by genescan. in nfr patients, abnormalities in the distribution of v repertoires were few in both cd + and cd + t cells. in fr/sd patients the patterns were normal in cd + t cells, while selected v repertoires were significantly increased in cd + t cells in some patients. furthermore, tcr diversity was significantly reduced in both cd + and cd + t cells in fr/sd patients as shown by marked skewing of cdr size distributions. it is noteworthy that in some fr/sd patients the initially abnormal tcr diversity improved as the clinical symptoms improved such that they became nfr over the years. analysis of tcr diversity may delineate the subgroup of patients with fr/sd and provide a rationale for early intervention with immunosuppressive therapy for these patients. background: transforming growth factor-β is known to play a role in the interaction between metabolic and homodynamic factors in mediating accumulation of extracellular matrix in the diabetic nephropathy. tgf-β gene polymorphism was associated with circulating tgf-β levels and influenced the pathogenesis of fibrotic diseases including diabetic nephropathy. in this study, we examined the relationship between tgf-β gene codon polymorphism and type diabetic nephropathy with more than -year history of disease. methods: we conducted a case-control study, which enrolled type diabetes. a total of patients with diabetic nephropathy were compared with patients without diabetic nephropathy. tgf-β codon genotyping was determined using polymerase chain reaction with sequence specific primers method. results: distribution of tgf-β codon genotype in the patients either with nephropathy or without nephropathy is confined to hardy-weinberg equilibrium. methods: nzb/w f female mice were distributed into three experimental groups (n= per group) according to age: , . and months. at specific time-point for each group, -hour urine and blood samples were collected to determine proteinuria, osmolality and creatinine levels. after sacrifice, kidneys were removed to measure chemokines and cytokines levels by elisa (pg/ mg of tissue). results: urinary flux was significantly lower at . than at and months. a significant reduction in creatinine clearance and an increase in proteinuria were detected at . and months when compared to months. no significantly changes were observed in serum and urinary osmolality. regarding inflammation, mcp- significantly increased at . ( . ± . ) and remained elevated at months ( . ± . ) when compared to months values ( . ± . ). kc was also higher at than at months ( background: nephrotic syndrome (ns) is related to immunological factors and renal inflammatory mechanisms. many studies showed that inflammatory mediators, especially interleukin- (il- ) and monocyte chemoattractant protein- (mcp- ), have a role in kidney injury. changes in their urine concentration were found in lupus nephritis and iga nephropathy. thus, the aims of this study were to evaluate il- and mcp- in serum and urine samples of pediatric patients with primary ns and to verify the relation between these measurements and protein excretion. methods: patients were divided according to current -hour proteinuria into two groups: lower than mg/ hours (group , n= ) and higher than mg/ hours (group , n= ). blood and -hour urine samples were collected and stored at - °c. il- and mcp- were measured by elisa standard methods. results: blood il- and mcp- did not differ between the groups. urinary il- levels (pg/mg of creatinine) were significantly elevated in patients of group when compared to group ( . ± . vs. . ± . , p< . ). although group also exhibited higher values of urinary mcp- ( . ± . pg/mg creatinine) than group ( . ± . pg/mg creatinine), they did reach statistical difference. conclusion: the inflammatory process in ns seems to be a local phenomenon, since blood levels of these chemokines were similar in all groups. moreover, our findings showed a relation between il- and the presence of proteinuria and suggested a role for this local inflammatory mediator in disease activity. the characteristics of iga nephropathy detected in school urinary screening iga nephropathy (igan) is one of common types of glomerulonephritis in children. however, progression to esrd in patients with igan is not as rare as originally thought. in korea, school urinary screening (sus) program, an useful tool to find out abnormal urinary findings, initiated in . igan was the most common histopathological change in children with isolated hematuria and/or proteinuira in sus. we studied to clarify the clinical and pathologic characteristics of iga nephropathy detected by sus in korea. we investigated patients (symptomatic group= vs sus group= ) had been diagnosed with igan following renal biopsy at the yeungnam univ. hospital between may and may . these patients were analyzed clinical nature, laboratory data and histopathologic findings (haas classification in lm) and progress, retrospectively. their mean age were . ± . and . ± . , respectively, at the time of kidney biopsy. gross hematuria and edema apt to be common in symptomatic group. there were no significant difference in serum iga level, estimated ccr, -hours protein amount, light microscopic class and electron microscopic findings between two groups. mesangial iga deposition was significantly more intense in symptomatic group with gross hematuria. in addition to iga deposition in capillary and immune dense deposition in intramembrane is significantly common in symptomatic group with nephrotic range proteinuria. however, progression to chronic renal failure was not noted in both groups during . ± . and . ± . months respectively. also there were no difference in outcome according to treatment modalities. a longer follow-up period is needed to obtain more information on progression of igan with nephritic range proteinuria by disclosing iga deposition in capillary and immunedense deposition in intramembrane. outcome of srns is uncertain and especially patients unresponsive to treatment have a high risk to develop esrd. prognosis has improved with the introduction of csa, however but long-term follow-up data are scarce and response to csa in patients with genetic forms of srns is uncertain. we report on patients with srns, that was diagnosed at a median age of . (range . - . ) years. treatment with csa was initiated on concomitant prednisone therapy, however steroids were discontinued after due course in all patients. median follow-up is . ( . - . ) years. patients had fsgs on renal histology and patients had mcns. complete remission (cr) was defined as reduction of proteinuria < mg/m /d. partial remission (pr) was defined as reduction of proteinuria of at least % and cessation of edema with serum albumine levels > g/l. results: patients ( fsgs, mcns) reached cr with csa treatment. in of these ( fsgs, mcns) csa could be tapered and discontinued successfully after a median time of ( . - . ) years. eight patients showed ( fsgs) a pr while patients ( fsgs) showed no repsonse (nr). of patients going into esrd had podocin mutations (pm). only one patient with pm showed partial remission on csa. our data indicate a positive effect of csa treatment in srns, especially in sporadic cases. in patients with cr tapering and even discontinuation of csa is possible. prognosis of srns has improved with csa treatment. objective: we planned to investigate the effects of rsv on the proteinuria and glomerular structure of rats and to explore the role of rsv in the pathogenesis of minimal change nephrotic syndrome. methods: sd rats were inoculated with , , and pfu rsv respectively, and sacrificed on days , , , and postinoculation (rsv , rsv , rsv , rsv , rsv ). renal histology was observed by light microscopy and electron microscopy. meanwhile, the proteinuria and serum parameters were measured. the rsv rna and rsv titer were determined by in situ hybridization and plaque assay respectively. immune complex deposits were detected by immunofluorescence microscopy. results: after inoculation, the urinary protein excretion was increased, especially in pfu rsv , , (p< . ). the serum albumin of pfu rsv , , and different-titer rsv decreased, but no significant differences in cholesterol, urea nitrogen and creatinine were found among all. slight hypercellularity in minority glomeruli and swelling of partial tubular epithelial cells were observed in rsv , of different-titer, whereas a relief of the above changes and no abnormalities were detected in rsv and rsv respectively under a light microscopy. extensive foot process effacement was observed in pfu rsv , , under an electron microscope. rsv rna signal and rsv titer of renal and pulmonary tissues, depending on the dose of inoculum, reached their climax on day postinoculation, especially in pfu rsv . no immune complex deposits were detected in the renal tissues. conclusion: our study reports for the first time that rsv can lead to nephropathy in rats on day - postinoculation, especially in pfu rsv-inoculated rats, which may be a new exploration of the pathogenesis of mcns. objectives of study: podocytes play an important role in maintaining the glomerular filtration barrier structure and functions, which associates with several podocyte-specific proteins. our previous study indicated the antiproteinuric effects of dexamethasone were achieved by changes the expression of certain podocyte molecules in vivo. the extracellular signal-regulated kinases regulates a wide range of cellular processes. the aim of the present study is to analyze the potential effects of dexamethasone on podocytes in vitro and to investigate its associated signal transduction pathway. methods: immortalized mouse podocyte clone was divided into three groups: the dexamethasonetreated group (dex-group), the dexamethasone with puromycin aminonucleoside-treated group (dex-pangroup), and control. in dex-group, cultured podocytes were treated with dexamethasone, while in dex-pan group, cells were treated with dexamethasone for min first, then added puromycin for different time periods. changes of the protein expression of podocyte-specific proteins and phosphorylation of erk were analyzed by western blotting analysis. result: compared with the control group, in dex-group, the expression of nephrin, podocin, cd ap, α-actinin proteins and vegf protein started to elevate at hr, while neph showed no obviously change. erk signaling pathways was activated. increased phosphorylation of erk was marked but transient, which increased from min to min, then decreased. at min the level of phosphorylation of erk returned to the baseline. the phosphorylation of erk level was significant raised in dex-pan group, and lasted to min. conclusion: dexamethasone alters the expression of certain podocyte-specific proteins not only in vivo but also in vitro, and in part, through the activation of the erk signal pathway. kh. kim minimal lesion in the renal biopsy of idiopathic nephrotic syndrome (ns) patients (pts) generally predicts a benign course. fsgs lesions in nspts, on the other hand, are associated with increased risk of steroid resistance and progression to renal failure. fsgs may be observed in follow-up biopsies despite being initially undetectable. whether this represents sampling error or the true natural history of this condition, earlier markers of steroid resistance and poorer prognosis could prove helpful. renal morphometric analyses was performed in ns pts, ages to years, initially diagnosed with minimal lesion, with (n= ) or without(n= ) subsequent progression to fsgs or end stage renal disease (esrd), along with controls ages to years. the age of patients in progressive and non-progressive group and controls were similar. gbm width in patients with minimal lesion ( ± nm) who subsequently progressed, was significantly greater than that in non-progressive group ( ± nm, p< . ). gbm width in both groups was not significantly different compared with the controls ( ± nm). average foot process width was increased in patients both with progression and non-progression as compared with controls, but there was no significant difference between progressive and nonprogressive group. the length density of podocyte detachment per gbm surface was not significantly different between progressive, non-progressive groups and control groups. there were no significant differences in the mean glomerular volume and cortical interstitial volume fraction between progressive and non progressive group. in conclusion, gbm width may help to differentiate between progressive and non-progressive groups in minimal lesion nephropathy. this may be a pathogenetic clue and needs further study. objective: our study is to investigate the correlation between clinical features and pathological characteristics on henoch-schönlein purpura nephritis (hspn) and the therapeutic methods. methods: fifteen boys and five girls aged - years (median . years) with hspn were analyzed retrospectively. the clinical characteristics, laboratory data, pathological findings and therapeutic methods were investigated. results: the patients with isolated hematuria and isolated proteinuria, the pathologic patterns were lighter then gradeii b ; eight patients with hematuria and proteinuria and seven patients with nephrotic syndrome, the pathologic patterns of injury is more severe then gradeii b , whose pathologic patterns injury exceeded gradeii b is . %. twelve patients with nephritic-range proteinuria (> mg/kg.d) and nephrotic syndrome received corticosteroids, cyclophosphamide, heparin and dipyridamole treatment. nine of twelve patients received intravenous pulse methylprednisolone (mp) and pulse cyclophosphamide (ctx). fourteen of twenty patients obtained stable remission after months to years, and five of twenty patients have asymptomatic microscopic hematuria, another one only has minimal proteinuria. conclusions: if the clinical features showed nephritic-range proteinuria or nephrotic syndrome, the renal pathologic changed markedly as well. for patients whose pathologic exceeded grade iii b or have renal tubule and interstitial damage, our study suggests that mp pulse therapy have satisfied curative effect. materials and methods: in experiment , higa mice, c bl/ mice and balb/c mice were inoculated intravenously with live cb and inactivated cb once a month from to mo of age. in experiment , higa mice, c bl/ mice and balb/c mice were inoculated intravenously with live cb and inactivated cb once at wk of age. mice in the control group were inoculated with vehicle. the kidneys were extirpated from mice of each group killed with time after inoculation for histological evaluation. experiment : we examined prostaglandin (pg) synthetic activity of cultured human mesangial cells. results: the scores for mesangial iga deposition, pcna-positive and matrix scores at weeks were higher in higa mice with live cb than in higa mice with inactivated cb or without cb . on em examination, swelling and detachment of endothelial cells from hours after inoculation and increase of serum ifn-gamma concentration were found in mice with live cb . the scores for mesangial iga and igg depositions, pcna-positive and matrix scores at weeks were more frequently found in balb/c mice with live cb . production of pge and txb significantly increased in cultured human mesangial cells damaged by live cb . conclusion: these results suggest that cb provokes exacerbation of renal pathological findings in higa mice via endothelial injury and ifn-gamma production, and may play important roles in igalike glomerulonephritis pathogenesis. rapidly progressive glomerulonephritis (rpgn) is a rare occurrence in alport syndrome (as). this report describes the case of a -year-old malewith as who developed rpgn and considers the cause of rpgn in this patient. he had a history of persistent hematuria and proteinuria since birth. at the age of years, he was diagnosed with as based on a renal biopsy. he developed nephrotic syndrome at the age of years. before administration of cyclosporine (cya), repeated renal biopsy was performed at the age of years. the biopsy specimen showed pathologic lesions characteristic of as without crescents. using immunofluorescence (if) staining, the expression of alfa- chains of collagen iv was found to be absent in the glomeruli. therefore, cya was administered for eight months. although he recovered from nephrotic syndrome, the effect of cya was limited. after the cessation of cya, his renal function slowly exacerbated. at the age of years, the administration of angiotensin receptor blocker was started. no subsequent anti-proteinuric effect was noted and his renal function improved to cr . mg/dl. however, by the age of years, he showed macrohematuria and acute deterioration in renal function to cr . mg/dl. subsequently, he underwent a third renal biopsy. on light microscopy, the biopsyspecimen showed diffuse cellular crescentic glomerulonephritis. if findings indicated pauci-immune type and electron micrography showed a few subepithelial deposits. a serological study revealed negative results for mpo-anca, pr -anca, and anti-glomerular basement membrane antibody. despite immediate treatment with pulses of methylprednisolone, cyclophosphamide, and plasma exchange, he progressed to end stage kidney disease. the patient reported here presents either a super imposition of rpgn upon a preexisting case of as or a new morphologic and clinical presentation for as. the wt gene encodes a zinc finger transcription factor involved in kidney and gonadal development. mutations of the wt gene have been shown to cause denys-drash syndrome (dds) and frasier syndrome (fs). the association of early onset nephrotic syndrome progressing to renal insufficiency, xy pseudohermaphrodism and wilms' tumor characterizes dds. renal biopsy shows diffuse mesangial sclerosis (dms). fs is also characterized by xy pseudohermaphrodism and nephropathy, but patients have delayed kidney failure characterized histologically by fsgs. this report examines three girls with nephrotic syndrome related to mutations in the wt gene, but with normal female karyotype and development. two girls with early-onset steroid-resistant nephrotic syndrome presented classical wt mutations coding for an amino acid change (d n) and (r w) at exon that is typical of dds. both children were phenotypically and genotypically females. they developed end stage renal failure within years. one girl had a wilms' tumor on the right kidney. the third child was identified with heavy proteinuria at years of age. laboratory investigations revealed a protein level of . g/dl ( - g/dl), albumin . g/dl ( . - . g/dl). proteinuria worsened to g/ h and she failed to respond to prednisone. renal biopsy demonstrated fsgs in % of glomeruli. the splice site mutation ivs + g >a, known to be associated with fs, was found in this patient. karyotype was , xx and she had normal uterus and adnexae on ultrasound. angiotensin-converting enzyme inhibitors were prescribed but she still has heavy proteinuria without renal failure. the classical clinical presentation of dds and fs is out dated. pediatric nephrologists need to consider the possibility of these genetic syndromes in evaluation of females with steroid-resistant nephrotic syndrome. we aimed to compare the effects of cyclosporine (csa) or mmf with or without combination of vitamin a,d,e or n-acetyl-l-cysteine (nac). the study included rats in eight groups: control, nephrotic syndrome without treatment, treatment with csa, mmf, vitamin a,d,e, combination of csa and vit ade, combination of mmf and vit ade and combination of nac and vit ade. all rats except the control group were given adriamycin. blood samples were drawn and -h urine were collected on day and at weeks and . at the th week, -h urinary protein excretions in the treatment groups were higher and serum albumin levels were lower than that of th week and control groups (p> . ). at the th week, urinary protein excretions in group csa&ade was lower than of the groups of csa, mmf, mmf&ade, ade and nac&ade with non-significance (p= . , p= . , p= . , p= . , p= . ) . serum albumin in group mmf&ade and group ade were significantly higher than of control group (p= . , p= . ). serum albumin in group ade was significantly higher than that of groups of csa and csa&ade (p= . , p= . ). serum triglyceride in group mmf&ade was significantly lower than that of groups csa and csa&ade. serum creatinine in group mmf&ade was lower than that of the groups of csa, csa&ade, mmf, ade and nac&ade and was significantly lower than that of control group (p= . ). serum creatinine in group csa was significantly higher than of groups of csa&ade, mmf, mmf&ade (p= . , p= . , p= . , respectively). in group nas+ade, total oxidant was significantly higher and total anti-oxidant was significantly lower than other treatment groups (p< . ). we showed that the better effect on proteinuria, serum triglyceride and albumin and lower serum creatinine by adding vitamin a, d, e in the treatment of experimental nephrotic syndrome with csa or mmf. conclusion: ht is associated with known risk factor of progression of biopsy-proven gn such as s-cr or proteinuria. the crb is an important tool for studies focusing on the epidemiology of gn in the czech republic and serves as a basis for cooperation in this field. ( ), lupus-nephritis ( ), iga-nephropathy ( ), minimal change disease and membranous nephropathy (by ) were observed. the distinction of morphological variants of the fsgs was started recently (last months). among the patients with fsgs, which were biopsied during this short period ( ), all have had a tip-lesion. these patients were started cyclosporine a mg/m /day with complete ( ) and partial ( ) remission achievement after - months. thus, the focal and segmental glomerulosclerosis is the most frequent cause of the nephrotic syndrome in children. the focal and segmental glomerulosclerosis with tip-lesion is characterized by favourable course and good response to therapy with cyclosporine a during the short-time period. objectives of study: molecules of monocyte chemoattractant protein- (mcp- ), β-catenin and cytokeratin (ck ) express increased in cellular crescent, which is a severe pathological change in renal diseases. however, it is unknown whether these molecules in urine correlate to the number or extent of cellular crescents. methods: urinary molecules mentioned above were detected in healthy subjects and patients with renal diseases by elisa. the expressions of these molecules and macrophage (cd positive) in biopsy specimens were also investigated. results: significant higher levels of these molecules in urine were demonstrated in all patients with renal diseases compared with healthy subjects (p< . ), but the highest level in patients of the cellular crescent group. the significant correlations were revealed between these molecules in urine and the index of cellular crescents (r= . , r= . , r= . , p< . ), between these molecules in glomeruli and the index of cellular crescents (r= . , r= . , r= . , p< . ), and between these molecules in glomeruli and in urine (r= . , r= . , r= . , p< . ). conclusions: this study suggested that the detection of urinary mcp- , β-catenin and ck might become potential biomarkers for clinical diagnosing cellular crescent lesions and assessing cellular crescent extent in renal diseases. this study aims to evaluate the benefits and harms of levamisole in steroid dependent (sd) and frequent-relapsing (fr) nephrotic children. material and methods: a total of steroid-sensitive nephrotic children were recruited prospectively from january to december . females and males, ( %) fr, ( %) sd. mean age at the beginning of levamisole was , years. twelve didn't receive any alternative drug before, received cyclophosphamide. renal biopsy was perfomed in patients, had minimal change disease (mc), one patient had mc at the first biopsy and fsgs in the second. the patients were divided in two groups according to their steroid response: sd and fr. levamisole was started at a dose of , mg/kg/ h as a second line drug in order to try to prolong periods of remission. clinical and laboratorial controls were performed monthly. patients were evaluated as: total responders: when steroid withdrawal was possible, partial responders: when steroid reduction was possible, non-responders: no steroid modification in months. the responders used levamisole for one year. results: the response of frequent-relapsing patients was: % of total response, % of partial response and % of non-responders. steroid-dependent patients had % of total response, % partial and % non-responsers. only one patient developed leukopenia. now % ( ) are out of levamisole and in remission, % ( ) are still using levamisole(alone or low-dose of prednisone), % ( ) are using cyclosporin, one used cyclophosphamide and one is using low-dose prednisone. conclusion: levamisole is a promising alternative drug for nephrotic syndrome. the major advantage of levamisole is its steroid-sparing effect with minimal toxicity. conclusions: hypertension and renal insufficiency were less frequently seen in chinese children with fsgs, isolated hematuria as unique clinic presentation was common in fsgs. all pathological variants had tubular-interstitial lesions, but vascular lesions were rarely seen. most fsgs children with nephrotic syndrome were sensitive to steroid at initial stage, and easy to develop frequent relapse gradually, immunosuppressive agent may be helpful to elevate remission rate. the aim of the study was to assess whether the serum index iga/c can be a usefull marker of activity igan and hsn in children. twenty children with igan (mean age . ± . years) and children with hsn (mean age . ± . years) were retrospectively analysed. in all children urine analysis, gfr were checked and the levels of serum iga and c were measured before therapy, serum iga/c was than calculated. at the onset of illness, igan and hsn was diagnosed based on the renal biopsy in mean time . ± . years. changes in light microscopy were graded i-v according to the classification of who (cwho). all biopsies were scored for activity and chronicity index (ai max score , ci max score ) (pediatr.nephrol. , , heparan sulfate proteoglycans are present both as structural components of the gbm and as modifiers of growth factor signaling on the cell surface. in mcns the presence of certain hs epitopes inthe gbm is decreased. hsulf and hsulf are recently identified endosulfatases, that can remodel the sulfation pattern of hs and thereby control the availability and presentation of factors such as fgf and hgf to their high affinity receptors. sulfatase activity requires posttranslational modification by formylglycine-generating enzyme or sulfatase modifying factor (fge/sumf ) that is counteracted by its paralogue pfge/sumf . we demonstrated that podocyte, endothelial and tubular epithelial cell lines express mrna for sulf , sulf , sumf and sumf . we investigated the in vivo distribution patterns of these enzymes in human kidney specimens by in situ hybridization. in histologically normal kidneys (n= ) expression of hsulf mrna was largely restricted to peritubular and glomerular endothelial cells, where as hsulf mrna was weakly expressed in all glomerular resident cell types. expression of sumf and sumf mrna was present in a minority of mesangial cells and podocytes, as well as in avariable number of glomerular and peritubular endothelial cells and invascular smooth muscle cells. in mcns (n= ), the glomerular expression patterns of hsulf , sumf and sumf mrna did not differ significantly from that in controls. in contrast, hsulf mrna expression was increased in podocytes. increased hsulf expression by podocytes is a novel factor to be considered in the pathogenesis of mcns. the onset and duration of ins, histopathological changes in renal biopsy, results of corticosteroid therapy and proteinuria selectivity reflecting the alteration of glomerular capillary wall were analysed. materials and methods: children with ins aged - , followed up to month, and healthy children were studied. in all patients stage of ckd were diagnosed. ins children were divided in two groups regarding to serum cystatin c levels as a marker of gfr: group i (n= )children with unchanging gfr, ii (n= ) -patients with impairment renal function over the study period. serum total protein, albumin, cholesterol, cystatin c, creatinine and immunoglobulin igg, and urinary protein, albumin, igg and creatinine were measured. results: serum cystatin c levels were higher in both groups of ins patients compared to healthy children (gr. i: . ± . , gr. ii: . ± . vs . ± . mg/l; p< . ). in group ii amount of -hour proteinuria was significantly higher than in group i ( . ± . vs . ± . g/l; p<. ), however other biochemical parameters (including igg excretion, albuminuria, selectivity index) were not different. in group ii higher age of onset was found. in this group mesangial proliferation and focal segmental glomerulosclerosis more often were observed. conclusions: the age of onset, histopathological diagnosis and proteinuria can be considered as important markers of ckd progression in children with ins. probably, longer follow-up of children with ins is necessary to find other prognostic factors. k. kilis-pstrusinska, k. fornalczyk, d. zwoliñska cyclosporine a (csa) has been used as a therapeutic option for steroid-dependent and steroidresistant nephrotic syndrome (ns). the aim of the study was to assess the effects of long term csa treatment in children with ns. methods: we performed retrospective study to evaluate safety and efficacy of csa therapy in children with ns ( girls and boys), aged - years. results: before introducing csa, in patients steroid-dependent ns and in -steroid-resistant ns were observed. children presented symptoms of steroid toxicity. pre-treatment renal biopsy was performed in patients ( children without biopsy because of renal agenesia). minimal change disease was diagnosed in ( %) children, focal segmental glomerulosclerosis (fsgs) in ( %), mesangial glomerulonephritis (gn) in ( %) and membranoproliferative gn in ( %) cases. all children were taking csa (target blood trough levels - ng/ml) more than months, mean months (range - ). complete remission was achieved in ( %) children, partial in ( %). in ( %) patients csa treatment was continued with mild dose of steroids. patients ( %) did not respond to the therapy and one of them end stage renal failure developed. following side effects have been observed: hyperuricuria ( % of patients), hyperuricaemia ( %), hypomagnesaemia ( %), hypertension ( %), hypertrichosis ( %), gingival hyperplasia ( %), hepatotoxicity ( %), gastritis and ileitis symptoms ( %). in patients control renal biopsy was performed after - months of csa therapy. in patients progression to fsgs was seen. only in one case histological findings of csa nephrotoxicity occurred. conclusion: long-term csa treatment in children with steroid-dependent and steroid-resistant nephrotic syndrome can be consider as an effective and safe therapy. introduction: membranous nephritis represents a rare disease in childhood with an incidence of . to % in renal biopsy specimens among various types of glomerulonephritis. although in many cases the disease is considered as idiopathic the association of membranous nephritis and infectious agents it is also well known. aim: we report a case of a months old baby girl of asian origin, presented with macroscopic haematuria of glomerular origin, proteinuria, - gr/ hours, hyaline and granular casts, maculopapular rash on the legs and microcephaly. methods: renal function tests in terms of plasma urea and creatinine were normal. the renal biopsy showed membranous nephritis. tests for infectious diseases (torch screen) showed a primary cmv infection. this diagnosis was based on the presence of high level cmv specific igm antibodies, increased igg antibodies and low avidity of cmv specific igg antibodies. a real-time-pcr of the renal biopsy specimen was positive for cmv as well, confirming this virus as the causative agent of membranous nephritis in the presented case. treatment with gancyclovire per os was introduced and it was most impressive since proteinuria disappeared in the following two to three weeks. two years after the diagnosis the child remains well and asymptomatic. in summary: to our knowledge, among various infectious agents, there is no case of congenital or secondary nephropathy described so far due to cmv infection in children. objective of study: pulse methylprednisolone therapy (pmt) has been shown effective in proteinuric renal diseases. but its exact effect in children with steroid-sensitive relapsing nephrotic syndrome still has no definite conclusion. to evaluate the effect and adverse effects of pmt, we performed a retrospective study. methods: there were cases of steroid-sensitive relapsing nephritic syndrome received pmt. they all had been treated with oral prednisone in similar condition previously. a self control design was used to compare the effect of pmt and oral prednisone. results: the average age was . ± . years. ten cases attained complete remission after the first course of pmt, and the average duration of pmt until remission was . ± . days. one case attained complete remission after the second course of pmt. compared with the effect of oral prednisone previously, seven cases attained complete remission more rapidly. paired-samples t-test was performed to compare the effects of pmt and oral prednisone in six cases with very similar state, however, the difference between them was not significant (p= . ). during the treatment of pmt, adverse effects were found in cases. conclusion: compared with oral prednisone, the superiority of pmt had not been definitely confirmed, and adverse effects might appear during the treatment. therefore we should be very strict with administering pmt in children with steroid-sensitive nephrotic syndrome. the study we performed was retrospective, so it was necessary to design a prospective clinical randomized controlled trial to further evaluate its effect. objective of study: pulse methylprednisolone therapy (pmt) has been shown effective in proteinuric renal diseases. but the exact effect of pmt in children with steroid sensitive nephrotic syndrome (ssrn) still has no definite conclusion. to evaluate the effect and adverse effects of pmt, we performed a prospective study. methods: a prospective clinical randomized controlled trial was conducted to compare the effect and adverse effects of pmt with oral prednisone (op) in children with ssrn. thirty-one children were enrolled with only suitable for evaluation including patients in the pmt group and in op group. results: there was no significant difference between both groups in complete remission rate. the average durations of therapy until remission were . ± . days in pmt group and . ± . days in op group, respectively. complete remission was more rapidly attained in pmt group (p= . ; < . ). during the treatment and the following months, no significant difference of adverse effects was found between both groups. there was no significant difference between both groups in relapse rate during months follow-up. conclusion: compared with oral prednisone, pmt could induce complete remission more rapidly and did not company with more adverse effects in children with ssrn. pmt had no effect on the reduction of relapse rate in the following months after administration. outcome of childhood henoch-schönlein purpura nephritis with nephroticrange proteinuria in a single center objective: the majority of children with henoch-schönlein purpura nephritis (hsn) only with hematuria and/or mild proteinuria have good chances for recovery. however, it is still unclear how we should treat hsn with persistent massive proteinuria. the aim of this study is to evaluate the outcome of childhood hsn with nephrotic-range proteinuria treated with angiotensin converting enzyme inhibitor (acei) and corticosteroids. methods: patients with henoch-schönlein purpura ( boys, girls) ranging from . to . ( . ± . ) years old at onset visited our hospital between april and december . thirty seven ( . %) developed hsn. mean age of ( boys, girls) hsn patients with nephroticrange proteinuria (> mg/h/m ) at the time of diagnosis was . ± . years old. two developed nephrotic syndrome, but none had renal insufficiency at onset. one patient suffered moderate proteinuria and renal dysfunction years after the onset. renal biopsies were done in cases and showed for grade i, for grade ii and for grade iii respectively (classification by international study of kidney diseases in children). results: eleven of the patients received acei and no patients were treated with immunosuppressive agents except for corticosteroids and methylprednisolone pulses. after a mean follow-up of . years, patients showed complete remission, had mild proteinuria or microscopic hematuria, only one postpartum patient presented with nephrotic-range proteinuria, and none developed renal insufficiency. conclusions: our results suggested that the short-term outcome of childhood hsn with nephroticrange proteinuria but not renal insufficiency was relatively favorable. thus, the degree of proteinuria is not a sole prognostic factor for childhood hsn. therefore, the indication for corticosteroid therapy should be clarified. recent observations determined a r x specific exon mutation in the gene encoding nephrin (nphs ) which evidenced an unexpectedly mild finnish-type congenital nephrotic syndrome (cns) phenotype. the long-term follow-up of patients with this mutation is actually known only in a few patients. we reported the long term follow-up of a girl originary of sicily (italy) presenting such a mutation. the first years of her life were previously reported (s.guez et al pediatr nephrol ). in brief the child was pre-term born from related parents and she presented proteinuria ( - g/day) from birth. renal biopsy was consistent with the diagnosis of cns and molecular evaluation demonstrated a homozygous exon r x nonsense mutation in the nphs gene. in the first years she was treated by human albumin without a regression of proteinuria that decreased up to . - . g/day with enalapril treatment ( . mg/kg/day); clearance of creatinine at years of age ranged between and ml/min/ . mq. during the following years (at the last control the girl was year old) she had continued enalapril treatment ( . mg/kg/day). creatinine clearance was ml/min/ . mq/day, serum total protein g/l; serum albumin g/l and proteinuria ranged between . - . g/day. both height and weight were at th for age and pubertal stage was normal; blood pressure was / mmhg. in conclusion, this is the first reported long-term follow-up in an italian patient affected by finnishtype cns with the specific r x nonsense mutation in the nphs gene: even if proteinuria persisted there was no worsening in gfr. serum total protein, albumin and growth were normal confirming the milder phenotype in comparison with the typical finnish forms. long-term enalapril treatment may also have contributed to the prognosis in this specific form of congenital nephrosis. atypical hemolytic uremic syndrome (ahus) frequently results in end-stage renal failure and can be lethal in many cases. recently, it has been recognized that many cases of ahus are associated with a defective control of the complement activation cascade. more than sixty different mutations in complement factor h gene (cfh) have been reported so far. guidelines for treatment modalities are yet to be established although plasma infusions and exchanges are often advocated. we describe a patient who presented at months of age with ahus (anemia, thrombopenia, acute renal failure requiring hemodialysis) associated with heterozygous combined de novo complement factor h mutations (s l and v a) on the same allele. laboratory investigations showed normal levels of complement c , c and factor h. during the first episode, daily plasma exchanges (pe) using cryosupernatant (cr) as replacement fluid resulted in a resolution of hemolysis and complete normalization of renal function. two ahus recurrences were successfully treated with daily pe and subsequently pe were weaned to twice weekly. one year after the first episode, pe were stopped and pi regimen ( ml/kg twice weekly and weekly thereafter) was started. at the present time, the patient has been receiving weekly pi ( ml/kg) for one year. transitory falls in haptoglobin levels or platelet counts are observed periodically and successfully treated by intensification of pi ( ml/kg) twice weekly for one or two weeks. renal function remains normal.although our observation demonstrates the effectiveness and good tolerance of large volumes of pi ( ml/kg), long-term efficacy of such a therapy remains to be evaluated. because of the possibility of secondary failure of plasma therapy, it is important to investigate alternative approaches such as combined liver-kidney transplantation. common variable immunodeficiency (cvid) is characterized by reduced serum immunoglobulin levels and recurrent bacterial infections. there have been only previous case reports of renal granulomas in cvid and only one of them was associated with immune complex glomerulonephritis. we present a case of renal granuloma and glomerulopathy in a patient with cvid. a -year-old girl, with a past history of uveitis, presented with cardiac tamponnade and bilateral pleural effusions. investigations revealed nephrotic syndrome (serum albumin of (normal - ) g/l and proteinuria > g/l), microscopic hematuria and reduced serum igg levels ( . g/l, normal . - . g/l). lupus nephritis and serositis were first suspected and corticosteroids were initiated. no serum anti-nuclear or anti-dna antibodies, nor complement activation were detected. a renal biopsy was performed and showed global glomerular endocapillary proliferation. intratubular calcium deposits were present. in the interstitium, a noncaseating epithelioid granuloma was found. immunofluorescence studies showed significant mesangio-parietal igm deposits with few c and c q. as igm-immune complex glomerulonephritis has been reported in sarcoidosis, this diagnosis was highly suspected. further investigation revealed normal lung parenchyma and mediastinum, normal serum angiotensinconverting enzyme, . oh d , calcemia and calciuria. the nephrotic syndrome gradually improved, but serum igg levels remained persistently low ( . g/l). the diagnosis of cvid was confirmed and iv immunoglobulins were initiated. this is the first report of concomitant renal granuloma and igm-immune complex (without igg) glomerulonephritis in a cvid patient. in summary, cvid must be included in the differential diagnosis of renal granuloma and should be differentiated from sarcoidosis to ensure appropriate therapy. o. nwobi, c. abitbol, j. chandar, w. seeherunvong, g. zilleruelo background: rituximab, an anti-cd antibody, has been proposed as therapy for refractory systemic lupus erythematosus (sle), although its use in children remains anecdotal. we present our initial longterm experience on the safety and efficacy of rituximab for treatment of sle in children. methods: pediatric patients with sle refractory to standard treatment protocols were treated with rituximab for - doses ( mg/m ). all had proliferative nephritis and systemic manifestations of vasculitis. clinical disease activity was scored using the sle-disease activity index (sledai). proteinuria is reported as the urine protein to creatinine ratio (upr/cr). patients have been followed an average of . ±i. years. results: b cell depletion occurred within month and remained suppressed for up to months. clinical course, renal function and proteinuria improved in the majority of patients as summarized below: objective: to assess efficiency and safety of treating crns patients with srl. subjects: patients, mean age . years old ( yrs- yrs) ( females) affected by crns. inclusion criteria: histological diagnosis of focal and segmental glomerulosclerosis, glomerular filtration rate (gfr) above ml/min/ . m , negative plasma pregnancy test, signed child and parents informed consent. exclusion criteria: secondary nephrotic syndrome, white blood cells (wbc) count below /mm , chronic hepatopathy, coagulopathy, tumoral or infection processes. discontinuation criteria: sustained decrease in gfr by more than % of the initial rate, decrease of the wbc count to less than /mm , occurrence of lymphoprolipherative and tumoral processes, severe infection, alterations in coagulation parameters, positive pregnancy test or inflammatory process or lack of changes in proteinuria or its increase after four-month treatment. methods: srl dose and dosage: dose of to mg/m /day (up to mg/day) administered once a day. expected dosage range: to ng/ml (hplc-uv method). treatment duration: months. results: patients showed nephrotic syndrome remission; average srl dose: mg/m /day; average srl dosage: . ng/ml (range . - . ). average proteinuria prior to treatment: mg/m /hour (range - ); average proteinuria after treatment: mg/m /hour (range . - ); average time of remission: months and days, none of patients showed adverse events that would have lead to the treatment discontinuation. if these data are representative of the universe of patients we are dealing with, the confidence interval (p= . ) of the percentage of patients with not proteinuria after treatment is going to be between % and % if patients are assessed. conclusions: srl caused crns remission in patients who were refractory to traditional immunosuppressive treatments. background: retinoic acid-inducible gene-i (rig-i) may play an important role on inflammatory and immune processes by regulating the expression of various genes, and has been reported to be expressed in various inflammatory diseases. we studied the expression of rig-i in human lupus nephritis and evaluated the correlation between its expression and the histological activity of the renal disease in these cases. methods: expression of rig-i in the glomeruli was assessed by indirect immunofluorescence method; frozen sections of ten kidney tissue specimens obtained from eight patients with lupus nephritis were stained with a monoclonal antibody for rig-i. kidney tissue specimens from eight patients with minimal-change (mc) disease were used as controls. results: expression of rig-i was detectable as granular immunofluorescence in a mesangial and capillary distribution in all the patients with lupus nephritis, but was absent or only trace-like in the patients with mc disease. the glomerular immunoreactivity for rig-i was correlated with the histological activity and severity of the renal disease in the patients with lupus nephritis. conclusions: rig-i expression occurs at levels detectable by indirect immunofluorescence and may be potentially useful as a parameter reflecting the renal histological activity in cases of lupus nephritis. cyclophosphamide pulse therapy for crescentic, proliferative iga nephropathy in children iga nephropathy is one of the most common glomerular kidney diseases in europe, up to % of affected adults need dialysis after years. therapy of crescentic, proliferative iga nephropathy in children is not well examined. between / and / seventeen children (main age years ( - ), male/female= / ) with biopsy-proven mesangioproliferative glomerulonephritis as manifestation of iga nephropathy were enrolled. nine patients (male/female= / ) had severe clinical manifestations (renal failure, nephrotic proteinuria or cerebral vasculitis) with extracapillary glomerular proliferations (crescents). this children were treated by intravenous methylprednisolone pulses ( / / / mg/m body surface area over days) followed by monthly intravenous cyclophosphamide (cph) pulses ( x mg/m body surface area) with gradually tapered oral prednisolon ( - mg/m body surface area/ h over months) and aceinhibitor (enalapril . - . mg/kg/d). after months of treatment a significant reduction of proteinuria ( . ± . to . ± . g/m /d; p< . ) and improvement of kidney function (gfr ± . vs. ± ml/min/ . m , p< . ) was observed. no notable adverse events were recorded. six patients had a second renal biopsy after completing cph-therapy; only crescent was found in examined glomeruli (initial findings: crescents in glomeruli). after follow-up of ( - ) months all children have unaltered renal function, further episodes of macrohematuria or gross proteinuria did not occur. intravenous cph pulse therapy seems to be an effective therapeutic option in paediatric patients suffering from crescentic iga nephropathy. eye involvement in children with primary fsgs distinct eye abnormalities have been described in children with nephrotic syndrome, particularly in diffuse mesangial sclerosis (pierson syndrome). the aim of the study is to investigate whether there are any associated ocular anomalies in childhood primary focal segmental glomerulosclerosis (fsgs). demographic characteristics, age at onset, drug therapy and duration of the disease were defined in patients ( girls, boys, mean age . ± . years) with biopsy proven fsgs. standard steroid therapy was prescribed to the patients. a detailed ophtalmological examination was performed in all patients. the median age at diagnosis was years ( - years). mean followup time was months ( - months). eleven patients ( . %) reached to chronic renal failure during follow-up period. overall, patients ( %) showed various eye abnormalities. nuclear opacity was found inone child and posterior subcapsular opacities probably due to corticosteroid therapy were present in two cases. two patients had myopic astigmatism and two had exotrophia. importantly, patients had anisometropic ambliyopia, had mittendorf spots and had pigmentary changes in macula, which had never been described in the literature. mutational analysis for nephrin, podosin, wt and lamb genes are still going on. we don't know whether particular mutations are related to particular eye findings like pierson syndrome, yet. however our findings emphasize that ophtalmological evaluation should be performed in all patients with primary fsgs at the time of diagnosis. regardless of the underlying disease, the proteinuric condition demonstrates ultrastructural changes in podocytes with retraction and effacement of the highly specialized interdigitating foot processes. to investigate whether high glucose and advanced glycosylation endproduct (age) induce podocyte phenotypical changes, including quantitative and distributional changes of zo- protein, we cultured rat glomerular epithelial cells (gepc) under ) normal glucose ( mm,=control) or ) high glucose ( mm) or ) age-added or ) high glucose plus age-added conditions. high glucose plus age-added condition could increase the permeability of monolayered gepcs and induce ultrastructural separation between confluent gepcs. zo- moved from peripheral cytoplasm to inner actin filaments complexes by both age-added and/or high glucose condition in cutured gepc by confocal imaging. high glucose plus age-added condition also decreased zo- protein amount and its mrna expression to statistically significant level compared to normal glucose or osmotic control conditions. we could also confirm the activation of pkb/akt signaling pathway in gepc by age, high glucose and insulin in pi k-dependent manner. in addition, an inhibition of pi kinase by ly was able to prevent quantitative and distributional changes of zo- protein induced by high glucose and age. these findings suggest that both high glucose-and age-added condition induce the cytoplasmic translocation and suppresses the production of zo- at transcriptional level and these changes may be mediated by pi k/akt signaling. this pathway could explain the role of zo- in the phenotypic changes of podocytes in diabetic conditions. henoch-schönlein purpura (hsp) is common in the pediatric population, while wegener's granulomatosis (wg) is rare. although both diseases are classified into the vasculitis syndrome, their clinical symptoms, the treatment and the prognosis are considerably different. the classic clinical triad of wg consists of upper and lower airway disease, renal involvement and small vessel vasculitis. we present a rare childhood case in whom hsp-like symptoms were developed prior to wg symptoms. a -year-old girl developed ankle joint pain and swelling and purpura on bilateral legs and hands in the absence of abdominal pain. she was diagnosed as hsp and treated with oral prednisolone (psl) therapy. although high dose psl temporarily rescued these symptoms, purpura and joint swelling and pain reappeared in parallel with a reduction of psl dose. at this moment, because microscopic hematuria, mild proteinuria and hoarseness were also noticed for the first time, serum proteinase- antineutrophil cytoplasmic antibody (pr- anca) was evaluated and detected to be high. moreover renal pathology showed necrotizing pauci-immune glomerulonephritis, leading to the final diagnosis as wg. after methylprednisolone pulse therapy followed by oral psl combined with cyclophosphamide, her clinical symptoms with wg were resolved together with the reduction of serum pr- anca titer. taken together we emphasize that pr- anca should be evaluated even in the patients who only develop hsp symptoms. background: short-term efficacy of steroid therapy for pediatric patients with iga nephropathy (igan) has been reported. however, there are a number of cases in whom their igan recurs after stopping the steroid therapy. recent japanese study indicated that tonsillectomy had a significant impact on renal outcome. also, another japanese study showed mizoribine was effective for igan in children. in this study, we examined the effects of a treatment regimen consisting of tonsillectomy and steroid pulse therapy followed by mizoribine (tx) for chronic relapsing igan in children. method: ten cases who showed chronic relapsing igan were included as the subjects (mean age at onset: . yrs, mean age at initiation of tx: . yrs). they were divided into two group, a normal renal function group (group a, n= ) and an impaired renal function group (group b, n= ). the changes in hematuria, proteinuria, renal function, and adverse events were prospectively examined for more than months. result: a negative of hematuria was observed in % of group a and % of group b. a negative of proteinuria was seen in % of group a. in addition, in group b, deterioration of renal function was not observed during the observation periods. there were no serious adverse events associated with this treatment regimen. conclusion: a treatment regimen consisting of tonsillectomy and steroid pulse therapy followed by mizoribine treatment seems to be effective to control of acute inflammation coexisting with chronic glomerular lesions, and can be a valuable addition to therapeutic options for treating patients with chronic relapsing igan in children. objective of study: to present a case of silent stenosing ureteritis in a boy with henoch-schönlein purpura (hsp). case report: a -year-old boy was admitted with a typical hsp. urine findings were normal on admission. a gastrointestinal bleeding on the th day of illness suggested corticosteroid treatment. the ultrasound on the th and th day revealed a normal urinary tract. on the th day he developed non-painful macroscopic haematuria, followed by microscopic haematuria and proteinuria, which reached the nephrotic range on the th day. thus, the boy was treated with methylprednisolone pulses and cyclophosphamide for weeks. renal biopsy was not performed because of his parent's refusal. microscopic haematuria and proteinuria gradually subsided, with complete disappearance at the th month. during this time he was asymptomatic, with no episodes of macroscopic haematuria or colicky flank pain. at the th month of illness a new ultrasound revealed a major left hydronephrosis. computer tomographic urography showed a complete ureteropelvic junction obstruction. the mtc-dmsa scan revealed a % relative function ipsilaterally. a left pyelostomy was performed. during the next four months after draining, the urine volume of the affected kidney was . - . ml/kgr/hour, the creatinine clearance - ml/min/ . m and the mtc-dmsa scan showed a % relative function. based on the above findings a nephrectomy was decided. conclusions: although rare, stenosing ureteritis should be considered in hsp. the typical clinical presentation with haematuria in association with colicky flank pain may not always occur, as in the present case, or may be confused with the symptoms of hsp itself. thus, the repetition of an ultrasound during the process of the disease may be necessary, in order for this complication to be diagnosed and treated early, preventing serious renal outcome. mitochondrial diseases are either due to sporadic or inherited mutations mainly in mitochondrial dna located genes. with regard to renal manifestations, tubular dysfunctions are common; however, the existence of solitary glomerulopathy has recently become apparent. in such case, the pathomechansim of the glomerular proteinuria is still obscure. wepresent a year-old girl who was found to have asymptomatic proteinuria (up/cr . ) in the absence of hematuria, azotemia, tubular dysfunctions, lacking any neurological manifestations. her family history showed maternal inheritance with mild proteinuria of grandmother and renal insufficiency of young uncle. light microscopy revealed glomeruli of normal appearance and of global sclerosis. electron microscopy showed swollen mitochondria in podocyte of normal appearance glomerulus. pointmutation rate of mitochondrial dna, a g, was detected as less than % in grandmother, % in mother and % in the patient examined byperipheral blood cells. the proteinuria completely disappeared months after treatment with combined therapy of arb and acei. to determine the responsible molecule for the pathomechanism of proteinria, immunostaining followed by conforcal microscopy with slit diaphragm associated molecules (sdm) (nephrin, podocin), gbm associated molecules (type iv collagen alpha chains, laminin isoforms, perlecan) and podocalyxin was studied and compared to the controls. interestingly distinct decrease of expression with sdm was observed even in normal appearance glomerulus of the patient. taken together, a g mutation itself may lead to depletion of atp and/or increase of free radicals in podocyte, which predominantly affect the biogenesis of sdm, result in pathological glomerular proteinuria. the mechanism of antiproteinuric effect of arb/acei therapy should be evaluated by serial biopsy specimen. objectives: to report the effectiveness of pulse cyclophosphamide induction therapy in children with diffuse proliferative lupus nephritis. to identify predictors for unresponsiveness to the treatment. methods: thai children under years of age with biopsy-proven diffuse proliferative lupus nephritis who were admitted to chiang mai universityhospital between and were retrospectively studied. responsiveness to treatment, defined as urinary protein to creatinine ratio of less than . , was assessed at the end of induction period. the clinical characteristics and laboratory data including gender, age at diagnosis of sle, duration of disease before treatment, hypertension, clinical nephrotic syndrome, amount of proteinuria, serum creatinine, creatinine clearance, serum c level and presence of crescentic formation in renal biopsy were compared between the two groups who responded and did not respond to the treatment. results: a total of patients ( % female) with the mean age at diagnosis of sle of . ± . year were studied. nineteen patients ( %) achieved remission at the end of induction therapy. there were no significant differences in all parameters studied between responsive and nonresponsive groups. despite the indifference in the amount of proteinuria, the proportion of patients with nephrotic-range proteinuria was higher in unresponsive group. conclusions: pulsecyclophosphamide is an effective regimen for induction therapy in children with diffuse proliferative glomerulonephritis. although no definite predictor was detected in this study, higher proportion of patients with nephrotic-range proteinuria in the unresponsive group wasnoted. born small for gestational age, but not early postnatal weight gain aggravates the course of idiopathic nephrotic syndrome in children clinical and animal studies have shown a higher risk of an aggravated course of renal disease in childhood after birth small for gestational age (sga). fast catch-up growth after sga seems to support the development of later disease. in a retrospective analysis of cases with idiopathic nephrotic syndrome treated between and in a university centrefor paediatric nephrology we identified children as sga and asappropriate for gestational age (aga). we related the course of disease to birth weight and catch-up growth. median age of manifestation in sga was . ( . - . ) years vs. . ( . - . ) years in aga children. in all sga children renal biopsy was performed, while only % of the aga children underwent renal biopsy showing nodifference in renal histology. in the sga group, % patients developed steroid resistance (vs. % aga, p< . ). the number of relapses was not different. % sga children needed antihypertensive treatment inthe course of the disease compared to % of aga children. catch-up weight gain between birth and months of age did not influence the course of disease. in conclusion we could find evidence for an aggravated course of idiopathic nephrotic syndrome in former sga children, but weight gainduring the first two years of life did not influence the course of disease. the mechanisms of perinatal programming in later renal disease need further investigation. wilson's disease(wd) is a disorder of copper metabolism that affects numerous organsystems including kidneys. besides renal tubular dysfunction as a result of excessive storage of copper, renal manifestations due to therapeutic complications can also develope specially with d-penicillamin. in this study we investigated the frequency and spectrum of renal manifestations during d-penicillamin therapy in wd. of patients receiving d-penicillamin for wd, patients( . %) ( boys, girl) developed findings of glomerulopathy within month to year after initiation of therapy and all were histologically diagnosed to have membranoproliferative glomerulonephritis (mpgn). the patients were between - years old, and they had normal urinalysis and renal function tests in their first presentations. two siblings developed hematuria and proteinuria below nephrotic range while the other two developed nephrotic syndrome. one of these latter patientsalso had acute renal failure needing temporary peritoneal dialysis. three patients had low complement (c) levels, had antinuclearantibody (ana) positivity, two had c-antineutrophil cytoplasmic antibody (anca) and one p-anca positivity. d-penicillamin therapy replaced by zinc sulphate in all patients. all renal findings improvedin patients within - months with normal renal functions and complement levels, and negative ana, p and c-anca tests. after years all were clinically in remission of mpgn confirming the role of d-penicillamin in development of renal disease. objectives of the study: the use of tacrolimus in steroid-resistant (sr) focal segmental glomerulosclerosis (fsgs) has been reported in single and small series. the aim of this report is to exhibit experienceon the management of children with sr fsgs in whom tacrolimus had been started on due to the therapy resistance. methods: fk combined low-dose oral steroid was started on three male patients ( , , -yearold) with sr fsgs who had been following for three years. all of them had failed various cyclosporin a, cyclophosphamide and steroid regimens prior to treatment with fk . the application was . mg/kg/day in two divided doses over h adjusted to a trough blood level between and ng/ml for months. other therapies included angiotensin-converting enzyme inhibitors, vitamin d and calcium analogues, and lipid-lowering agents. results: a reduction in proteinuria to normal levels was noted between - weeks following the initiation. the remission was achieved overall during the treatment. the relapse was recorded following cessation of tacrolimus in - weeks. the drug was generally well tolerated with no sideeffects and adverse reactions. the ratio of infectious events did not differ from the former regimens. conclusion: tacrolimus may be effective in controlling the proteinuria of patients with srfsgs during the therapy. there is a trend of relapse following cessation of treatment. the duration for drug uptake is a topic of debate. further study in larger population is warranted. introduction: histological features of focal segmental glomerulosclerosis are found in % of pediatric patients with steroid resistant nephrotic syndrome. upto % (between - %) children with fsgs progress to esrd. objective: to study the clinical course of childhood fsgs and determine the possible predictive factors of chronic kidney disease. method: case records of children who had biopsy proven fsgs and had presented to the sindh institute of urology and transplantation between - , were retrieved. clinical and laboratory parameters at baseline, response to steroids and cyclosporine, development of crf (as defined by a gfr of < ml/min/ . m ), and histopathological details were analysed. result: a cohort of children with a mean age of . ± . years and a m: f ratio of : was identified. after a mean follow-up time of years, / ( . %) developed crf. on univariate analysis, male sex ( % vs %, p- . ), > years age at onset ( % vs. %, p- . ), hypertension ( % vs. %, p- . ) and microhematuria at presentation ( % vs. %, p- . ) were significantly associated with risk of developing crf. steroid resistant course ( % vs. %, p= . ) was more prevalent in those who developed crf. the crf group was also more likely to have an elevated creatinine at baseline ( . % vs. %, p< . ). moderate tubular atrophy and a high percentage of segmentally and globally sclerosed glomeruli were found in those who developed crf. patients progressing to crf were more likely to have a partial response to cyclosporine ( % vs. %, p= . ) conclusion: factors such as age, microhematuria, hypertension, elevated baseline creatinine, steroid resistance, tubular atrophy, percent global sclerosis and partial response to cyclosporine are likely predictive of progression to chronic kidney disease in children with fsgs presenting to our center. chronic glomerular nephropathies in children are marked by an often unfavourable evolution, so that the establishing of a prognosis at the time of the diagnosis is both a professional and a moral duty for the pediatric nephrologists. purpose: the estimation of the current practice renal survival prognosis in children with chronic glomerular nephropathies, by using clinical and laboratory elements in different histological forms of primitive chronic glomerulonephritis (cgn), with a minimum period of observation of one year. we analyzed parameters that may intervene in the duration of renal survival: type of cgn, age at the debut of the illness, histological scores of activity and chronicity, the presence of tubular atrophylesions and that of interstitial fibrosis, renal failure (rf) installment time, in cases with normal renal function at the beginning, the time until the initiation of dialysis in cases with esrf, respectively. the statistic analysis of data has been carried outwith epi soft (fishcer test). the results have been as follows: unfavourable evolution has been taken into consideration in the cases which have presented fixed nitric retention or which required the initiation of dialysis. the initiation of dialysis was necessary in cases ( %), out of which ( %) having associated between and of the considered risk factors. if the histological type (sfgs, dgs, mpgn) is added to the obtained score, the accuracy of the estimation increases to %. in conclusion: the usage of prognosis scores composed of current elements of diagnosis that have proven to have statistical significance, as far as the renal survival prognosis is concerned, may allow the invoking of a medium-term prognosis in the evolution of children with cgn. introduction: the srns can lead to a progressive deterioration of the renal function and therefore needs an aggressive therapy. one of the alternatives of treatment is the association described by mendoza et al which consists of prolonged use of methylprednisolone with cyclophosphamide (cp), which has a remission rate of %. the objective of this study is to evaluate retrospectively the clinical evolution of children with srns treated with mendoza's protocol. method: between and , children, male and female, with srns were subjected to a renal biopsy and later treated with mendoza's protocol. cp was used in children that had not responded to pulses of methylprednisolone and presented a relapse. all of the patients received supplemental calcium. the clinical evaluation included stature, weight, ophthalmic fundus examination, proteinuria in urine recollection of hours and/or protein to creatinine ratio and blood chemistry. results: eleven patients ( %) had fsgs. nine ( %) presented complete remission, two ( %) had partial remission, four ( %) did not respond to treatment, of which evolved to terminal kidney disease. nine patients received cp. of the complications secondary to treatment with steroids, % had a linear growth suppression and an increase in their bmi and patient presented cataracts with visual impairment. conclusion: the prolonged treatment with boluses of methylprednisolone and cyclophosphamide is a good alternative in patients with srns. the prolonged use of high doses of steroids can cause linear growth suppression and other adverse reactions, so it is advisable torealize a genetic study in all of the patients with srns to be able to exclude the patients that have a genetic mutation and so avoid unnecessary treatment. objectives: to study the clinicopathological profile and outcome of lupus nephritis (ln) in indian children. methods: clinical and histopathological features and outcome of children with ln was retrospectively reviewed. patients were included if they fulfilled the acr criteria for the diagnosis of sle and had either of persistent proteinuria, active urinary sediments or renal dysfunction. outcome was analyzed at years and at last follow-up. results: ofthe children studied, were boys. the mean age (sd) at diagnosis was . ± . (median . , range - . ) yr; children were youngerthan years of age. the mean age at presentation and renal biopsy was . ± . (median . , range . - ) years. the mean duration of follow-up was . ± . (median . , range . - . years) years. . % patients were followed for more than years. commonest clinical manifestations were fever ( %), hypertension ( %) and malar rash ( %). and % of patients presented with nephrotic and nephritic syndrome respectively before the diagnosis of sle. the commonest pathology was class iv nephritis ( %) followed by class ii ( %). hypertension, hematuria, nephrotic syndrome and decreased egfr were significantly associated with class iv ln. at last follow-up . , . and % patients were in ckd stage ii, iii, and iv respectively. the patient survival rate at year and at last follow-up was and % respectively, while no patient developed esrd at years. infections were seen in % cases that resulted indeath in patients; died of hepatic encephalopathy. conclusion: sle nephritis has a varied presentation and high morbidity. a significant proportion of patients developed infections during the course of disease. clinical, pathological features and outcome in our study do not differ markedly from those in most pediatric series. background: atypical hus has a frequently relapsing course and a poor renal prognosis. low c plasma concentration suggests alternate complement pathway regulatory abnormalities: factor h (fh), factor i (fi) and membrane cofactor protein (mcp). case report: we report an year old girl with atypical hus due to acquired fh deficiency caused by anti-fh antibodies (abs). hus was diagnosed on the basis of acute renal failure, microangiopathic hemolyticanemia and thrombocytopenia. past history: recurrent fever with culturenegative pharyngitis (suspected pfapa syndrome). decreased c ( mg%, normal> ) with normal c . adamts activity was depressed, no cleaving protease abs. hemodialys (hd) and plasma exchange (pex) were started days later. severe urticaria and angoiedema during pex was treated with methylprednisolone and chlorpheniramine. hematological and renal improvement were observed after the rd pex session. relapses occurred in months: -controlled by pex; -(with suspected pfapa) with single dose corticosteroids, -with prednisone therapy, terminated with single dose ivig mg/kg. elevated anti fh ab titer- au with decreased fh functional activity were found in pre-pex plasma. fh, fi, factor b and c antigenic levelsnormal. hematological remission and renal function improvement without hus relapse ensued while tapering corticosteroids. two years after presentation, onprednisone mg/day anti fh titer dropped significantly with restoration of functional fh activity, gfr ~ ml/min/ . m . conclusions: in cases of atypical hus, active search for anti fh ab iscrucial for implementing specific and effective therapy: plasma exchange, iv ig and steroids for improving course and longterm prognosis. research centre for child health rams, department of pediatric nephrology, moscow, russian federation children aged , - years with idiopathic biopsy-proven steroid-resistant focal and segmentary glomerulosclerosis (fsgs) were treated with cyclosporine a (csa) , - , mg/kg as initial dosage, oral prednisolone , mg/kg every other day tapered to the -th month and methylprednisolone pulses (mp) - mg/kg every other day for the first - weeks in of patients. serum creatinine level was controlled once a month. after months of csa treatment complete or partial remission of proteinuria was in ( %) of children, no effect in ( %). serum creatinine level increased in % on an average in the group remission of proteinuria. in the group of non responded patients the creatinine elevation was significant same - %. after year of csa treatment complete or partial remission observed in ( %), no effect in ( %). elevation of serum creatinine level in children with remission was , % (without significant difference compared to month's csatreatment). increasing of the creatinine level more than % in two patients leaded to double tapering csa dose resulted in normalization of serum creatinine level. in the group of csa non responders the significant increasing of serum creatinine level ( %) was revealed (compared to month's csa treatment). in cases the elevation ofcreatinine level was more than % and these patients turned into esrd eventually. in all of non-responders csa was discontinued. we concluded that serum creatinine level in csa respondrers was stable without significant elevation during the year of treatment. csa therapy for year without any effect influenced on renal function decreasing. clinical objective: to describe the clinical course and outcome of pediatric patients with cgd treated with iv mpt ( mg/kg x doses monthly for months, then dose monthly for the next months) methods: patients' medical records were reviewed. pre, post-treatment and follow-up hr urineprotein, creatinine and gfr were compared using paired t-test; and proteinuria, hematuria and blood pressure using mcnemar's chi square. outcome measures were analyzed usingmean ± sd and frequency distribution. results: patients were included, male, female. mean age at disease onset is . ± . years. mean duration of follow-up is . ± . months. % achieved complete remission after a mean of . cycles, % partialremission after a mean of . cycles and % were treatment failures. mean relapse rate is . ± . on treatment and . ± . at follow-up. renal survival rate is %. hour urine protein and the proportion of patients with proteinuria, hematuria and hypertension significantly decreasedafter treatment and remained stable at follow-up. serum cr/gfr were also stable pre, posttreatment and at follow-up. no serious side effects were noted. conclusion: this protocol induced a high and early remission rate ( % after . cycles)among the patients. majority demonstrated stable renal function and blood pressure over time. relapse rates were low and treatment is generally safe. recommendation: the protocol can be offered to oral-steroid or alkylating agent-resistant patients with satisfactory remission rates. objectives of study: nestin, an intermediate filament protein which has a role in regulating cellular cytoskeletal structure, is restrictedly expressed in the podocytes of human kidneys. in the present study nestin expression was investigated in biopsy specimens of children with focal segmental glomerulosclerosis (fsgs). methods: kidney biopsy specimens taken from children with diagnosis fsgs were investigated. diagnosis was performed on light microscopy, immunofluorescence microscopy, taking into account clinical data. for immunomorphology monoclonal anti-nestin antibody from mouse (sc- , clone c . a , santa cruz biotechnology) diluted : , was applied on cryostat or paraffin sections using labeled streptavidinebiotin (lsab+ dako) method. visualization was performed by dako aec substrate. kidney biopsies of patients without nephrotic syndrome, mainly with mesangioproliferative gn were used for control staining. results: the mean age at the time of biopsy was . ± . years, and all patients had nephrotic syndrome. half of them revealed some focal tubulointerstitial changes: tubular atrophy, slight interstitial fibrosis and lympho-monocytic infiltration. in two cases mutation of wt gene and in one case mutation of nphs gene was detected. four cases had familial character of fsgs. nestin expression was variably present in different cases of fsgs. decreased expression was detected in glomeruli with segmental mesangial sclerosis and capsular adhesions. conclusion: fsgs revealed heterogenity concerning nestin expression. nestin expression was diminished in affected glomeruli. background: renal effects of altered ob/ob-r pathway may contribute to obesity, and diabetesassociated proteinuria. in the kidney ob/ob-r stimulates collagen type i and iv synthesis and upregulates tgfβ and tgfβ receptors. objective: to determine ob/ob-r and its downstream (jak/stat/socs) pathway expression in nephrotic syndrome (ns) and fsgs. design/methods: microarray analysis of kidneys of -week ( w) and -month ( m) old transgenic mice (tg) and controls (ctr) was performed, and confirmed by quantitative pcr. kidney sections were analyzed by immunohistochemistry (ihc) and western blot analysis (wb). urinary ob/ob-r of children with ns classified as steroid sensitive (ssns) or steroid resistant (srns), were measured by elisa. results: ob, ob-r, and jak , , mrna expressions were not statistically different at w and m between ctr and tg. stat and socs mrna were increased . -fold (sem ± . ), and . fold (sem± . ) at m in tg, p= . and p= . respectively. ihc and wb (p= . ) of kidney sections showed no significant difference between the groups. we examined ctr, ssns, and srns patients with comparable bmi, age, race and gender. urinary protein to creatinine ratio in ssns and srns was . (sem± . ) and . (sem± . ) respectively, p= . . urinary ob (p= . ), ob-r (p= . ), and tgfβ (p= . ) were not statistically significantly different between the groups. conclusions: ob/ob-r was not upregulated in tg at the onset of proteinuria and fsgs. however, advanced fsgs ( m tg) showed significant activation of socs , an ob/ob-r negative regulatory pathway. pediatric patients with early srns had no significant increase in urine ob/ob-r. this data suggests the role for ob/ob-r regulatory pathways in the development of advanced fsgs. primary fsgs presents clinically with steroid-resistant (srns) or steroid-dependent (sdns) nephrotic syndrome or proteinuria. the data shows, that % patients with fsgs progress to esrd in years follow-up. objectives: the aim of the study was to analyze the long-term outcome of patients with primary fsgs diagnosed in kidney biopsy. material: the study group consisted of children ( males, females) followed from . all patients were treated with immunosupression and renoprotection. the clinical data were analyzed after follow-up lasting for mean ± , years ( , - years) . children presented with nephrotic syndrome ( srns and sdns) and with proteinuria. the age ranged from , - years mean , ± , at the time of diagnosis. more then kidney biopsy was performed in children -in progression from mcd (n= ) and mes (n= ) to fsgs were observed. results: the clinical remission was observed in / patients ( %) and was not correlated with initial proteinuria (mean , ± ). in / patients crf was observed, of them progressed to esrd ( were successfully transplanted). among patients, who had fsgs as their initial glomerular lesion (n= ), the percentage of glomerular sclerosis was significantly higher in a group in which remission was not obtained after long-term follow-up ( , vs. %, p< , ). in out of patients with follow-up over years progression to esrd was observed ( , %), / were transmitted to adult centers with persistent proteinuria. conclusions: immunosuppression and renoprotection in patients with fsgs can prevent the progression of crf. extensive glomerular sclerosis is a predictor of unfavourable outcome. further clinical and genetical studies are needed to establish the effective therapy modalities. mycophenolate and who had previously undergone a renal biopsy, recieved mg twice daily (maximum gram twice daily) during six months. prednisone was concurrently prescribed at at dosage of mg/kg/every other day, during weeeks and . mg/kg/every other day during the subsequent weeeks. results are expressed as mean±sd. results: seven chidren, boys and two girls were enrolled. oncet of their ns was at age . ± , yr (range - yr) and mmf was initiated at . ± . yr ( . - . yr) . six were sr and one sd. two patients had previously recieved cyclosporine, two patients cyclophosphamide and one chlorambucil. renal histology displayed: focal segmental glomerulosclerosis (n= ), minimal change (n= ), mesangial proliferation (n= ) and membranous glomerulonephritis (n= ). at the end of the follow-up: three patients were in partial remission, two were in complete remission and two had no response to mmf. initial and final serum creatinine concentration . ± . vs . ± . mg/dl), estimated gfr ( . vs. ± ml/min/ . m ) and serum albumin ( idiopathic nephrotic syndrome is the most frequent glomerular disease in childhood. most patients are steroid responsive but half of them relapse and often become steroid-dependent. they are exposed to long term steroid complications on the one hand and relapses due to insufficient disease control on the other hand. our aim is to determine predictive risk factors for high degree steroid dependence. in france, steroid-resistance is defined as persistent proteinuria after one month of daily oral prednisone ( mg/m ) and pulses of methylprednisolone (mpn) ( g/ . m ). we included steroid responsive children with disease onset between and . the mean age at diagnosis was . years (range . - ). all patients initially received prednisone mg/m per day. the following parameters were analysed: age at onset, gender, days to remission with initial steroid therapy, mpn pulses, numbers of relapses, steroid dependency, immunosuppressive drugs. twenty of the patients were steroid-dependent; among the steroid dependent patients, received mpn pulses. % of those patients ( / ) were treated by cyclosporine during follow-up. on the other hand, only % ( / ) of the patients who did not receive mpn required cyclosporinebased therapy during follow-up (chi-square test, p= . ). interestingly, there was no correlation between treatment days until remission during the initial prednisone course and the risk for later steroid dependence. conclusion: the need for mpn pulses, but not the time interval until remission helps to predict steroid dependence. patients, necessitating mpn pulses to obtain remission are at risk to require cyclosporine for disease control. by identifying these children, we could eventually / avoid multiple relapses by earlier use of adequate immunosuppression and / avoid side effects related to long term high dose steroid therapy. membranous nephropathy (mn) with antitubular basement membrane antibodies is a rare condition. relapse of tubular dysfunction in renal transplant recipients has been published in one case, but relapse of mn in the renal graft has not yet been reported. a -year old boy presented first with steroid resistant nephrotic syndrome associated to tubular dysfunction. renal biopsy revealed mn associated to interstitial fibrosis and granular deposits of iga, igg, and c along the tubular basement membrane. indirect immunofluorescence (if) revealed circulating anti-tubular basement membrane antibodies. he received a renal allograft at the age of years. an acute rejection episode on day required three steroid pulses and okt- . renal biopsy revealed the presence of interstitial and vascular rejection (banff iii) and relapse of tubular basement membrane deposits. renal function normalized within days and remained stable (gfr estimated by schwarz formula= ml/min per . ). proteinuria remained negative and urinalysis normal over years under the immunosuppressive regimen including fk, azt, and prednisone. at the age of years, proteinuria increased progressively over weeks reaching . g/day, whereas serum creatinine remained stable. renal biopsy revealed the presence of granular deposits along the glomerular basement membrane suggesting a late relapse of mn in the transplant. rituximab therapy (day , , , and ) followed by switch from azathioprine (aza) to mmf resulted in a complete biological remission with negative proteinuria. indirect if revealed progressive decrease of antitubular basement ab level during rituximab treatment and a negative signal was obtained months after the switch from aza to mmf. this is the first report of glomerular relapse of mn with anti tubular basement antibodies in a renal transplant recipient. nephrotic children are at risk for severe pneumococcal infections. the best moment for antipneumococcal vaccination is controversially discussed. we investigated the serologic response after pneumo vaccination in children ( girls) with nephrotic proteinuria and hypoalbuminemia, immediately after initialisation of prednisone therapy at mg/m (group ) and in children after tapering down of prednisone to < . mg/kg eod (group ). there was no difference in both groups concerning antibody (ab) response, relapse frequency, or number of steroid dependent forms. in group , pneumo ab levels at presentation (m ) were . ± . (mean±se) . at m antibody levels increased -fold to . ± . (p< . ). serum levels at m were . ± . . one year after vaccination ab levels ( . ± . ) decreased compared to m (p< . ), but remained increased compared to m (p< . ). there was no increased delay until remission in both groups compared to a retrospective control group. severe hypoalbuminemia (< g/l) at the time of vaccination was not related to a lower serological response on m . during relapses, antibody levels decreased significantly compared to levels before relapse (p< . ), but increased again once remission was obtained. even during relapses, ab levels remained higher (> -fold) than pre-vaccination levels. conclusion: nephrotic children on high dose glucocorticoid therapy respond to anti-pneumococcal vaccination and their ab levels remain elevated during relapses. vaccination at disease onset may be beneficial as those patients with relapses during the tapering down of steroids already have increased anti pneumo ab at the time of relapse. crescentic glomerulonephritis with isolated c deposits associated to complement abnormalities: a new entity? introduction: several progressive renal diseases present proteinuria, as a result of glomerular and tubulointerstitial injuries. thus, some studies prove that proteinuria is an important predict factor for progression of renal failure. angiotensin converting enzyme inhibitors (acei) are efficient in reducing proteinuria and preserve renal function in patients with diabetic or non-diabetic nephropathy. the purpose of this study was to evaluate the efficacy and security of acei in children. material and methods: the acei (enalapril) was used in normotensive and hypertensive patients with chronic renal disease, with microalbuminuria/proteinuria. results: we studied patients ( girls), for at least months, mean age was . ± . years ( month to years). / patients had glomerulopathy, / chronic pyelonephritis, / systemic disease, / renal hypoplasia/ dysplasia, / cystic renal disease and / arterial hypertension. the mean dose of enalapril was , mg/kg/d ( , to , ) and it was used during , months (mean). we observed a normalization of proteinuria/microalbuminuria in , % of cases. in seven patients, the drug was discontinued due to: / irregular use, / vertigo, / hypercalemia and acute renal failure recovered after withdrawn the drug. during the use of enalapril we did not observe significant difference in potassium or creatinine serum levels, as well as blood pressure measurements. conclusions: the use of enalapril in pediatric patients with renal disease and proteinuria/ microalbuminuria showed security and efficient. therefore, we suggest it as a antiproteinuric and renoprotective agent in children. a. filleron, al. adra-delenne, l. ichay, f. dalla-vale, h. valette, d. morin chu montpellier, pediatric nephrology, montpellier, france in order to evaluate the long-term efficacy of oral cyclophosphamide (cp) in children with sdns, the outcome of patients ( girls) treated in our unit for steroid sensitive ns were studied retrospectively. median age at diagnosis was . years (range . to ). initially, they received oral prednisone (p) : mg/m /d for weeks and p dosage was then tapered for the next weeks (totale dose p: mg/kg). relapses of proteinuria were treated with p ( mg/m /day) and, in case of steroid dependency (sd), p was maintained on an alternate day regimen. one single child had no relapse, while had a relapse rate of less than /year. the remaining frequently relapsed and received oral cp - mg/kg/day for weeks, totale dose mg/kgbecause of their high relapse rate with steroid toxicity. median duration of p treatment was . years (range . to ) before cp was given. in one case cp had to be stopped because of hemorragic cystitis. follow-up after cp treatment was, at least, years. p was stopped in the following months after cp in / children, but has to be continued in the remaining because of early relapse of proteinuria. among those children, only one had no more relapse years after cp. in children, relapse of proteinuria occured . ± months after cp. in those patients, / had to receive another steroid sparing drug such as cyclosporine or mycophenolate mofetil (mmf) because of recurrence of sd. in our experience, cp treatment in ns with steroid toxicity is associated with a significant change in the relapse rate in only / children and in the remaining , improvement was transient. our results suggest that alternative treatment, such as mmf, has to be evaluated as first-line steroidsparing agent in those patients with sdns and steroid toxicity. interleukin - the aim of our investigation is to compare the concentration of total ige, specific ige, interleukin- (il- ) and gamma-interferon (gamma-ifn) in serum of children with initial and relapsed steroid-sensitive mcns and of children with atopic dermatitis at the age from to years. the concentration of total ige was measured by immunoenzymatic method and il- , gamma-ifn by immunoassay technique using monoclonal antibodies. the result showed that % of children with atopic dermatitis had the increased concentration of total ige; specific ige was increased to alimentary allergens- , %, household- , %, inhaled- , %. the concentracion of il- was , ± , pg/ml, of gamma-ifn was ± , pg/ml. the result showed that % of children with mcns had increased concentration of total ige; specific ige was increased to alimentary allergens- , %, household- , %, inhaled- , %. the concentration of il- was , ± , pg/ml, of gamma-ifn was , ± , pg/ml. according to our investigation, the concentration of il- and gamma-ifn in children with mcns were not significantly different then in children with atopic dermatitis. conclusion: the fact that there were not significant differences in serum total ige and specific ige, il- and gamma-ifn in children with mcns and atopic dermatitis gives us a reason to suppose that these diseases have identic mechanisms of pathogenesis with ige reaction i-type with activation of t-limfocyte. to clarify the pathogenesis of mcns, comprehensive studies for these cells would be worthwhile. there are several lines of evidence that the slit diaphragm (sd) not only serves as a structural framework for filtration barrier but also has an essential role as a signaling platform. nephrin is tyrosine phosphrylated by src-family tyrosine kinase, fyn. phosphorylated nephrin recruits nck to sd, and regulates assembly of actin filament. the crucial roles of tyrosine phosphorylation in podocyte is also indicated by renal malfunction observed in fyn knockout mice. neph has a longer cytoplasmic domain and a larger number of tyrosine residues in its cytoplasmic region than nephrin. but knowledge about tyrosine phosphorylation of neph is limited. here we characterize neph as a substrate of fyn. fyn interacted with and phosphorylated cytoplasmic domain of neph in vitro and in cultured cells. peptide mass fingerprinting of neph cytoplasmic domain phosphorylated by fyn in vitro identified at least five tyrosine phosphorylation sites. site-directed mutagenesis confirmed that these tyrosine residues were indeed phosphorylated in cultured cells. in pull-down analysis with neph from rat glomerular lysate, neph specifically bound to an adaptor protein grb and a tyrosine kinase csk in a phosphorylation-dependent manner. coimmunoprecipitation experiments revealed phosphorylation of y and y were crucial in neph -grb binding. furthermore, tyrosine phosphorylated neph suppressed erk activation elicited by fyn, and also inhibited fyn-induced ap- transcriptional activation. these inhibitory effects required the intact binding motif of the grb sh domain, and both y f and y f mutants failed to inhibit erk activation. these results indicate that fyn orchestrates a wide spectrum of protein-protein interactions at sd by phosphorylating neph as well as nephrin, and neph modulates downstream signaling by phosphorylation-dependent association with adapter proteins. celiac disease (cd) is a common disorder in southern europe and has a protean clinical presentation. hla class ii aplotypes dq and/or dq are present in % of cd patients and in % of the normal population. the observation of three patients with both cd and nephritic syndrome (ns) prompted us to study hla class ii aplotypes in our patients with ns. in all children with ns admitted to our unit we determined the presence of dq /dr , dq /dr , dq /dr e dq /dr aplotypes and anti-transglutamidase antibodies (ab-httg). hla typing was done by dna extraction and pcr amplification and electrophoresis in agarose; ab-httg determination was made by elisa. as control groups we examined children with cd and first degree relatives (of theirs). in so far we have studied children with ns ( males, females, age ranged - years); are steroid sensitive (ssns), steroid resistant (srns). a renal biopsy was done in and showed minimal lesions in , focal and segmental sclerosis in , membranoproliferative gn in , membranous gn in and iga deposition in . corticosteroids or other immunosuppressant were administered in when blood was drown. dq and/or dq aplotypes were present in out of patients ( . %), in out of ssns ( . %), in out of cd relatives ( %) and in all cd patients. dq /dr combination was present in a smaller percentage of ns compared to control groups. ab-httg were detected in one patient out of ( . %). purpose: to investigate activity of antithrombin and a protein c at children with mcns: at active period (proteinuria more g/m /d; hypoalbuminemia < g/l), at in incomplete remission (the third day of absence of proteinuria, hypoalbuminemia < g/l), at in proof remission. methods: activity of natural anticoagulants in blood was defined by a clotting method with use of reactants "roche" and "behring". results: activity of antithrombin in blood in the active period of disease sharply decreased ( , ± , %, p< , ), and already in the period of incomplete remission came back to norm ( , ± , %), characteristic for the period of full remission ( , ± , %). activity of a protein c in blood in the active period of mcns was high ( , ± , %, p< , ), during incomplete remission decreased ( , ± , %, p< , ), in the period of proof remission was in norm ( , ± , %, p< , ). at children with mcns dependence of decrease in activity antithrombin from weight hypoalbuminemia (r= , , p< , ), hyperfibrinogenemia (r=- , , p< , ), hypercholesterolemia (r=- , , p< , ) and hyper-lipoproteinemia (r=- , , p< , ) is established. authentic distinctions of factor of the attitude of activity of protein c/ activity of antithrombin depending on the period (the active period - , , incomplete remission - , , proof remission - , ) are received. conclusion: at children with mcns changes in system of natural anticoagulants: decrease in activity antithrombin below % and increase of factor of a parity of anticoagulants (more than , ) testify to hypercoagulation and risk of thrombosis. varicella objectives: the pattern of steroid responsiveness of nephrotic syndrome may change during the course of the disease in children with steroid sensitive nephrotic syndrome (ssns) and/or in different populations. patients and results: a prospective cohort study was conducted in centers. patients who were initially diagnosed as ssns in and followed for five years were included. standard questionary forms from children( boys) with a mean age of . years ( months- years) at presentation were submitted for entry to data coordinating center. / patients who showed initial steroid sensitivity with a follow-up period of at least one year ( - years) were included in the study. seventy three ( . %) children remained in sustained remission at year; nine patients showed steroid resistance. / patients were followed for years, whose clinical course were sustained remission in ( %) and steroid resistance in ( %). steroid response rate from to years remained stable ( - %). eight children out of totally patients who were steroid sensitive initially, became steroid resistant in the first year. the remainder showed steroid resistance at the nd year ( ), at th year ( ) or at th year ( ) . renal biopsy was performed in children who developed steroid dependency or steroid resistance. nine patients revealed fsgs, minimal change disease, mesangioproliferative gn, membranoproliferative gn, one igm nephropathy. only two patients who had minimal change nephropathy in initial biopsy progressed to fsgs after and years. conclusion: steroid response rate was between - % and steroid resistance was - % in years follow-up. secondary steroid resistance within the first year of presentation seemed to be predictive for their subsequent courses. the need of biopsy was not high. ssns seemed still as a relatively benign condition in our population. the aim of this study was to asses the changes in coagulation/fibrinolysis system in chronic renal disease (crd) by measuring plasma levels of von willebrand factor (vwf) and plasminogen activator inhibitor - (pai- ). we studied children ( - years old) with nephrotic syndrome (ns): minimal change disease (n= ), focal segmental glomerulosclerosis (n= ), mesangioproliferative glomerulonephritis (n= ), membranoproliferative glomerulonephritis (n= ). relapse of the disease was observed in patients. healthy age matched children served as controls. serum levels of pai- : ag and vwf were measured by elisa. results. pai- and vwf levels were elevated in all morphological forms of ns in relapse and remission compared with controls (p< , ) except the mcd remission in which they were the same as controls (p> , ). the highest levels of pai- and vwf were discovered in relapse of proliferative forms (mespgn, ± ng/ml and , ± , me/ml, respectively; mpgn, , ± , ng/ml and , ± , me/ml, respectively) compared with nonproliferative (mcd , ± , ng/ml and , ± , me/ml, respectively; fsgs , ± , ng/ml and , ± , me/ml, respectively, p< , ). conclusion. these data suggest activation of coagulation/fibrinolysis system in relapse of ns and the absence of normalization in the remission phase. our results confirmed that more severe fibrin formation via activation of intraglomerular coagulation and fibrin accumulation is characteristic for mpgn, likely by deficiency of the fibrinolysis system. introduction. several recent case reports suggest that rituximab (rtx) could be an effective treatment for idiopathic nephrotic syndrome. in a retrospective study, data were collected from patients (mean age: . years) treated with rtx for steroid dependent nephrotic syndrome (mean duration of the disease: months). four of were treated during a remission period. eight of were treated in association with one or several other immunosuppressive (is) treatments (prednisone, anticalcineurin, mycophenolate mofetil). rtx efficacy was admitted when the previous is treatment was withdrawn or significantly tapered-off, or when the proteinuria disappeared with no other change than rtx treatment. a complete b-cell depletion was confirmed in all patients when assessed ( / ) even when rtx was infused during a period with nephrotic proteinuria. rtx was considered to be effective in cases especially when given in association with other immunosuppressive treatment during a period with remission of proteinuria ( / success, follow-up to months). conversely rtx failed to induce remission among patients who were treated during a proteinuric period with no other immunosuppressive drug ( / failures). finally rtx was considered to be effective among of patients treated in association with other is drugs during a proteinuric period (follow-up and months). there was no significant side effect during rtx infusion. delayed side effects were observed for patients: case of neutropenia and pneumocystis pneumonia and case of hypogammaglobulinemia. conclusion. rtx is an effective treatment in a subset of patients with severe steroid dependent nephrotic syndrome. further prospective data are necessary to determine if rtx could become an alternative to other immunosuppressive drugs in patients with toxic side effects. infections are leading causes of death in lupus patients. disseminated histoplasmosis has been commonly documented in immunocompromised patients including lupus patients. we report a case of lethal cerebral histoplasmosis in a child originating from french guyana. lupus disease was revealed by typical malar rash. she developed a class ii lupus nephritis treated with prednisone and azathioprine. then she developed restrictive lung disease, recurrent arthritis and pericarditis. later on, nephrotic syndrome revealed a class iii lupus nephritis treated with methylprednisolone pulses and mycophenolate mofetil. four years following the onset of the disease, she was admitted because of febrile seizures and five months later for a febrile coma. repeated lumbar punctures displayed hypercellularity with depressed levels of glucose and elevated protein concentrations but sterile cultures. according to the presence of high titers of lupic specific antibodies and cerebral mri suggesting vasculitis, neurological flare of lupus was considered and immunosuppressive treatment was increased (methylprednisolone and cyclophosphamide pulses, plasma exchanges). a repeated lumbar puncture evidenced presence of histoplasma capsulatum. despite antifungic treatment the child died. our report emphazises the difficulty to discriminate opportunistic infections from the wide spectrum of lupus clinical features. symptoms of infection may mimic those of lupus, or conversely, may be masked by immunosuppressive drugs. infection screening should take in account clinical feature as well as endemic context. our report is the first case of isolated cerebral histoplasmosis in a child with systemic lupus. renal manifestations of mitochondrial cytopathies have been described, but nephrotic syndrome with respiratory chain disorders (rc) was described extremely rarely in infancy. we report a months-old boy with a mitochondrial cytopathy preceded by months history of steroid-resistant nephrotic syndrome. on admission his clinical condition was deteriorating rapidly with gross oedema, ascites, hypertension and oliguria. fundoscopic examination revealed salt-pepper sign which was thought to be consistent with intrauterine infection (iui) at that time. however, serologic and microbiologic investigation of iui was inconclusive. a sensorineural hearing loss was found to associate his findings. podocin mutation was negative. a percutaneous renal biopsy was undertaken and revealed diffuse mesengial sclerosis. a significant decrease in mitochondria was observed on electron microscopic examination. the child progressed to end stage renal failure and was successfully managed by peritoneal dialysis. during his follow-up a fine tremor was observed in his hands and cranial mri revealed demyelinisation in left thalamus and occipital lobe. steroid resistant nephritic syndrome, sensorineural hearing loss, ocular and neurologic findings has led us to be suspicious about mitochondrial cytopathy and muscle biopsy was done. though muscle biopsy was normal, the results of biochemical analysis showed a deficiency of the respiratory chain complex iv (cytochrome c oxidase) (rc iv). the clinical phenotype and the deficiency of respiratory complex iv thought to be compatible with deficiency of the cytochrome c oxidase deficiency protein cox . nephrotic syndrome with rc disorder were described extremely rarely in infancy. based on these observations, we suggest that rc disorders should be considered in patients with early onset nephritic syndrome. human parvovirus b (hpvb ) was identified as the cause of a self-limited childhood febrile illness with rash, namely erythema infectiosum. most of hpv-b infections are usually mild or asymptomatic, but in some cases infection is associated with serious systemic complications. renal involvement in patients with hpvb infection was discussed in recent, mostly anecdotal, case reports. the majority of these reports were described in adults, whereas only a few cases of childhood were defined whom presented with mesangiocapillary proliferative glomerulonephritis, fsgs or tubulointerstitial nephritis. a literature search revealed no cases of acute endocapillary proliferative glomerulonephritis in childhood. a -year-old girl was admitted with fever, cough, maculopapuler rash, hemoptysis, dark-colored urine, multiple lymphadenopathies, hepatosplenomegaly. she developed acute nephritic syndrome during the course of this complex clinical features. laboratory data showed proteinuria, hematuria, hypocomplementemia, the presence of igm and igg antibodies to hpvb and positive reaction of serum hpvb dna using a polymerase chain reaction. renal biopsy showed acute endocapillary proliferative glomerulonephritis with coarse granular c depositions in a "starry sky pattern" which is more peculiar to poststreptococcal glomerulonephritis. electron microscopy revealed subendothelial and hump-shaped subepithelial dens deposits. there was no evidence of either a mycobacterial or a streptococcal infection and the diagnosis of goodpasture syndrome and connective tissue disorders were excluded by clinical and laboratory investigations. based on the literature review, this case represents, to our knowledge, the first time that a direct relationship between parvovirus infection and acute endocapillary proliferative glomerulonephritis has been demostrated in a child. objective: the purpose of this retrospective cohort study was to report the clinical course of children and adolescents with focal segmental glomerulosclerosis (fsgs) according to steroid response. methods: the records of patients with biopsy-proven fsgs admitted between and were retrospectively reviewed. demographic, clinical and laboratory data at entry and at the end of the follow-up were analyzed. the patients were classified according to the initial prednisone response into two groups: group (g ): response (complete or partial remission) (n= ) and group (g ): non-response (prednisoneresistant) (n= ). renal survival analysis was performed using the kaplan-meier method. results: the median age at admission was . years (iq range: . ± . yr) in g and . years (iq range: . ± . yr) in g . seventeen patients ( %) of g , and patients ( %) of g presented with hematuria at admission, and ( %) children of g and ( %) of g presented blood pressure levels above the th percentile. g presented a higher h proteinuria ( . mg/ h) at admission when compared to g ( . mg/ h, p= . ). median follow-up time was . years in g and . years in g . the renal survival rate was % at years and % at years in g , % at years and % at years in g . conclusion: progressive renal insufficiency was more frequent in patients with fsgs who have initial resistance to prednisone therapy. objectives of the study: adults with chronic kidney disease (ckd) show impaired immune status. in this study, the profile of mononuclear cell subsets was related to the age and actual gfr in children and compared to healthy controls. methods: the expression of lymphocyte surface antigens was evaluated on peripheral blood (pb) mononuclear cells using three-color flow cytometry in children with ckd (stage - ) on conservative treatment. we analyzed absolute and relative numbers of total leukocytes, total lymphocytes and subsets: cd +, cd +, cd +cd +, cd +cd +, cd -cd / +, cd +hla-dr+, cd +cd +, cd +, cd +αβ+, cd +γδ+, cd ra+, cd ra+cd +, cd ra+cd +, cd ro+, cd ro+cd +, cd ro+cd +, cd +cd +. results: in younger ckd children (below years) absolute numbers of cd +, cd +cd +, cd +cd +, αβ+t, γδ+t cells and cd /cd ratio was higher, the percentage of cd +cd +, cd ra+cd +, cd ro+cd +, cd ro+cd +, αβ+t cells and the absolute number of cd ro+cd + cells was lower than in the oldest group. in children with the lowest gfr (below ml/min) the percentage of cd +, cd + was lower, the absolute number of cd +cd +, cd +, and the percentage of nk-cells, cd +cd +, cd +, cd ro+cd + cells was elevated as compared to ckd stage group. the absolute number of cd +, cd +cd +, cd ra+cd +, αβ+t, γδ+t cells and percentage of total lymphocytes, cd +, cd +cd +, cd + was lower in ckd children than in controls. conclusion: impaired immune status is observed already in early stages of ckd. progressive disturbances in pb lymphocytes percentage mostly in the naive and memory t cells and the shift in the cd /cd balance were found in pre-dialysis children with ckd. with progressive loss of renal function, we observed an increased expression of activation markers on t cells such as cd or cd . introduction: relapse of steroid resistant nephrotic syndrome (srns) after renal graft occurs iñ % of the pediatric patients. medical management is based on increased immunosuppression with the use of iv cya and plasma exchanges (pe). however, this strategy fails in ~ % of the treated patients. new immunosuppressive agents may improve the outcome of relapsing srns post transplant. case report: a -year-old boy with srns reached esrd and received a cadaveric kidney transplant after two years on hemodialysis. the immunosuppressive regime was cya, mmf and steroids. seven days post transplant gross proteinuria ( g/day) reoccurred. iv cya was administered over two months (blood level: ~ ng/ml) associated to pefloxacine and pe (n= ), and followed by oral cyclophosphamide (cyp), resulting in partial disease control. cyp was discontinued due to haematological toxicity after one month. proteinuria increased again from to g/day within months, despite high dose oral cya ( mg/kg/day) and mmf. etanercept (a tnf blocking agent) was introduced at a dose of mg twice weekly (combined with three steroid pulses) and maintained over two months: proteinuria decreased to . g/day over days. etanercept was discontinued followed by a relapse of the ns and re-introduced eight months later, with, again a significant decrease of proteinuria to a baseline level of . g/day. conclusion: treatment with anti-tnf agents in nephrotic children has been reported once in a boy with high degree steroid dependent ns; a spontaneous decrease of disease activity over time cannot be excluded in this patient and might jeopardize data interpretation. our case is the first report of successful antiftreatment despite a constantly high activity of the nephrotic syndrome, demonstrated by relapse after discontinuation of etanercept while the patient was on post transplant immunosuppression. fournier´s gangrene (fg) is defined as a specific, quick and progressive form of synergic necrotizing fasciitis of multi-bacterial origin that affects perineum muscular fascia, genital region and surrounding areas with skin gangrene due to thrombosis of subcutaneous blood vessels. it describes the clinical case in a male preschooler of four years of age with idiopathic nephrotic syndrome (ns) that subsequent presented fg of the scrotum. broad-spectrum antibiotics, intravenous albumin and surgical cleaning of the scrotal necrotic tissues were indicated. pseudomona aeruginosa was isolated from necrotic tissue cultures. the later evolution was satisfactory with healing of the affected area and remission of the ns subsequent to the steroidal treatment. fg is an uncommon in children, rapidly progressive infection of the genital, perineal and perianal regions. it is characterized by a synergistic necrotizing fasciitis leading to thrombotic occlusion of small subcutaneous vessels and development of gangrene. until now few cases have been report fg in children, and still less associate to the kidney diseases. et all ( ) described a -year-old boy presenting with steroid resistant ns developed fg of the scrotum so that to our knowledge, this patient seems be the second case reported in medical literature with both pathologies. high index of suspicion, prompt diagnosis, broad spectrum antibiotics followed by wide debridement is the key to successful treatment. objectives of study: to evaluate a long term experience on iga nephropathy (igan) presenting in childhood and investigate clinical and histological factors that may act as early markers of renal disease progression. methods: retrospective review of data from children and adolescents with biopsy proven igan in the last years. demographic and clinical data at presentation and severity of renal histological involvement were recorded and related to renal dysfunction markers identified at the last review. results: twenty-five patients were studied ( m/ f) with median age at onset of ( - ) and follow-up of ( - ) years. on presentation recurrent macroscopic hematuria was present in patients, microscopic hematuria (mh) in , proteinuria in ( nephrotic), hypertension in and transient acute renal failure in . renal histology findings were focal mesangioproliferative in , focal proliferative in , diffuse proliferative in and focal sclerosing glomerulonephritis in . six patients showed tubulointersticial and extraglomerular vascular lesions (tevl) with glomerular crescents in . on follow-up, patients remitted ( spontaneously, with ace inhibitors). of the remaining, were kept on ace inhibitors due to proteinuria ( ), hypertension ( ) or both ( ). one patient (with focal glomerulosclerosis and tevl) developed esrd within a year after diagnosis, despite treatment. at last review, patients presented progressive renal disease with a mean decrease of ml/min/ , m in gfr per year. these ( m/ f) showed mainly mh and proteinuria at onset and tevl. conclusions: early renal function impairment in childhood igan can occur and may be associated with mh and proteinuria at presentation and with focal glomerulosclerosis and tevl on renal histology. proteinuria persistence in a number of patients emphasizes the need for long term followup into adulthood. adhesion molecules, il- +p and cd +cd + and cd +cd + lymphocyte subsets in childhood nephrotic syndrome background: parathyroid hormone (pth) can modulate t cell activation and proliferation through as yet incompletely identified mechanisms. since the pth receptor (pthr) is a g protein-coupled receptor and thus a candidate for association with lipid rafts, and since pth has been shown to alter membrane phospholipid metabolism, we explored the relationship of the pthr with lipid rafts in human t cells. methods and results: we found by flow cytometry that neither physiologic nor pathologically elevated concentrations of pth affect the up-regulation of the raft marker gm- or of the partially raft-associated activation marker cd in purified t cells stimulated with phytohemagglutinin (pha). moreover, we detected the pthr exclusively in non-raft fractions of these cells after sucrose gradient separation. conclusions: these data indicate that in human t cells, the pthr does not associate with lipid rafts and that pth does not modulate these domains. accordingly, other mechanisms underlying the actions of pth on human t cells need to be sought. the direction and magnitude of potassium transport in nephron segments depend on the sitespecific distribution of transporters in tubule cell membranes. potassium depletion has been demonstrated to be associated with altered sodium reabsorption in renal tubule segments. we examined whe her potassium transporters protein expression is associated with altered abundance of major renal na + transporters, that may contribute to the development of hypokalemia in lp. after weaning rats (n= ) were fed days with lp diet ( %), then they were recovered with a normal protein diet ( %, rp), each group had a control group ( %, np). we examined the changes in the abundance of the na + /h + exchanger (nhe ), na + k + atpase, na + k + clcotransporter (bsc- ), na + clcotransporter (tsc), epithelial sodium channel (enac) subunits and romk in kidneys of lp, np, rp rats. controls were normalized to . results reduced clcreat (ml/min) in lp vsnp ( . ± . vs . ± . ), hypokalemia ( . ± . vs . ± . meq/l) and increased fe k+ ( . ± . vs . ± . %) were demonstrated. immunoblotting revealed that the abundance of nhe in cortex was severely decreased. the amount of bsc- ( . ± . , p< . ) and tsc ( . ± . , p< . ) protein levels were enhanced in the inner stripe (isom) and outer stripe of the outer medulla (osom), respectively. romk protein levels were increased in lp ( . ± . , p< . ), the protein abundance of the enac subunits α, β and γ was increased near . fold each in response to lp. na + k + atpase protein levels showed no differences in cortex and osom. after rp, na + transporters expression returned to control values. conclusion: increased expression of bsc- , tsc, enac subunits and romk, contributing to distal potassium secretion was shown in hypokalemia from lp. a role of aldosterone may be suggested. v. belostotsky , mz. mughal , j. berry , n. webb royal manchester children's hospital, pediatric nephrology, manchester, united kingdom st. mary's hospital, pediatrics, manchester, united kingdom manchester royal infirmary, vitamin d laboratory, manchester, united kingdom aims: to describe the prevalence of vitamin d deficiency in south asian and white uk children with renal disease. to establish how decreased levels of vitamin d affect pth in patients with a normal gfr. methods: children aged - years were enrolled in the study: were of white uk, of s asian and of other ethnic origin. were on dialysis, had chronic renal failure, had various renal disorders with normal gfr (> ml/min/ . m ), had a transplant ( with anormal gfr). blood samples were collected to establish the levels of -vitamin d ( -ohd); pth; creatinine. -ohd concentration < ng/ml was defined as vitamin d deficiency; levels between - ng/ml as vitamin d insufficiency. serum pth of . - . pmol/l was defined as normal. results: the prevalence of vitamin d deficiency/insufficiency was higher in s asian ( %) than white ( %) children (p< . ). ofthe ( s asian, white and other) children with normal gfr / s asian and / white children had pth concentrations > . pmol/l. of these / s asian, / white children had low levels of -ohd (p= . ). of transplant patients with reduced gfr, of with a high pth had low -ohd levels, compared with of with a normal pth (p= . ). conclusions: many s asian children attending our renal clinic are vitamin d deficient/insufficient and the prevalence of this problem is significantly higher than that in the white population. high pth values in the setting of a normal gfr can often be explained by vitamin d deficiency and should result in serum -ohd levels being measured. nephronophthisisis a rare recessive autosomal disease which may be either limited to progressive chronic tubulointerstitial nephritis or associated with extrarenal involvement (eye, liver, central nervous system, etc.); mutations/deletions have been found in at least nphp genes. fibrous dysplasia is a benign skeletal lesion due to an activating mutation inthe gene that encodes the α subunit of stimulatory g protein and occurs after fertilization in somatic cells; it involves one or several bones and may be part of mccune albright syndrome. we report on a boy with fibrous dysplasia of bone diagnosed at yrs of age, who underwent protocol renal function tests at yrs of age in the follow-up of pamidronate treatment. inulin clearance was ml/min/ . m and potassium reabsorption rate was . % where as there was neither urinary phosphate wasting nor hypercalciuria. serum magnesium was decreased ( . mmol/l) without reabsorption abnormality and serumuric acid progressively increased with age. in addition, due to increasing microalbuminuria, a treatment with acei was started at yrs of age. renal ultrasonography at yrs of age showed hyperechoic reduced-sized kidneys with few microcysts. a renal biopsy (light and electron microscopy) was performed at yrs of age, which showed nephronophthisis-like lesions, i.e., diffuse interstitial fibrosis and focal thickening of tubular membrane basement. dna analysis revealed no nphp gene deletion but is still under investigation.nephronophthisis has been reported in association with skeletal involvement (coneshapedepiphyses) and fibrous dysplasia with hypophosphatemic rickets or fanconi syndrome. however no association between fibrous dysplasia of bone and nephronophthisis-like lesions has been described and may be a new picture of the nephronophtisis/medullary cystic kidney disease complex. m. bald, m. holder, h. leichter olgahospital, pediatric nephrology, stuttgart, germany puumalaviruses belong to the group of hanta viruses and are transmitted by inhalation of aerosolized particles of the red bank vole (cletriomonysglareolus) which is endemic in the alb-danube region of southern germany. infections with puumala virus were first described as "nephropathia epidemica" in scandinavia with the clinical symptoms of fever, thrombocytopenia and acute renal failure. over the last seven years three boys with acute renal failure were admitted to our hospital after vacationing in the region endemic for puumalavirus. all three presented with high fever, influenza like symptoms aswell as pronounced abdominal or flank pain. they showed a decreased gfr ( , and ml/min/ . m , respectively) with hematuria and proteinuria. cbc revealed no leucocytosis or anemia, but thrombocytopenia in of the patients. they had no oliguria, but patients had marked polyuria in the recovery phase of renal function. arenal biopsy in the boy with the most severe presentation showed diffuse tubular damage. puumala virus infections were confirmed in all patients by serological tests, and renal function normalized within - weeks. nephropathia epidemica due to puumala virus infections have to be included in the differential diagnosis of acute renal failure in patients from endemic regions. severe abdominal or flank pain are common symtoms in these patients; renal failure is transient and the general prognosis is good. aims: the objective of this study is to determine the relationship of urinary calcium excretion (uca) with sodium and protein intake in a pediatric population of families with low income. methods: children, f and m, ages to years from families with income <$ /month were studied. protein intake was estimated with a -day dietary record. a nonfasting urine sample was collected for dipstick, calcium, creatinine, sodium, potassium, urea and uric acid. urinarycalcium/creatinine (ca/cr), sodium/potassium (na/k), uricacid/creatinine (au/cr) and urea/creatinine (u/cr) ratios were calculated. children with a urinary ca/cr > . mg/mg, were submitted to a day period of high sodium foods restriction after which a second urine sample was collected. results: mean (x) and standard deviation (sd) for ca/cr, na/k, au/cr and u/cr ratios were: . ± . mg/mg, . ± . meq/meq, . ± . mg/mg and . ± . mg/mg respectively. the th percentiles for ca/cr, na/k, au/cr and u/cr were . , . , . and . respectively. x±ds for protein intake was . ± . g/kg/day. the incidence of hypercalciuria was . % in the initial urine sample and . % in the second. correlation was significant between ca/cr ratio and na/k ratio (r: . , p< . ), acu/cr ratio (r: . , p< . ) and u/cr (r: . , p< . ), not significant between ca/cr ratio and protein intake. conclusions: the incidence of hypercalciuria in this serie is lower than previously reported values in venezuela for the general pediatric population and decreases further when sodium intake is controlled. although no correlation was found between uca and protein intake, we could speculate that protein intake near to the daily recommended requirements of g/kg/day, could be a possible reason for the lower incidence of hypercalciuria in this population. -year old girl presented with rapid onset of muscular weakness and a short history of severe dysphagia, dysphonia nad significant wasting. on examination, she was dystrophic (bmi , ) and had signs of myopathy. laboratory findings confirmed myopathy (cpk , ukat/l, ast , ukat/l, myoglobin ug/l). there was striking hypokalemia (s-k , mmol/l) suggesting hypokalemic paralysis. diagnosis of distal renal tubularacidosis (drta) was based on confirmation of hyperchloremicmetabolic acidosis, severe hypokalemia, high urinary ph and positive value of urinary anion gap (s-cl mmol/l, ph , , be , urinary ph , ). there was evidence of other signs of renal tubular impairment (urinary beta- -microglobulin mg/l, glomerulo-tubular proteinuria , g/ h). autoimmune tests (high positive rheumatoid factor, anf, ena ss-a/ro, ss-b/la, high circulating immunocomplexes) and low values of sialometric measurements ( , ml/ x minutes) revealed primary sjogren´s syndrome as the underlying cause of drta. the renal biopsy confirmed chronic tubulo-interstitial nephritis compatible with this diagnosis. full recovery of muscle weakness and laboratory findings of hypokalemia and acidois followed potassium and alkali replacement. corticosteroids were administered with subsequent addition of cyclosporine a because of disease activity. conclusion: primary sjogren´s syndrome is a rare diagnosis in childhood and adolescence and should be considered in patients presenting with hypokalemic paralysis due to drta. m. caletti, h. lejarraga, s. caíno, a. jiménez introduction: ndi is a chronic, genetic disease caused by an inability to effectively conserve urinary water, due to a lack of response of distal renaltubule to antidiuretic hormone. the main symptom is polyuria, polydipsia and growth impairment. objective: to evaluate long term growth in height and weight of children with ndi. patients and methods: sixteen patients with ndi attending hospital for a median period of . years (range . / . yrs) were studied. treatment consisted of indometacine, hydroclorotiazide and amiloride (iha). height and weight was measured with standardized anthropometric techniques. z scores(sds) for all measurements were calculated according to national standards. results: all children responded favourably to treatment. mean birth weight sds was not different from zero; mean height and weight at diagnosis was ± . and ± . sds respectively, and at the end of follow-up was ± . and ± . respectively. the majority of patients´s growth curves evolved below the th centile. ten out of children experienced some catch up in height (mean height gain: . sds (r: - . / . )). mean weight gain during follow-up was . sds (r: . / . ) . mean gain in body mass index was . sds (range . / . ). in the two patients who attained adult height, adolescent growth spurt was normal, and final height was within normal limits for standards and for parental height. correlation coefficient between gain in height andage at diagnosis was ± . . conclusion: although mean height at follow-up was below the expected normal value, combined therapy with iha is compatible with some catch up growth in height and weight. the lower the initial height, the greater the height gain. adherence to treatment is essential for normal growth in children with ndi. body growth of children with steroid-responsive idiopathic nephrotic syndrome m. noer, i. irwanto, n. sumiarso, m. chalim soetomo hospital, school of medicine airlangga university, department of child health, surabaya, indonesia objectives of study: the present study was designed to evaluate the statural growth of children with steroid-responsive idiopathic nephrotic syndrome, attending the pediatric nephrology unit department of child health, school of medicine airlangga university, soetomo hospital, surabaya, indonesia, with a minimum follow-up of years. methods: anthropometrice valuation included weight, height, and growth velocity expressed as mean and standard deviation scores (sds), relative to the normal population (nchs/cdc ). these indices were analyzed at admission and then every months of follow-up. all patients were treated with prednisone, according to indonesian consensus of management of idiopathic nephrotic syndrome in children. results: of children ( boys and girls), patients ( boys) aged / years to years (mean . years) were analyzed. initial mean height and z score (height for age) were . ± . cm and - . ± . , respectively. mean height and z score (height for age) of the last follow-up were . ± . cm and - . ± . , respectively. mean growth velocity were . ± . cm/year where boys ( . %) had growth velocity less than cm/year. total cumulative dose of steroid during years of follow-up were . ± . mg or . ± . mg/kgbw. conclusions: the cumulative dose of steroid up to . mg/kg body weight in children with nephrotic syndrome during years of treatment did not influence their growth velocity. background: recently it has been reported in adult patients (pts) that deterioration of renal function was associated with the lost of nocturnal blood pressure (bp) dip and enhanced urinary sodium (una) and protein (uprt) excretion during night. objectives of study: to investigate the circadian rhythms of bp, una and uprt in children with chronic kidney disease stage i (ckd i). methods: in pts ( boys) aged . ± . years with ckd i (chronic glomerulopathy confirmed by renal biopsy in % pts), hour bp was monitored during daytime (d) and nighttime (n) and urinary samples for uprt, urinary creatinine (ucr), and una, were collected for both periods. results: serum creatinine-based gfr was ± ml/min/ . m , uprt ranged from to (median ) mg/ h, and una from to (median ) mmol/ h. in general we found a highly significant nocturnal decrease in systolic bp (from to mmhg), diastolic bp ( to mmhg), mean arterial pressure ( to mmhg), heart rate ( to /min) urinary output (uo), una and uprt. the regression equations were as follows: uod (ml/m /h)= + . xuon (ml/m /h); unad (mmol/l)= . + . xunan (mmol/l); uprtd (mg/m /h)= . + . xuprtn (mg/m /h) and urinary osmolality (us) d= + . xusn. nocturnal decrease of uo correlated with nocturnal decrease of ucr and uprt, and nocturnal decrease of uprt correlated with nocturnal decrease of uo. more than half of the patients were classified as non dipper. they differ significantly from dipper only in night/day changes of us. conclusion: night/day changes of uo, una and uprt in pts with ckd i may be calculated from the given regression equations. these changes are not correlated with nocturnal bp decrease. non dippers have greater nocturnal change of us compared to dippers. follow-up of these parameters will clarify their importance in progression of ckd. autosomal autosomal dominant proximal renal tubular acidosis (prta) it is described l. g. brenes ( ) at seven members of one family. we diagnosed seven members of the afghani family with prta: mothers and children ( girls, boy from , till years) with hyperchloremic metabolic acidosis. pedigree analysis suggested an autosomal dominant inheritance pattern. observable patients did not have ricket and nephrocalcinosis. deafness and ocular abnormalis are absent. the plasma hco concentration is decrease in the range of , to , mm/l, minimal urine ph is < , . parameters of blood creatinin and glomerular filtration rate were normal. urine calcium excretion was normal. therapy strategy of prta at observable patients provides high dozes of citrates/bicarbonates - mmol/kg per h. all india institute of medical sciences, division of nephrology, department of pediatrics methods: retrospective case-search. data of previously reported prospective trial (n= ) was also included. results: all except patients had previously been treated with both levamisole and cyclophosphamide. forty-two cases qualified for the study and were administered mmf for a mean duration of . months ( % ci, . , . /patient in the first months of treatment and . episodes (n= ) in next six months of mmf treatment (p< . ), an average reduction of % ( % ci, . , . ) from the pre-mmf phase. nine ( . %) patients had no relapses while on mmf therapy we present sibling cases of as with heavy proteinuria at early childhood. a boy ( year-old) and a girl ( yearold) were diagnosed as x-linked as. since a boy developed persistent heavy proteinuria (up/cr . ) with macrohematuria andresistant to arb/acei therapy, we treated him with cyclosporina (csa) that could lead to complete remission. to investigate pathomechanism of proteinuria, we tested immunostaining for slit diaphragm associated molecules (nephrin, podocin), gbmassociated molecules (laminin, perlecan, agrin) and podocalyxin using frozen sections from his firstand second biopsy and girl's one (up/cr . ). in the specimens from boy's first biopsy and girl's one, light microscopy revealed mild mesangial proliferation and no differences ofthe expression with perlecan, agrin and podocalyxin compared with controls. however, when determined laminin isoforms, fetal type laminin (alpha beta gamma ) wasdistinctly observed in the gbm, whereas that was localized only inmesangium with controls. interestingly when compared mature laminin isoform (alpha beta gamma ), beta chain was specifically less expressed in the gbm. however there were no differences of expression of these molecules in the specimens between pre-and post-treatmentwith csa. in boy's second biopsy, % glomeruli were detected to becollapsed. together with the recent report showing that laminin beta mutation causes congenital nephrotic syndrome factor v leiden mutation and steroid resistant membranous glomerulonephritis: a case report m. buyukcelik , m. karakok turkey renal compications of d-penicillamin therapy in wilson's disease sami ulus children's hospital, department of pediatric nephrology sami ulus children's hospital, department of pediatrics sami ulus children's hospital hass classification), treatment and outcome. thirty-nine patients; boys ( . %) and girls ( . %) time of the last examination (median months, min< year) after the admission as a long term follow-up. clinically, group i; while microscopic hematuria was detected in patients, patients had repeated attacks of hematuria, had isolated mild proteinuria/hematuria, group ii; patients had nephritic, had nephrotic syndrome and had both. biopsy grades in the patients: %, % had grade i, . %, % had grade ii, %, % had grade iii, %, % had grade iv in group i and ii, respectively. group i and ii patients recovered completely (no hematuria and proteinuria) . %, . % as well as %, %, short-term, longterm, respectively. while recovery rates in fish-oil and/or ace-inh treatment group was . % and . %, in corticosteroids group, it was %, % short-term, long-term,respectively. no patients who received immunosuppressive treatment had improved. however, ( . %) patients would suffer from esrd. initial presentation, severity of renal involvement and type of the treatment were not found to have a prognostic value (p> . ). in children, igan is characterized by extreme pathogenetic, clinical and histological polymorphisms radojevic university of belgrade, faculty of medicine, institute of pathology, belgrade, serbia institute of mother and child health of serbia, belgrade, serbia university children's hospital, department of nephrology, belgrade, serbia celiac disease hla aplotype in children with nephrotic syndrome s i (if) or mcp or with anti-cfh autoantibodies. varicella hasn't been described as a triggering event of ahus. we report two cases of ahus associated with complement dysfunction revealed after varicella infection. case . a five year-old boy presented with non post-diarrheal hus, days after varicella. serum creatinine was μmol/l, hemoglobin . g/dl, schizocytes %, platelets g/l. glomerular filtration rate normalized within days. search for shiga toxin-producing e coli in the stools and serum anti-lipopolysaccharides antibodies were negative. plasma c , cfh and if levels were normal. no mutations of cfh and if were found. mcp cell-surface expression was decreased and a c f mutation in mcp exon was demonstrated. case . a four year-old girl had ahus days after varicella at that time, complement system study showed normal c level ( mg/l, normal to mg/l), normal cfh level ( %, normal - %), but the presence of anti-cfh autoantibodies. no mutations of cfh, if or mcp were found. in conclusion, these cases outline that varicella can be the triggering event of ahus associated with complement dysregulation about ( . %) children had relapses after initial remission. various infections were responsible for relapsed with in / ( . %) who had relapses. about children ( . %) relapsed with out cause where as poor compliance was observed in ( . %). overall infection and relapse rate was . and . /pt/yr respectively. among children with infections, most common types of infections were acute respiratory infections (ari), diarrhea and uti seen in ( . %), ( . %) and ( . %) of cases respectively. other types of infections like malaria, peritonitis, skin infection and pulmonary tuberculosis were seen serum pai- and tgf-beta levels in profliferative forms of glomerulonephritis in children russian federation research centre for child health rams, department of pathology, moscow, russian federation we aimed to investigate serum levels of plasminogen activator inhibitor - (pai- ) and transforming growth factor-beta (tgf-beta ) in children with proliferative forms of glomerulonephritis (gn). children were examined ( - years old) with gn (steroidresistent ns, n= ; steroidsensitive ns, n= , isolated haematuria, n= ) and healthy age matched controls. mesangioproliferative gn (mespgn) was detected in patients, membranoproliferative gn (mpgn) in cases. serum levels of pai- : ag and tgf-beta were measured by elisa. results. the highest levels of pai- : ag and tgf-beta were observed in relapse of mpgn: , ± , ng/ml and these results confirm prosclerotic effects of pai- and tgf-beta via increased fibrin deposits and extracellular matrix accumulation in the renal tissue and promotion of disease progression rituximab treatment for idiopathic nephrotic syndrome: a retrospective study of cases v. guigonis , a. dallocchio , m. dehennault urinary and serum annexin v levels in children with steroid sensitive and steroid-resistant nephrotic syndrome hôpital robert debré-aphp, pediatric intensive care unit indonesia this study was aimed to evaluate the efficacy of pulse dose of cyclophosphamide in children with srns admitted in child health department faculty of medicine university of indonesia/cipto mangunkusumo hospital jakarta between - . -month period, one child died, and the rest ( children) did not complete the regimen. five out of children who finished the treatment had remission, while others were still experiencing heavy proteinuria. remission was achieved in various time, children were in remission after the first dose, in children it was achieved at the third and sixth dose. in further follow-up time; one child remained in remission, one child had relapse when still receiving cpa, children got relapse one month after stopping cpa, and one child had relapse after months ceasing cpa. nausea and vomiting were found in children indonesia this study is to evaluate the anthropometric measurements of children with nephrotic syndrome methods: a descriptive retrospective study at child health department, cipto mangunkusumo hospital, jakarta. data were collected from medical records of nephrotic syndrome %) irns; body height and body weight of <p was found in none of frns/sdns, / ( , %) srns, and / ( , %) irns; bmi >p was found in / ( , %) frns/sdns, / ( , %) srns, / ( , %) irns. conclusion: the percentage of children with frns/dsns and srns with body height <p il- ) during active stage (as: urinary protein > mg/m per hour, serum albumin < . g/dl) and remission stage (rs) in ss-mcns. a total of patients with ss-mcns ( of patients with as and of patients with rs) and healthy children were recruited for studies. the mean±sd of serum il- , se-selectin and sicam, levels were significantly higher in patients with as than in patients with rs ( ± . / . ± pg/ml; . ± . / . ± . ng/ml and . ± . / . ± . ng/ml respectively, p< . ). in spite of, higher levels of il- , se-selectin and sicam in patients with as than controls, difference was not statistically important. the percentage of cd +cd + lymphocyte subsets were statistically grater in patients with as severe proximal renal tubular acidosis in pearson syndrome birth weight was g. pallor was initially noted during the neonatal period and referred to our hospital with anorexia, vomiting, diarrhea, weakness, and increased pallor at wk of age. on the physical examination she was pale and the other systems were unremarkable. investigation showed hypoplastic anemia, and bone marrow examination showed cytoplasmic vacuolization of both myeloid and erythroid precursors, and maturation arrest of granulopoesis. family history was negative for hematological disease. the diagnosis ps was considered on the basis of early severe refractory anemia associated with vacuolization of bone marrow precursor cells and ring sideroblasts. treatment was started consisting of vitamine b and folic acid. she was followed with growth retardation, moderate anemia and leucopenia up to age . . at that age, the girl was readmitted with severe vomiting and dehydration. on admission, she had moderate metabolic acidosis, hypokalemia, high plasma lactate, and hypophosphatemia. further investigations showed tubuler proteinuria, glucosuria, aminoaciduria, and defective bicarbonate reabsorbtion in the proximal tubule. she developed refractory metabolic acidosis resulting in a cardiac and respiratory failure and death. to confirm the diagnosis of ps, molecular studies were performed bp common deletion was found medial calcification in intact human arteries from children with chronic kidney disease is associated with apoptosis and osteogenic differentiation -clinical and laboratory correlations r using intact human vessels we studied the phenotypic changes in medium sized arteries ex vivo and in vitro after exposure to ca and po . arteries were retrieved during insertion of pd catheters or at transplantation from children: dialysis (n= ), ckd stage iv (n= ) and compared with mesenteric vessels from controls. vessel rings were incubated with graded concentrations of ca and po upto days. calcium and alkaline phosphate (alk) were measured by cresolphtalein complexone and colorimetry. immunohistochemistry for bone marker proteins, inhibitors of calcification and apoptosis were performed. laboratory findings were related to patient's clinical and biochemical parameters, carotid intimamedia thickness (cimt) and coronary calcification. vessels from ckd or dialysis patients had increased baseline vessel wall ca compared with controls (p= . ). when exposed in vitro to ca and/or po , dialysis vessels showed greater calcification than those from controls or ckd patients (p< . ). in the presence of elevated po even a small increase in ca increased calcification (p< . ). calcification was associated with apoptosis (tunel +) and could be inhibited using apoptosis inhibitor zvad. alk in ckd and dialysis vessels and along with upregulation of bone-markers suggests an osteogenic conversion of vsmcs using our unique in-vitro model, we have shown for the first time that vascular damage induced by elevated ca-po as well as factors specific to dialysis primes vessels for rapid progression of medial calcification altered expression of major renal na + and k + transporters c. ruete , p. vallés , university of cuyo, department of pathology turkey the effect of corticosteroid therapy on bone metabolism in nephrotic syndrome was examined. sixty-nine patients with idiopathic nephrotic syndrome (age: . ± , years) and healthy controls (age: . ± , years) were divided into groups: group : patients who were on remission but still receiving steroid therapy, group : patients who were on remission and free of steroids within the last year and group : patients with active nephrotic syndrome and receiving steroid therapy. serum total calcium, ionized calcium, phosphorus, alkaline phosphatase, magnesium, parathyroid hormone, (oh)d, serum cystatin c, urine protein, urine creatinine and urine cystatin c levels measured in all patients including the control group. in addition, lumbar spine bone mineral density z scores were measured in the patient group objectives of study: we evaluated the clinical, laboratory and urinary tract echosonographic findings in patients with ah and rh. methods: there was prospective clinical study, included patients (mean age . ± . ) with ih (normocalcemic, normophosphatemic, with hours urinary calcium excretion greater than mg/kg/day) all analyzed parameters (dysuria, positive family history of urolithiasis, microscopic hematuria, urinary tract microlithiasis) showed low sensitivity and specificity, and none of the parameters could be considered reliable in differentiating ah versus rh. average value of una/cr was greater in patients with rh conclusion: none of the analyzed clinical parameters, laboratory and echosonographic parameters except values of urinary excretion after calcium deprivated diet could be considered reliable in differentiating ah versus rh. patients with rh have higher level of hours urinary calcium excretion than patients with ah. patients with rh have significantly greater excretion of urinary sodium compared with patients with ah idiopathic hypercalciuria (ih) is defined as hypercalciuria with no detectable cause. low bmd with increased fracture rate and tendency to short stature has been reported in ih patients. we aimed to perform calcaneus qus in children with ih and relate to u-ca, body height and number of prevalent fractures (fx). children ( girls, boys; patient. body height was recorded and qus was measured on both heels with cuba clinical. the -h u-caexcretion (u-ca/ h) was assessed and calculated in mmol/kg/ h. results were expressed as z-scores ±sd. czech anthropometric parameters from a survey and previously obtained qus values of the healthy czech pediatric population served as reference data. qus results were also calculated as height adjusted values with the use of heightmatched standards. u-ca/ h was matched to healthy european paediatric population values we found no correlations between fx and bua (either age-related orheight-adjusted) or fx and vos (age-related or height-adjusted). neither were there any correlations between u-ca and fx, or u-ca/ hand bua or vos, respectively. in conclusion, children with ih had normal height, normal values of bua and low vos (fc) (p) (p) (mr) (fc) (fc) (op) (p) alpay h. (p) (p) amann k. (fc), (p), (p) amanullah f. (p) (op) amaro a. (op) (op) amore a. (sy) (p) anarat a. (fc) (mr) (p) (op) (fc) (op) (p) (p) bael a. (op) (p), (p), (p) (fc) (fc) (p) balat a. (p) (p) (fc) bayazit ak. (p) (p) (p), (p), (p) (p) (p) (p) (p) bensman a. (op) (sa), (p) (p) (fc) bereczki cs. (op) (fc) (op), (fc) (op) (sy) bi yl. (p) (fc) (p) (op) (p) biyikli n. (p) (p) (fc) bocanegra v. (fc) (fc) (p) boh m. (fc) bökenkamp a. (op) (fc) (fc) (op) (op) (op) bourrier t. (p) bouts ah. (op), (fc) (op) (p) bubic-filipi lj (p) (op), (fc) (op) (p) (p) caropreso m. (op) (fc), (p) (fc) (p), (p) chartapisak w. (p) (p) (p) chaves a. (op) (p) chemodanova m. (p) (p) chen j. (op) (p) (p) (p) (p) (op) (p) (p), (p), (p) clermont mj (p) (fc), (p) (sy) codoceo a. (p) coelho g. (op) (sy), (fc) (sy) (p) (fc) (fc) (p) (fc) (p) coutinho s. (p) coviello d. (p) (fc) craig j. (op), (p) cransberg k. (fc) (p) (p) cristino s. (p) (fc) (p) cross j. (op) cruz mr (fc) (p) (fc), (p), (p) (sy) deanfield j. (fc) (p) decena-galvez a. (p) (fc) (p) (p) deguchtenaere a. (op) (p) (p) (sa), (p) (p) delucchi a. (p) (p) (p) (p) (p) (p) (fc), (p) (fc) dinda a. (p) (p) (p) (p) dittrich k. (fc) (fc) (p), (p) dötsch j. (fc), (p), (p) dragon-durey ma (p) (fc) (p) (fc) (p) (p) (p) (p) dursun i. (p) (p) (p) edefonti a. (p) (p) eke f. (fc), (p) (p) (fc), (fc), (p), (p) (fc) (p) (p) (p) evim m. (p) f faerch m. (p) fallahzadeh mh. (p) (p) (sy) feig d. (p) (p) (p) fella a. (op) feneberg r. (op) (op) (p) filler g. (fc) (p) (op) fischbach m. (op) sy) fitoz s. (p) (fc) (p) (p) fujita h. (op) (p) fujita t. (p) (p) fukuhara d. (p) (op) (p) (p) (op) (op) garnier a. (p) (p) (op) (sy) geary-joo c (fc) (fc) (op) (sy) (fc) (p) gross ml. (fc) (p) (p) (fc) (fc) (p) (p) guo w. (op) (p) (op) (p) haberal m. (p) (fc) (op), (fc) (fc), (p) (fc) (fc), (p) (fc) (p) (mr) (p) (p) (op) (op) hernández am. (p) (op) (op) (fc) (op), (fc) (p) hou jr. (p) (p) (op) (p) (fc) (fc) (p), (p) iharada a (op) (op) (p) (fc), (fc) (p) (p) (sy) (p) kathiravelu a. (fc) (op) (op) (op), (fc) (p) (p) (p) (p) (p) (p) (mr) (p) (op) (p) kondo y. (fc) (p), (p) kosuljandic-vukic d. (p) (fc) kovalski y. (p) (op) (p) (p) (p) kru èic d. (p) krylova-olefirenko a. (p) (p) (p) (p) (sy) (fc) (p) (p) kurayama r. (op) (p) (fc) lalatta f. (op) (p) (sy), (p) (op) (p) lau yw (op) (op) (p) llanas b. (op), (fc), (p) llewellyn-edwards a. (fc) (fc) (p) (fc) luis-yanes m (p) (p) (sy) maeda a. (p) maekawa k. (p) (p) (p) (p) (p) (p) (p) mak r. (sy) (op) (op) (p) (fc), (fc) (fc) (p) (sy) (fc) (p) (p) (p) medynska a. (p) (p) mehls o. (fc) (p) (fc), (p) (op) (op) (op) (fc), (p) (p) (fc) (p) molnár-varga m. (p) (fc) (fc) (p) montini g. (fc) (p) (p) (op) (p) (p) morimoto t. (op) (p) (op) (p) morita t. (p) (p) mortazavi f. (p) (fc) moscaritolo e. (p) (p) mosig d. (p) (op) (fc) (p) moxey-mims m. (fc) (op) (p) mudun a. (p) (fc) mughal mz. (p) (p) müller t. (op) müller v. (fc), (sy) müller-esterl w. (p) müller-wiefel de. (fc) (sy), (fc) (op) fc) (op) (fc) (p) nghia h. (p) niaudet p. (mr) (p) (p) nuzzi f. (op), (op), (p) nwobi o. (p) (op) (op) (p) (op) (p) (sy) (p) ostalska-nowicka d. (p) (p) otukesh h. (p) (p) (p) (p) ozen a. (p) (sy), (p) (p) (p) paik kh. (p) (p) pan'czyk-tomaszewska m. (p) (p) (fc) paripovic d. (p), (p), (p) (fc) pasqualini t. (op) fc) pastori a. (p) pászka d. (op) (op) (p) pereira a. (op) (fc) (fc), (p) (p) fc) (op), (p) raes a. (op), (op), (fc) (fc) (p) rigden s. (fc) (fc) ring e. (p) rink n. (op) (op) ristoska-bojkovska n (fc), (p) roszkowska-blaim m. (p) (p) (p) ruffo gb. (p) ruhlmann a. (op) ruiter j. (op) rumeau r. (fc) rusai k. (fc) rusnak f. (p) rüther u. (p) rutjes n. (p) rybarova s. (p) rychlik i. (p) ryckewaert-dhalluin a (p) sabasiñska a. (p) (p) sabolic-avramovska v. (p) (p) (op) safouh h. (p) saha a. (p) sahin h. (p) (op) saint-cyr c. (p) saito a. (p) (fc) sakalli h. (p), (p), (p) sakalli ercoban h. (p) (sy) (p) salusky i. (fc) (op) (p), (p) sarkissian a. (p) (p) (fc) (p) (fc) (op) sayili a. (p) schäfer b. (p) (fc), (fc), (fc), (sy), (fc), (fc), (fc), (fc) (fc) schmidt-gayk h. (mr) schmidts m. (p) schmitt cp. (fc) (op) (p) (fc) schneider-maunoury s. (p) (p) (sy), (fc) (fc) (op) (p) seeherunvong w. (fc) (p) (op) (p) semama d (op) (p) (p) (p), (p) shin yh (p) (p) (fc) (p) (p), (p), (p) siwiñska a. (p) (fc) (op) (p) spasojevic b. (p), (p), (p) spasojevic-dimitrijeva b stanic m. (p), (p), (p) stankovic a. (p) (p) (mr) (fc) (op) (mr) (p) (p) (p) (p) (p) (p) szteblich a. (op) t (fc) (p) taha g. (p) (p) taheri derakhsh n. (p) (p) (p) (fc), (p), (p) tan ph (p) (p) (fc) (p) (op) (p) (p) (p) tizard e. (fc) (p) toenshoff b. (fc) (p) tönshoff b. (fc) (p) (op) (fc) (fc) (op) (op) (p) (op) (fc) urdaneta-carruyo e. (p), (p) urdaneta-contreras a (fc) (p) (p) valverde s. (p) (p) van den heuvel l. (fc) (p), (p) van't hoff w. (sy), (p) (p) (fc), (p) (sy) (sy) (fc), (fc) (p), (p), (p) waters a. (op) (fc), (fc), (fc) (mr) (op) (fc) (fc) (op) (fc), (p) (fc) wingen a. (op) (sy) (fc) (sy), (fc) (fc), (p) (fc) (sy) (p) (fc) (p) (p) (p) (op), (p) (fc) (p) yap hk. (fc) (p) yata n. (p) (op) (p) (p) yilmaz a. (p) (op) (op) (p) (p) (p) zhou jh (fc) (op), (fc), (sy) zingg-schenk a (p) (fc) zurowska a. (fc) (op) the il (- g/c) polymorphism is associated with initial peritoneal transport status in children commencing chronic pd acknowledge: this study was from iran university of medical science. atypical hemolytic uremic syndrome: an unsolved case of complement dysregulation (p) aim: we have shown that rats overexpressing il- gene developed a mcn with proteinuria, hypoalbuminemia and hypercholesterolemia. this study aimed to determine the role of il- on hypercholesterolemia in this model. methods: recombinant rat il- gene in a mammalian expression vector was transfected into quadriceps of wistar rats by in-vivo electroporation. serum il- , albumin, cholesterol, creatinine and urine albumin were measured serially. after sacrifice on day , hepatic gene expression of hmg-coa reductase (hmg-coar), acat , cholesterol- a-hydroxylase (ch ah), ldl-receptor (ldlr) and il- receptor subunits were determined by rt-pcr. results: compared to control rats (n= ), il- -transfected rats (n= ) showed significant albuminuria ( . ± . vs . ± . mg/day, p< . ), hypoalbuminemia and hypercholesterolemia ( . ± . vs . ± . mmol/l, p< . ) at day . serially, this rise in serum cholesterol preceded the increase in proteinuria and fall in serum albumin. serum cholesterol correlated significantly with il- levels (r= . , p< . ). in of the il- -transfected rats with serum cholesterol> . mmol/l, hepatic gene expression (mean±sem) was significantly upregulated compared to controls for hmg-coar ( . ± . vs . ± . , p= . ), acat ( . ± . vs . ± . , p= . ), ch ah ( . ± . vs . ± . , p= . ) ldlr ( . ± . vs . ± . , p= . ) and il- ra ( . ± . vs . ± . , p< . ). conclusion: the increased cholesterol synthesis in il- -induced mcn was associated with increased hepatic gene expression of hmg-coar and acat , which are important enzymes for cholesterol synthesis. associated increased hepatic gene expression of ch ah and ldlr involved in cholesterol metabolism could be a negative feedback response. e. bordador, f. anacleto philippine general hospital, pediatric nephrology, manila, philippines general objective: to formulate a clinical scoring system that will predict the presence of glomerular crescents in patients with severe nephritis. specific objectives: ( ) to describe the profile of children with acute nephrotic-nephritic syndrome ( ) to correlate clinical parameters with renal histopathology. methods: this is a retrospective study. twenty six charts from the philippine general hospital, admitted between january -march were retrieved. included in the study were children with acute nephritic -nephritic syndrome who underwent kidney biopsy. excluded were patients with small/contracted kidneys on renal ultrasound. statistical tool used were univariate analysis, pearson's product moment method and chi -square test. results: profile variables of the subjects were analyzed. afterwhich, each clinical parameter was tested using univariate analysis, if significantly correlated with the renal biopsy result using pearson's product moment method at critical value= . at p< . . out of parameters, only parameters were noted to be significant, these were serum creatinine, blood urea nitrogen and glomerular filtration rate. further analysis was made by separately treating male from female population using a chi-square test with critical value x ( ,. ) = . . the test identified another three clinical features among female which were significantly associated with renal biopsy results, these were blood pressure, anemia and hematuria. from these significant parameters associated with renal biopsy results, a clinical scoring system was then conceptualized in order to identify patients with high probability of crescents on renal biopsy. conclusion: cresent maybe use as an accurate screening tool to predict presence of glomerular crescent in patients with severe nephritis. heterogeneous effect of acei therapy in children with proteinuric nephropathies b. kranz, s. diepenbruck, u. vester, r. buescher, a. wingen, p. hoyer university of duisburg-essen, pediatric nephrology, essen, germany background: chronic proteinuric nephropathies are at high risk of developing progressive renal insufficiency. the renin-angiotensin-aldosteron-system blockade is a well documented strategy to reduce proteinuria in adult patients. the efficacy and risks of renal-protective therapy with angiotensin-converting-enzymeinhibitors (acei) in children with proteinuric kidney diseases is of concern. method: in this retrospective study the efficacy of acei as antiproteinuric therapy in children with chronic proteinuric nephropathies is evaluated. patients: sixty-three children (mean age . ± . years) have been treated with acei for a mean of . ± . years (range . ± . years) because of proteinuria (hus n= , alport syndrome n= , psh n= , others n= ). results: proteinuria in all patients declined from a median of . g/d to . g/d after years (p= . ). there was a drop out of patients because of end stage renal failure during the followup. one-third of patients showed a continuous reduction in proteinuria from . g/d to . g/d (median) within years while a second third had a transientimprovement followed by a reincreasing proteinuria later. patientswith hus showed a good response (decrease of proteinuria from . g/d to . g/d) in contrast to patients with alport syndrome who developed increased proteinuria ( . g/d to . g/d) despite of acei and patients with psh who had no change in proteinuria.interpretation: it has to be discussed whether biological compensation mechanisms may bypass the ace inhibition in single patients and whether the underlying illness may predict the efficacy of acei.aims: to determine the clinicolaboratory renal manifestations; glomerular, extra-glomerular histopathologic lesions; renal tubular dysfunction (rtd) frequency, and outcome of a short-term renal follow-up in nigerian children with systemic lupus erythematosus (sle). methods: a non-randomized prospective study of consecutive cases of childhood-onset sle with nephropathy. baseline/follow-up clinicolaboratory data were collected. each patient was followedup for months. results: seven of children studied were girls (f:m, . ). median age at diagnosis was . years. median diagnosis time interval ( . years) and median time of renal disease onset ( . year) were similar. hypertension, nephrotic syndrome, and acute renal failure occurred in . %, . % and . % of the patients, respectively. the glomerular lesions were non-proliferative lupus nephritis (ln) in . % (class ii ln); focal (class iii ln) and diffuse (class iv ln) proliferative ln (pln) in . % and . %, respectively. tubulointerstitial nephritis (tin, . %), and rtd ( . %) were common. arf (p= . ) and rtd (p= . ) were significantly associated with severe tin. complete renal remission rate at end-point was . %. relapse and renal survival rates were . % and . %, respectively. rtd was persistent in . %. conclusion: renal function disorders, diffuse pln, and extra-glomerular lesions were frequent. significant association of arf and rtd with severe tin in this series suggests the need for early renal tubular function (rtf) assessment in our sle patients. deranged rtf may be marker of severe tin in sle warranting early confirmatory renal biopsy and aggressive interventional treatment.we report two cases of children with crescentic glomerulonephritis (gn) associated to isolated c deposits. patient . a year old girl was admitted for macroscopic hematuria, nephrotic range proteinuria (proteinuria/creatininuria= mg/mmol) and renal failure (serum creatinine μmol/l). anca and other antibodies were negative. c , c and ch activity were normal but c nef was detected. the patient was treated by prednisolone and cyclophosphamide pulses followed by oral corticotherapy. renal function normalized, but proteinuria persisted (proteinuria/creatininuria= mg/mmol). a relapse occurred ten months later. corticotherapy and cyclophosphamide pulses were reinitiated and were successful, followed by mmf maintenance therapy. patient . a year old girl was admitted after viral infection for macroscopic hematuria and fever. proteinuria was of nephrotic range (proteinuria/creatininuria= mg/l). the search for autoimmunity was negative. c nef was detected but c , c and ch activity were normal. serum creatinine increased to μmol/l. after three pulses of prednisolone followed by oral prednisone, renal function normalized. histological examination of the two renal biopsies revealed endo-and extracapillary gn with numerous granulocytes in the capillary lumen. cellular crescents involved % of the glomeruli. immunofluorescence demonstrated isolated c deposits in the mesangium and along the glomerular basement membrane (humps). c q, igg, iga and igm staining were negative. background: the risk of end stage renal disease (esrd) is low in unilateral wilms tumor, although patients with wagr or associated genitourinary anomalies are at higher risk. esrd is attributed mostly to hyperfiltration in the remnant kidney. immune complex glomerulonephritis (icg) has not been previously reported in wilms tumor patients. objectives: to report cases of icg in unilateral wilms tumor. methods: retrospective chart review. patient # a boy with cryptorchidism, diagnosed with unilateral wilms tumor at y of age. patient # a girl with wagr and unilateral wilms tumor diagnosed at y of age. both had chemotherapy after tumor resection. results: patient # : within mo of tumor resection, a proteinuria of . g/ hrs and rising creatinine were noted. renal biopsy was consistent with icg. within mo of surgery the patient developed esrd requiring chronic hemodialysis. patient # : within y of tumor resection, the patient developed progressive, asymptomatic proteinuria up to g/ hrs. the renal biopsy revealed changes typical for icg. the patient was treated initially with enalapril and prednisone. due to no response, mycophenolate mofetil (mmf) was added and prednisone was weaned. after mo of therapy, her proteinuria improved to . g/ hrs. her serum creatinine continued to be normal at . mg/dl, with calculated gfr of ml/min/ . m . conclusions: this is the first report of icg in patients with unilateral wilms tumor with rapid progression to esrd in the first patient, but successful response to mmf in the second patient. despite low risk for progressive proteinuria in wilms tumor patients, it is prudent to monitor these patients for proteinuria and perform a renal biopsy if proteinuria is progressive. mmf therapy may be attempted to decrease proteinuria and to delay the onset of esrd.aim of the study: to present our first results of rhgh treatment mainly in children on hemodialysis. patients and methods: sixteen children, aged . - . years (mean age . ± . ) with height below - . standard deviation score (sds) for age or height velocity below - . sds for age, were selected to receive rhgh therapy at our nephrology and hemodialysis department. most of them were on hemodialysis ( children) with mean spent time . ± . years ( - years) before an initiation of rhgh therapy. one half of patients were prepubertal ( children) and second half were in early puberty (testicular volume between and ml for boys and breast development b or b in girls). all received - iu/ml per week by daily subcutaneous injection for months to years. the year before rhgh therapy served as a control period. results: during the first year of treatment, mean height velocity in hemodialysis patients increased from . cm/year to . cm/year (p< . ) and in the second year was . cm/year (p= . ). the mean height sds in hemodialysis children did not improved significantly during the first year of rhgh treatment (from - . sds to - . sds, p= . ). neither weight, nor the body mass index varied compared with the pretreatment period. no change was observed in glucose, total proteins, albumins, cholesterol and triglycerides levels. the mean increment in bone age was . years. pubertal status had no influence on response to rhgh. conclusions: therapy with rhgh improved height velocity in children with esrd. no significant side effects were observed in children during the . treatment years. two patients developed secondary hyperparathyroidism but the relationship with rhgh remains uncertain. in our treatment group rhgh therapy was safe. a. waters , a. trautmann , p. zipfel , e. harvey , ch. licht hospital for sick children, department of pediatric nephrology, toronto, canada university children's hospital, department of pediatric nephrology, heidelberg, germany atypical hemolytic uremic syndrome (ahus) is characterized by the absence of a diarrheal prodrome, the tendency to relapse and a poor outcome. functional and quantitative deficiency of complement regulatory proteins or inhibiting autoantibodies result in uncontrolled complement activation, which eventually causes ahus. -we report a case of ahus with complement dysregulation associated with a progressive refractory response to plasma infusions. factor h and factor h-related proteins (fhr) were quantified by elisa and were further analyzed by western blot. complement activation was determined by measuring c . serial hgb (g/dl), platelet, creatinine (mg/dl), ldh (u/l) were measured. initial presentation was at months of age with thrombocytopenia, hemolytic anemia and increased creatinine. ahus was suspected as e coli infection was ruled out. disease remission followed several plasma exchanges. monthly plasma infusion maintained remission. therapy intervals exceeding month promoted relapses. nine years later, the relapse interval decreased and over the subsequent years, thrombocytopenia persisted as plasma infusion requirements increased. a concomitant decline in renal function (creatinine . mg/dl) occurred with the development of persistent proteinuria and hypertension. at years of age, she deteriorated acutely with hypocomplementemia and thrombopenia. quantitative factor h was normal. autoantibodies to platelets and factor h were negative. intravenous immunoglobulin combined with oral steroids resulted in normalization of platelet count. complement dysregulation is associated with ahus. hereditary defects can be treated with factor replacement therapy. refractory responses may subsequently arise due to the development of autoantibodies against complement regulatory proteins. complement dysregulation requires further analysis in our patient. objectives: angiopoietin-like protein (angptl ) is involved in lipid metabolism and angiogenesis. the present study was to examine angptl expression in human kidneys with proteiuria, in adramycin rats (adr), and in puromycin induced podocyte damage. methods: immunohistochemistry was performed on kidney biopsies from children with mcd, mn, fsgs, tbmn. in adr, angptl expression was determined by quantitative real-time pcr in glomeruli and tubuli dissected from frozen section of kidneys with laser microdissection system. in mpc , a conditionally immortalized mouse podocyte cell line in vitro, angptl , perlecan and agrin werer detected through real-time pcr with the induction of puromycin. detachment assay was performed in podocytes tranfected by angptl -pcdna . . results: in human kidneys, co-labeling showed angptl expressed in the cytosol of wt positive cells. quantitative computerized analysis showed that angptl in glomeruli in mcd and mn were significantly higher than that of tbmn, fsgs respectively (p< . ). in adr, angptl in glomeruli increased significantly at st or th day (p< . ) after adriamycin injection compared with control. and the expression of angptl in glomeruli was correlated with h urinary protein (r= . , p< . ). in mpc both protein and mrna expression of angptl on podocytes were up-regulated with the induction of puromycin. in podocytes transfected by angptl -pcdna . the expression of perlecan or agrin increased significantly compared with control (p< . ). the attachment ratio was shown . %± . % hs after puromycin treatment on podocytes transfected by angptl compared with . %± . % on normal podocytes, and . %± . % on untransfected podocytes. conclusions: angptl is predominantly expressed in podocytes which could be involved in podocyte damage and the development of proteiuria. purpose: we present cases of a previously undescribed pattern of membranoproliferative glomerulonephritis, in children with neuroblastoma on chemotherapy. the pattern of injury shows unusual focal capillary loop proteinaceous deposits possibly related to toxic chemotherapeutic drugs. the resultant hypertension and renal impairment made bone marrow transplant a challenging prospect. method: case series results: case : this boy with stage neuroblastoma, developed severe renal impairment and hypertension during treatment. thus there were difficulties in administration of chemotherapy and he required early surgery. at tumor resection a nephrectomy was necessary. he received an autologous stem cell transplant. he became unwell at transplant and required haemofiltration. he made a good renal recovery and did not relapse. case : he was diagnosed at months with stage s neuroblastoma. he completed treatment but later relapsed. during treatment his gfr reduced and he developed severe hypertension. this lead to restrictions in chemotherapy. renal biopsy was carried out at tumor resection. at bone marrow transplant he was very unwell and required haemofiltration. he has chronic hypertension and low gfr. light microscopy findings in both -global diffuse membranoproliferative pattern of injury -large numbers of proteinaceous resorption droplets -features of a protein deposition disease electron microscopy findings common to both -large number of differently sized protein droplets in the endothelial cells -no obvious immunecomplexes/deposits -protein deposition disease with a membranoproiferative pattern of injury conclusion: both cases showed deposits in the kidneys which may be tumor protein in origin and the resultant glomerulonephritis, hypertension and renal impairment lead to challenges in transplant. the long term consequences are yet to be revealed. methods: establish the cultured glomerular mesangial cells of rat in vitro, ~ generations of cells were used in the experiment after identification. the experiment included five groups: ctrl, lps, high, middle and low dose fos groups. gmc proliferation were detected by mtt. the changes of ln, fn and col protein secretion were detected by the elisa. the changes of lnbeta mrna expression were detected by semi-quantitative real-time pcr. results: ( ) fos can inhibit the effect of proliferation induced by lps. ( ) mesangial cells can secrete some ecm protein in normal culturing medium, ecm protein secreted by mesangial cells was significantly higher in lps group than that in ctrl group (p< . ), while ecm protein was significantly lower in all fos groups than that in lps group (p< . ). ( ) lnbeta mrna expression was significantly higher in lps group than that in ctrl group, while that in fos group was significantly lower than in lps group. conclusions: lps can induce the increase of secretion of the ecm, including ln, fn, col fos can inhibit the secrection of ecm in gmc as dose-dependent manner at the mrna and protein levels. the conclusion supplies the theoretical evidence for the renal protection of fos. h. hong, w. na, y. li, w. qiang guangzhou first municipal people's hospital, department of pediatrics, guangzhou, people's republic of china objective: to observe the effects of fosinopril (fos), the new generation angiotensin-converting enzyme inhibitor (acei), on protein and mrna expression of tgf-β of rat glomerular mesangial cell (gmc) induced by lps; to demonstrate the preventive mechanism against glomerular sclerosis by applying fos. methods: culture rat gmc in classic way. the cultured cell were divided into groups, namely ( ) control group, ( ) lps group, ( ) lps+fos group. detect tgf-β concentration in gmc supernatant fluid by elisa; estimate tgf-β mrna expression by semiquantitative real-time rt pcr. results: lps group is obviously higher than control groups in tgf-β secretion and mrna expression, while lps+fos group drops distinctively in tgf-β secretion and mrna expression compared with lps group. conclusions: fos has obvious inhibited on tgf-β expression of rat gmc both at protein level and mrna level, which reveals that it might be an important mechanism by fos on restraining the development of glomerulosclerosis. r. kahn , n. akbari , j. wieslander , w. müller-esterl , a. christensson , k. westman , t. hellmark , d. karpman lund university, pediatrics, lund, sweden wieslab ab, lund, sweden institute of biochemistry ii, frankfurt, germany lund university, nephrology, lund, sweden vasculitis is an inflammation with neutrophil influx in and around blood vessels. patients may have elevated plasma levels of neutrophil-derived proteinase and anti-neutrophil cytoplasmic antibodies (anca) directed to proteinase , suggested to be involved in the pathogenesis of disease. we have previously shown that the kallikrein-kinin system (kks) is activated in vasculitis. in vivo the kks is activated on endothelial cells and neutrophils when high-molecular-weight kininogen (hk) is cleaved by kallikrein thus liberating bradykinin. bradykinin is a potent mediator of inflammation. in the present study we investigated if neutrophil-derived proteases, and proteinase in particular, could induce activation of the kks and bradykinin release. purified neutrophils from ten vasculitis patients ( adults, children) and thirteen controls were treated with triton-x to induce lysis. proteinase was immunoadsorbed from the neutrophil extracts. bradykinin and proteinase levels were measured by elisa. hk proteolysis was detected by immunoblotting. proteinase incubated with purified hk induced physiological breakdown of hk and bradykinin release. this was inhibited by preincubation of proteinase with anti-proteinase . triton-x treated neutrophil extracts from both patients and controls induced hk proteolysis and bradykinin release whereas the neutrophil extracts from which proteinase had been immunoadsorbed did not. levels of proteinase in the neutrophil extracts from patients and controls did not differ. these findings suggest that neutrophil derived proteinase can proteolyse hk in a physiological manner thus liberating bradykinin, thereby initiating kallikrein-independent activation of the kks. introduction: this is a prospective study to evaluate the safety and efficacy of tacrolimus in consecutive children with steroid-resistant nephrotic syndrome (srns). methods: all of them were subjected to kidney biopsy. tacrolimus was given in dose of . - . mg/kg/day in two divided doses to attain trought levels of . - . ng/l. these patients were followed-up every weekly initially for the first month, followed by monthly visits. urine spot protein creatinine estimation was done at each visit. besides blood glucose, serum creatinine, urea, electrolytes, albumin, and complete blood count were done once a month. results: the mean age of onset was . ± . yrs. of the children, had mcd, had fsgs and another had dmh on histopathology. tacolimus had to be withdrawn in children: of the rest children who received adequate therapy, complete remission was seen in ( %) children, ( %) attained partial remission and was non responsive. the mean time to achieve remission was . + . days and the mean dose of tac was . + . mg/kg. the mean urine spot protein/creatinine ratios were significantly lower ( . ± . vs . ± , p= . ) and mean serum albumin significantly greater ( . ± . vs . ± . , p= . ) as compared to those prior to tac. of the children who attained complete remission, patients are off steroids and tac and in sustained remission, while the rest are still on tac therapy. conclusions: this is the largest study so far on the safety and efficacy of tacrolimus therapy in children with srns. we conclude that tacrolimus is a useful therapeutic alternative in children with srns who are unresponsive to cyclophosphamide and cyclosporine. objectives: to describe hiv infected paediatric patients from our centre with pathology proven renal disease. methods: retrospective review of biopsy data base and case notes of patients with hiv referred with renal problems. results: patients were identified who had biopsy confirmed renal disease. the mean age of the patients was , yrs (range: months to years). twelve of the patients were african and two were of mixed race. renal pathology was divided into three groups: ) hiv associated nephropathy (hivan): five patients. ) mesangioproliferative nephropathy: patients ) other: acute pyelonephritis in , mesangial proliferation plus interstitial nephritis in , renal tuberculosis in , hiv immune complex disease (hivick) in one. conclusion: there is a high degree of variability of renal pathology in children with hiv and renal disease which upholds the need accurate diagnosis when confronted with these patients. background: acute poststreptococcal glomerulonephritis (apsgn) is the most common glomerular disease of children in our country. it has not been studied well in this region yet. here, we report our experience with psgn in a tertiary referral center during a five-year period. method: hospital records of all children who had been admitted from mar. to mar. to nemazee hospital with diagnosis of acute glomerulonephritis (agn) were reviewed. all demographic, clinical, paraclinical data and consumed medications were obtained. results: among children diagnosed as agn, ( %) had apsgn. other ( %) children had mpgn (n= ), mespgn (n= ), iga nephropathy (n= ), lupus nephritis (n= ), rpgn (n= ), and fsgs (n= ). mean age in children with apsgn was ± . (range, years. children ( %) developed apsgn following a sore throat or upper respiratory infection while ( %) cases developed after impetigo. ninety-five ( %) patients developed apsgn during the cold seasons of the year. periorbital edema was found in children ( . %), hypertension in ( %), gross hematuria in ( %), oliguria in ( %), generalized edema in ( %), azotemia (bun> ) in ( %), and nephrotic range proteinuria in ( . %). aso titer was high in ( %). low c was detected in ( %) and low c in ( %). dilutional anemia in ( . %), hyponatremia in ( %), and hyperkalemia in ( %) children among whom, required hemodialysis. regarding medications, patients had received only furosemide, cases took furosemide and nifidipine and for patients furosemide+nifidipine+another antihypertensive medication was prescribed. conclusion: acute psgn is the most common type of glomerulonephritis in this region. it follows sore throat in the majority of cases. it usually has an uneventful course. y. guo, zh. wang, x. liu west china second university hospital, sichuan university, department of pediatrics, chengdu, people's republic of china objective: we planned to explore the mechanism of glomerular basement membrane (gbm) damaged by rsv, through investigating the effects of lmwh on proteinuria and glomerular structure of rsv nephropathy. methods: sd rats were inoculated with pfu rsv and lmwh iu/kg. group a: rsv was given in the first days, and lmwh was given for the following days; group b: the mixture of rsv and lmwh was given in the first days, then lmwh was given for other days; group c: lmwh was continuously given throughout days and on the th - th day rsv was also given; group rsv and the control were respectively inoculated by rsv and dmem for days. renal histology, urinary protein excretion and serum parameters were observed. rsv rna in renal and pulmonary tissue was determined by in situ hybridization. results: there was no significant increase in urinary protein excretion of the lmwh-treated groups (a . ± . , b . ± . , c . ± . , mg/ h) compared with the control, but that of group rsv ( . ± . mg/ h) gradually increased after rsv inoculation. there was just a decrease in albumin ( . ± . g/l) and an increase in urea nitrogen ( . ± . μmol/l) of group rsv only. no change of the glomeruli detected in all lmwh-treated groups, while congestion and swelling in glomeruli of group rsv were observed significantly. glomerular microstructures of the lmwh-treated groups were almost normal, while extensive foot process effacement was observed in group rsv. rsv rna signal expressed weaker in the lmwh-treated groups than in group rsv. conclusion: rsv damages hs on gbm by electrostatic interaction. lmwh, as the analog of hs, charged with anion, competes with hs to combine with rsv to keep gbm from being destroyed, and then reduce the proteinuria. s. zhai, zh. wang west china second university hospital, sichuan university, department of pediatrics, chengdu, people's republic of china objective: the study is to explore the relevance among gags, hpa and ela in the steroid responsive nephrotic syndrome (srns). methods: ( ) children with srns were selected, including the active (n= ), the convalescent (n= ), the remissive (n= ). purpuric nephritis and healthy children were served as the control.( ) using the improved whiteman process detected the urinary gags. ela activities in plasma were determined by the amount of -nitroaniline released per unit time. immunocytochemistry and image analysis method were used to detect the expression of hpa of peripheral blood leukocyte. results: . gags of the active were the highest ( . ± . ) of all (p< . ). in contrast with the healthy, the active and the convalescent ( . ± . , p< . ) were significant difference, but the remissive no difference ( . ± . , p> . ). . all of ns showed higher level of hpa than the healthy (p< . ). comparing with the healthy, hpa was significant difference both in the active (iod . ± . , p< . ) and in the convalescent (iod . ± . , p< . ),but no difference in the remissive (iod . ± . , p> . ). by contrasting the active and the purpuric, their difference of hpa was no statistic significance (p> . ). . all of ns showed higher levers of ela than the healthy (p< . ). the healthy was strikingly different, contrasting with the active ( . ± . ) and the convalescent ( . ± . , p< . ), but no difference with the remissive ( . ± . , p> . ). .there was a significant correlation among the urinary protein, urinary gags, hpa and ela with simple linear regression analysis. conclusion: in the srns, proteinuria may be resulted by the spallation of hpa and ela for gags on gbm. ( ), combination withhaematuria, hypertension and/or renal insufficiency ( ), extrarenalsymptoms ( ), and familial mediterranean fever (fmf, ) . of the non-nephrotic patients, had extrarenal symptoms, were nephritic, had rapidly progressive glomerulonephritis (gn), renal failure and isolated urinary abnormalities. biopsy samples were evaluated by light microscopy in yerevan and zurich and by electron microscopy (except for amyloidosis) and immunohistochemistry (last ) in zurich. results: the most common histological lesion was renal amyloidosis ( %), followed by focal segmental glomerulosclerosis (fsgs, %), lupus nephritis ( %),systemic vasculitis/hus and minimal change disease (mc, . % each),mesangioproliferative gn/iga-nephropathy and membranous nephropathy(mn, % each), hereditary nephritis and membrano-proliferative gn typei ( % each), acute postinfectious gn (apgn, %), and dense deposit disease (ddd, %). the miscellaneous group includes,apart from interstitial nephritis ( %), unclassified or inadequate biopsies and specimens with mostly sclerosed glomeruli( %). the majority of patients with amyloidosis of fmf, fsgs/mc andmn were nephrotic, but % of patients with amyloidosis had non-nephrotic proteinuria. conclusions: several glomerular lesions were considerably more frequent than in other studies, particularly amyloidosis of fmf, mn and lupus nephritis, and to lesser extent membranoproliferative gn type and ddd. apgn is underrepresented because less than % of all patients (> ) had a biopsy. this study would not have been possible without international collaboration. henoch-schönlein purpura in children: an epidemiological study amongst dutch pediatricians on incidence and diagnostic criteria j. aalberse , , k. dolman , g. ramnath , r. rodrigues pereira , j-c. davin the aim of the present study on the incidence of henoch-schönlein purpura (hsp) in dutch children is not only to give some insight in the epidemiology of hsp in the netherlands but also to record the diagnostic criteria used by dutch pediatricians and to evaluate the accuracy of the latter using the presence of iga in the skin when biopsies are available. methods: in , all dutch pediatricians received monthly a card asking to mention new diagnosed hsp. pediatricians reporting one or more new patients with hsp were sent a list of questions concerning symptoms, blood and urine parameters, skin biopsy, diagnostic criteria and follow-up duration needed. results: two hundred and thirty-two patients from - of age ( . / ) were reported as having started hsp in . twenty nine % presented with renal symptoms. in accordance with the classification criteria of the american collegeof rheumatology (acr), eighty percent of pediatricians consider that isolated purpura (without hematological abnormalities) is sufficient to allow the diagnosis of hsp in children. from the skin biopsies performed, only ( %) presented with iga deposits. the follow-up duration considered as necessary was longer in case of renal symptoms at presentation. however, % of patients without renal symptoms would be followed for more than one year. conclusion: considering the recent ( ) eular/pres endorsed consensus criteria for the classification of childhood vasculitides, hsp should have been diagnosed in only of the patients of our study. the use of isolated non-thrombocytopenic purpura as only criterian to diagnose hsp in children might therefore lead to over diagnosis and unnecessary follow-up. noteworthy, the eular/pres criteria remain to be validated by a prospective study. the clinical presentation and response to therapy of childhood pan in johannesburg, south africa. method: retrospective record review of twelve children with a clinical diagnosis of pan treated between and . results: there was unequal number of males and females; average age at presentation was . ± . - . years, all were black children. eight children had more than acr criteria and sufficient clinical criteria (eular/pres consensus criteria). musculoskeletal and cardiac diseases were the commonest finding at presentation ( %), cutaneous, hypertension ( %), renal and gastrointestinal disease ( %), central nervous system disease ( %) and constitutional features ( %). two children had bone involvementwith periosteal reactions on plain x-ray. angiographic abnormalities were found in ( %), and ( %) had positive histology (skin/renal biopsies). tuberculosis was diagnosed in ( %), and had positive streptococcal titers. all patients were ana and hepatitis b negative, but there were five patients anca positive ( =p-anca, =c-anca, =both) ( %). the crp was elevated in / ( %), esr also in / , while % had both elevated. all patients received oral glucocorticoids, methylprednisolone ( - pulses- mg/m ), ivi cyclophosphamide ( - pulses, mg/m ), oral azathioprine, and required i. conclusions: children with pan in johannesburg present at a younger age with multi-organ disease. they require aggressive therapy with both glucocorticoids and cytotoxic therapy to ensure good outcomes. objective of the study: in order to evaluate the predictive factors of chronic kidney disease (ckd), the records of children with biopsy-proven mesangioproliferative nephrotic syndrome (mpns) admitted between and were retrospectively reviewed. methods: renal survival was analyzed by the kaplan-meier method and cox's regression model. two multivariate models were developed: ( ) from the onset of symptoms to the occurrence of ckd and ( ) from the time of renal biopsy to ckd. the following data were obtained at admission an dat the time of renal biopsy: gender, race, age at the onset ofnephrotic syndrome symptoms, age at admission, blood pressure, laboratory data (serum creatinine, serum urea, glomerular filtration rate, -hr urinary protein excretion, hematuria). patients were classified according to the response to the initial course of prednisone: ( ) a complete response was defined as a proteinuria < . g/day; ( ) a partial response was defined as urinary protein excretion of < g/day and > . g/day, and ( ) no response was defined as urinary protein excretion of > g/day. results: median follow-up time was years (iq range, . ± . ) and patients ( %) progressed to ckd. at baseline, after adjustment variables remained as independent predictors of ckd: creatinine > . mg/dl (rr= . , ci %= . ± . ) and non-response to steroids (rr= . , ci %= . ± . ). at the time of renal biopsy, after adjustment variables remained as independent predictors of ckd: age> . yr (rr= . , ci %= . ± . ) and creatinine > . mg/dl (rr= . , ci %= . ± . ). conclusion: serum renal function at baseline and initial response to prednisone were strong predictors of progression to ckd in our cohort of children with mesangioproliferative nephrotic syndrome. methods: an illustrative case history of a boy with sle and vhd in the absence of antiphospholipid antibodies was described. results: a -year-old boy with a history of sle for about five years was admitted to our hospital due to intermitted arthralgia, facial erythema, increased serum creatinine and oliguresis in october . he had been treated irregularly with prednisone and immunosuppressants. however,the disease was not always controlled well. during thishospitalization, the problems of hypertension, renal failure and anemia had been resolved and maintained, but the problem of intolerance to increased circulation volume was obvious, and three times echocardiography (ecc) showed moderate to severe mitral valve insufficiency. reviewed his history, suspected mitral leaflets vegetations was revealed by ecc four months after onset, he complained of chest pain, chest distress and breathholding several times without causes since eighteen months after onset and manifested with heart failure once, and ecc showed moderate to severe mitral valve regurgitation four months ago and twenty days ago respectively. ruling out the possibility of infective endocarditis, rheumatic heart disease and congenital heart diseases, vhd were considered secondary to sle. since the vhd becomes hemodynamically significant, valve surgery is needed. conclusions: vhd is generally asymptomatic and omitted easily, so routine cardiac evaluation of children with sle using electrocardiography, echocardiography and chest x-ray is recommended to early detect and treat cardiac abnormalities, which may lead to better survival. objective: we have previously reported that deleted in esophageal cancer (dec ), a potent tumour suppressor gene, was specifically upregulated in cd + cells of patients with relapse of mcns, using differential display rt-pcr. this study aimed to further characterize the potential function of dec in mcns. methods: semi-quantitative rt-pcr was used to verify the dec gene expression in children with relapse and remission of mcns. jurkat cells were transfected with plasmid containing dec gene or vector alone. gene expression was regulated by tet-on/off system. the effect of dec on jurkat cell proliferation was assessed by h-thymidine incorporation. cell cycle analysis was performed following propidium iodide staining. protein localization was determined by immunofluorescent staining with anti-dec antibody. results: we confirmed that dec gene expression was significantly increased in children with mcns in relapse ( . ± . ), as compared to remission ( . ± . , p< . ), normal controls ( . ± . , p< . ), patient controls with viral infections ( . ± . , p< . ) and nephrotic patients with other forms of glomerulonephritis ( . ± . , p< . ). in dec -transfected jurkat cells, cell proliferation was inhibited by . %, compared with vector control. cell cycle analysis indicated that dec arrested jurkat cell cycle progression by blocking its entry into the g /m phase. immunofluorescent staining with anti-dec antibody suggested that dec was a cytoplasmic protein, which was in agreement with psort. conclusion: dec gene expression was significantly upregulated in children with relapse of mcns. our results showed that dec acts as a t-cell proliferation suppressor and arrests cell cycle progression, and thus may be important in mediating the number or function of cd + cells during relapse of mcns. objective of study: the aim of the study was to assess plasma and urine concentrations of vascular endothelial growth factor (vegf) in nephrotic syndrome children (ns) depending on the total dose of glucocorticoids (gc) and the percentage of lymphocytes with glucocorticoid receptor expression (cd /gcr). methods: we examined children ( - years) , allocated to three groups: group i: children with the first ns onset, group ii: children with ns relapse, group c: healthy children. the ns patients were examined: a: before treatment and b: - weeks after prednisone administration at a dose of mg/m / h. plasma and urinary vegf levels were determined using the immunoenzymatic elisa method. flow cytometry was applied to assess cd /gcr expression. results: higher plasma and urinary vegf concentrations were noted in ns children before treatment (a), as compared to control subjects (c). following prednisone therapy (b), vegf level was reduced but it was still higher than in the control group. positive correlation was observed between vegf and protein in the urine (group i r= . , p< . , group ii r= . , p< . ) and a weak positive correlation between vegf in plasma and urine (group i r= . , p< . , group ii r= . , p< . ). cd /gcr expression was lower in group ii. in both groups, the correlation between plasma vegf and cd /gcr was positive (p< . ). conclusions: . plasma and urinary vegf levels increase during nephrotic syndrome onset. . glucocorticoid treatment reduces plasma and urinary vegf levels in ns children. objective of study: the aim of the work was to determine the expression of p-glycoprotein (p-gp) on peripherial lymphocytes (cd ) in children with steroid-dependent nephrotic syndrome (sdns) during cyclosporine a (cya) and ace-inhibitor (ace-i) treatment. methods: the study group (i) consisted of children with sdns aged - years, with a subsequent proteinuria relapse at the time of prednisone dose reduction. all ns children were examined three times: a: at proteinuria relapse, before cya treatment, b: after months, c: after months of cya administration. control group (ii) consisted of healthy children. cd /p-gp was measured using a flow cytometry assay. serum cya level was assessed by means of the immunofluorescence method. results: the expression of cd /p-gp in ns relapse, prior to cya+ace-i administration was much higher (median . %, range . - . %) when compared to healthy controls ( . % range . - . %). the absolute number of cd /p-gp in this examination was almost times higher when compare to healthy controls (p< . ). after months of cya+ace-i therapy the expression of cd /p-gp decreased dramatically and was similar to the controls. similar results were obtained after -months of treatment. when analysing the correlation between cd /p-gp and serum cya concentration a strong negative correlation was found in both examinations. the correlation was stronger in group ib (during the treatment with higher cya doses): (r=- . , p< . ) than in ic (after reduction the cya dose: (r=- . , p< . ) conclusions: the results of our studies indicate that cya in sdns inhibits the expression of p-gp. cya is an alternative therapy that may lead to optimization of glucocorticoid doses, thus reducing the risk that goes along with treatment. backround: hemolytic uremic syndrome is considered as the main cause of acute renal failure in childhood. it is characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. the epidemiology of the disease varies between counties. aim of the study: to describe demographic and epidemiologic aspects of hus, presented in a years period at the biggest children's hospital in the country. material-methods: patients aged days - years, mean age . years, ( boys, girls) were diagnosed with the syndrome. of them , . %, presented as d+ cases, with preceeded respiratory system symptoms and with no preceeded symptoms. treatment consisted of fresh frozen plasma (ffp) and whole blood transfusions in all cases. peritoneal dialysis was necessary in cases, haemodialysis in , while plasmapheresis was performed in cases. three children, all boys, suffered from recurrent type of syndrome. a girl required treatment with peritoneal dialysis for months followed by recovery of renal function. one-five years follow-up: one baby months old died, children received renal transplantation, in renal function remained mildly reduced (gfr - ml/min/ . m ) and suffered of hypertension. the rest recovered fully. summary: hus represents a rather minor public health problem with low mortality rate in greece. methods: three children with pauci-immune ln were retrospectively reviewed. results: the reported cases fulfilled the american rheumatism association criteria for sle. at admission, all had a -month history of glomerulopathy without intensive therapy. case presented with nephrotic proteinuria, macroscopic hematuria and progressively deterioration of renal function. laboratory data included a positive antineutrophil cytoplasmic antibodies (anca) on myeloperoxidase immunoassay. she was positive for lupus anticoagulant (la) but negative for anti-cardiolipin (acl) and anti-beta- glycoprotein i (β gpi) antibody. renal biopsy showed pauciimmune necrotizing and crescentic ln. case manifested with proteinuria, microhematuria and hypertension. anca was negative. case had nephrotic proteinuria, microhematuria and hypertension. the case had positive la, acl and anti-β gpi antibody. anca was negative. the biopsy findings of both case and case indicated pauci-immune mesangial proliferative ln. electronic microscopy revealed segmental and diffuse foot process effacement respectively. all three ln remitted following the treatment of steroid and immunosuppressive agents. conclusions: these atypical ln were considered to be associated with the distinct pathogenesis, rather than immune complex-mediated glomerular injuries. we supposed the possibility of ancaassociated necrotizing and crescentic glomerulonephritis for the first case. for the others, primary or secondary podocytes lesions might alter the glomerular permeability. the nephrotic syndrome is a clinical picture that characterized by proteinuria, hypoproteinemia, oedema and hyperlipidemia. although the primer nephrotic syndrome is the most common type of nephrosis in children, it may also develop during the course of infections including hepatitis b and c virus infections, whereas hepatitis a virus infection related nephrotic sendrome is very rare in children. in this paper, we present a case of who had suspected diagnosis hepatitis a virus infection related nephrotic syndrome. the boy at the age of years was referred to our hospital due to vomiting, abdominal distension and oliguria. physical examinations were revealed palpebral and tibial oedema, hepatomegaly, decreased breath sounds and mat percussion on right hemithorax. icter were not detected. laboratory examination were showed proteinuria, hyperlipidemia, hypoalbuminemia, high alt and ast levels with normal levels of bilirubin, alkaline phosphatase, complement c /c , urea and creatinine. in viral serologic examinations, hepatitis b and c related antibody were found negative, but anti-hav igm was found positive. chest radiography and ultrasonography examination were revealed right pleural effusion and abdominal ultrasonography examination was revealed ascites. based on these findings, we thought that the nephrotic syndrome could be developed due to anicteric hepatitis a virus infection in our patient. low dose steroid treatment was started (prednisolon mg/kg/day, month). edema was improved, negative urine protein was seen, and liver functions were not deteriorated during this therapy in our patient. hepatitis a virus may be cause of nephrotic syndrome by forming of immune-complexes. in conclusion, although hepatitis a virus infection is rare cause of nephrotic syndrome in children, it should be investigated as a seconder casuse. membranoproliferative glomerulonephritis (mpgn) is a rare, chronic glomerulonephritis, and its prognostic factors and outcome are not known very well in childhood. in this retrospective study, we reviewed the clinical, laboratory and histopathological features of children with primary mpgn. thirty-three children ( boys, girls) presented at a mean age of . years (range - years). they were followed for a median of months (range - months). the clinical presentation in children was nephritic-nephrotic syndrome in children ( . %), nephritic syndrome in ( . %) and nephrotic syndrome in ( . %). nine patients had renal failure at presentation. at the end of study, patients ( . %) had complete remission and patients had abnormal findings ( proteinuria, microscopic hematuria, hypertension, esrd). all of patients were treated with steroid. eight patients were given another immunosuppressant drug (cyclophosphamide , azathioprine ) in addition to steroid therapy. the interval between appearance of symptoms and admission, durations of microscopic hematuria and proteinuria, and systolic blood pressure at presentation were higher in children with abnormal findings when compared with children with complete remission. there were no significant differences in clinical presentation type or histopathological features between children with abnormal findings and children with complete remission. our results showed that delayed detection and treatment, uncontrolled hypertension and unresponsiveness to steroid in early period were poor prognosis predictors. we did not determine any correlation between histopathological findings and outcome. we need further investigations including larger patient population. partial lipodystrophy (pl) is a rare condition of unknown etiology, with childhood onset. it is characterized by progressive loss of subcutaneous fat of face, neck, trunk and upper extremities together with c hypocomplementemia. usually, patients do not have clinically evident renal disease or abnormalities until they have had the disease for or more years. but, the case we reported here, firstly presented with membranoproliferative glomerulonephritis (mpgn), and during follow-up pl was observed. a six years old girl was presented with sore throat, vomiting and loss of appetite for the last fifteen days. her development was normal and the child was asymptomatic till years of age. the parents were relatives of the third degree. there was no history of similar cases in the family. the physical examination of the patient was normal. urinalysis revealed hematuria and pyuria. proteinuria was not present. renal function tests were normal. laboratory examination revealed low serum complement c but normal serum c . the lipid profile was also normal. patient was followed with the diagnosis of poststreptococcic glomerulonephritis. because of persistent low complement c and nephrotic range proteinuria renal biopsy was performed at the rd month of follow-up. renal histology revealed mpgn consistent with type . c nephritic factor was negative. at the same time it was observed that the face took on a cadaverous look with prominent malar bones, chin and zygoma because of the loss of buccal fat. according to these findings, partial form of lipodistrophy, which is frequently associated with mpgn, was considered in the patient. during two years of follow-up she had two recurrences of nephrotic range proteinuria and she is now in remission with prednisolone therapy. as far as we know this is the first example of pl which is developed during follow-up of mpgn. central nervous system abnormalities in children with acute post-streptococcal glomerulonephritis (apsgn) are rare and are considered to be secondary to acute severe hypertension, electrolyte imbalances and uraemia. cerebral vasculitis associated with acute post-streptococcal glomerulonephritis has been rarely reported in pediatric literature. a -year-old girl with a severe headache, vomiting, edema and macroscopic heamaturia is presented. she had history of upper respiratory infection before two weeks. so, the patient was diagnosed as apsgn. on admission, she was normotensive and biocemically well balanced. two hour later, she experienced a grand mal seizure. mri examination of brain showed not only multiple areas of increased density in white and gray matter, and cerebellum but also subarachnoid bleeding, consistent with vasculitis. during follow-up, abducens nerve palsy was detected. histopathological features on renal biopsy specimen, an elevated antistreptolysin level and fallen c complement level were compatible with apsgn. all clinical and laboratory abnormalities improved with steroid therapy (pulse and oral methylprednisolon). in conclusion, children with apsgn may present central nervous system abnormalities without hypertension, uraemia and electrolyte disturbances. results: hsp was diagnosed in patients, median age years old. all had the skin manifestations, . % abdominal pain and % arthritis. patients developed hsp nephritis ( . %), mean presentation time was . months after phs diagnosis. renal biopsy was performed in patients, and the most common histopathological finding was hsp nephritis grade iii a. age of onset older than years was statistically significant for nephritis development (chi square < . ). chronic renal insufficiency incidence was . %. conclusions: the main complication of hsp is nephritis. follow-up should include evaluation by a pediatric nephrologist. age of onset older than years is an important risk factor for hsp nephritis. objectives of study: acquired abnormalities of coagulation and fibrinolysis in nephrotic syndrome have been implicated in the pathogenesis of deep vein and arterial thrombosis. resistance to activated protein c due to amutation in the gene for factor v, the commonest inherited risk factor for venous thrombosis, could contribute to risk of both arterial and deep vein in patients with nephrotic syndrome. we report an arterial thrombosis in a young girl with idiopathic membranousglomerulonephritis (mgn) and factor v leiden mutation. case report: a year-old girl was admitted to our hospital with swelling of both legs and cyanosis of her toes. her mother had history of abortion in the second trimester of gestation, and parents were second-degree relatives. physical examination showed peripheral edema in both extremities and peripheral cyanosis in toes. laboratory study showed the nephrotic range proteinuria. serum albumin was . g/dl, and cholesterol was mg/dl. creatinine, electrolytes, prothrombin/partial-thromboplastin times, c , c , fibrinogen, protein s, c, antithrombin iii and homosistein levels were within normal limits. ana, anti-dsdna, p-anca, and c-anca, antiphospholipid igg/igm, anticardiolipin igg/igm were all negative. genetic study showed the heterozygote mutation of factor v leiden (fv/g a). in arteriography, there was complete occlusion on the posterior tibiaartery of left leg, occlusion of mid portion of right femoral artery and the posterior tibia artery of right leg. renal biopsy findings werefelt to be compatible with mgn. conclusions: we postulate that patients with concurrent nephrotic syndrome and factor v leiden mutation may have an increased risk of thrombosis. screening for factor v leiden mutation may be indicated in patients with idiopathic nephrotic syndrome. introduction: hus (d+) is the nd cause of chronic renal failure (crf) in children in argentina. proteinuria is the main predictor of progression to crf. patients with renal failure, when treated with restricted proteinin take show slower progression to end-stage of rcf. proteinuria appeared in patients with hus sequelae subject to an overload of protein intake. objective: to evaluate the effect of a controlled protein intake on proteinuria in patients with renal disease due to hus and normal renal function (> ml/min/ . m ). patients and methods: within a multicenter, randomized, double blind, controlled trial, carried out inorder to study the effect of iace on the development of renal disease*, proteinuria before and after a controlled diet was measured in patients with proteinuria due to hus and normal renal function. protein intake was indicated according to rda for age. protein intake was estimated with a questionnaire on former hours, and with hrs urea excretion. proteinuria was measured in hours urine collection at the beginning of the study and at , and days after onset of the study. results: median age at onset was . months (r: . - . ); mean of length of follow-up after hus onset was . months (r: . - ). in sixty five ( , %) patients, proteinuria reduced to normal values; in the remaining ( , %) there was no change. median of initial and final proteinuria in the children whose proteinuria became normalised, was . mg/k/day (ds . ) and . (ds . ) respectively < . . conclusion: controlled protein diet (rda) normalizes proteinuria in patients with significant proteinuria secondary to hus and normal renalfunction. * a trial financed by roemmers laboratory, argentina. differential diagnosis of hematuria is the significant task of any nephrologist while most common reasons for hematuria demand histopathological diagnosis. iga-nephropathy is the progressive glomerular disease which is known to be a common reason for hematuria. the diagnosis ofiganephropathy is often missed because of variability of clinical presentations, long-term asymptomatic course and therefore waiting tactics in prescribing renal biopsy. the aim of the study was to evaluate the incidence of iga-nephropathy and to define its characteristic clinical and morphological features in children in belarus. we present results of immunohistochemical staining for iga mesangial deposition of kidney biopsy preparations. the mean age of the patients enrolled in the study was , ± , years. at the moment of biopsy patients clinically presented isolated hematuria ( %), hematuria with proteinuria ( %), nephrotic syndrom ( %), nephrotic syndrom with hematuria and hypertension ( %), isolated proteinuria ( %) and others in less than % each. iga mesangial deposition was detected using immuno histochemical staining with polyclonal rabbit anti-human iga. we found diffuse mesangial deposition of iga in patients ( % of all). two of them had nonnephrotic isolated proteinuria, one nephrotic syndrom. vast majority of patients were hematuric (either isolated or combined with proteinuria). iga nephropathy incidence among hematuric patients was %. in histopathological examination we found mild segmental mesangial hypercellularity in patients, mild to moderate global and segmental mesangial proliferation in (in two of this patients we also found cellular and fibrous crescents in less than % glomeruli). one patient had focal-segmental glomerulosclerosis secondary to diffuse mesangial proliferative glomerulonephritis and clinically presented heavy proteinuria. we analyzed nphs mutations in chilean pediatric patients with srns due to fsgs, diffuse mesangial sclerosis (dms) and minimal change disease (mcd). nphs mutation analysis was performed in patients (sporadic cases n= , familial cases n= ). nphs exons and were amplified by pcr and subjected to automatic sequencing or enzyme restriction analysis using clai (c. g>a) and hin i (c. c>t) respectively. patients median age at disease onset was months (range , % of which were male. histological diagnosis were fsgs (n= ), dms (n= ) and mcd (n= ). ten of patients ( . %) had mutations in nphs ( / fsgs, / dms, / mcd). eight of patients bearing mutations were sporadic cases. seven patients were compound heterozygous for r q and a v. patients with mutations were significantly older than those without mutations (median age versus months, p< . ). resistance to cyclosporin was observed in of cases with mutations and of cases without mutations (ns). we studied the frequency of r q and a v in healthy volunteers with similar ethnic background. only one control individual was heterozygous for r q. no a v mutation was detected. our study demonstrated that nphs mutations are a major cause of srns in chilean pediatric patients. since most of the srns patients bearing nphs mutations were cyclosporin resistant, it is advisable to perform nphs mutation screening before starting immunosuppressives. in this study we aimed to investigate the long-term prognosis of henoch-schönlein nephritis (hsn) in childhood. between and , patients with hsn were investigated retrospectively. there were males and females with a mean age of . years. they were graded according to the degree of renal involvement. grade : isolated microscopic hematuria (n: ); grade : hematuria and mild proteinuria (n: ); grade : acute nephritic syndrome (n: ); grade : nephrotic syndrome/hematuria (n: ); grade : acute nephritic and nephrotic syndrome (n: ). renal biopsy was performed on patients in grade and . twenty patients had extensive crescent formation (> %) on renal biopsy, and were given triple therapy [iv pulse methylprednisolone (mpz) mg/kg/d for days, followed by oral prednisolone (op), oral cyclophosphamide- mg/kg/day for - months and dipyridamole]. the other patients with < % crescent formation were given mpz followed by op and dipyridamole. the patients in grade and were given op and dipyridamole. grade and were not given any immunosupressive agent. during the follow-up period (mean ± . ; range - months), patients in grade , patients in grade , patients in grade , patients in grade and patients in grade showed complete remission ( %). of the patients with extensive fibrosis on renal biopsy, had persistent nephropathy ( %) and developed endstage renal failure ( %). the remaining patients showed near-complete recovery with minimal urinary abnormalities ( %). in conclusion, although initial presentation of renal involvement determines the prognosis in hsn, intensive treatment with triple therapy appears to be effective in severe renal disease especially if started before the development of fibrotic changes in crescents and tubulointerstitial tissue. aim: the bacterial infection in nephrotic syndrome (ns) is still the big problem and is one of the leading death causes in ho chi minh city, vietnam. we did this study with aims to overview this complication in children with ns. methods: our study population consisted of children with nephrotic syndrome during one-year prospective cohort. twenty seven out of patients who developed severe bacterial infection including pneumonia, peritonitis, urinary tract infection, bacteremia or cellulitis were recorded. results: from june to june , there were children with nephrotic syndrome recruited to the study. the severe bacterial infection stood at . % (n= ). in these children, children were first ns, children were relapsing ns. the percentages of pneumonia, urinary tract infection, cellular infection and peritonitis were . % (n= ), . % (n= ), % (n= ) and . % (n= ), respectively. no patients with bacteremia were recorded. in patients with uti, e.coli wasin patients, proteus in and enterococus in . ns children with uti were asymptomatic. ns children with peritonitis had typically clinical manifestations of fever, abdominal pain, tenderness. one out of four patients with peritonitis cultured streptococcus pneumoniae inperitoneal fluid. some factors associated with severe bacterial infection were increase in weight ( . vs . %, p= . ), very low serum albumin ( . vs g/l; p= . ), rise in serum a globulin level ( . % vs . %; p= . ) and hyperfibrinogenemia ( . vs . g/l; p= . ). conclusions: bacterial infection has still been a common problem in children with nsin ho chi minh vietnam. it is important to investigate and manage this complication early to reduce mortality rate. primary nephrotic syndrome (ns) is the most common glomerular disease in children which mainly responds to corticosteroids. however, > % of children experience a relapse with recurrent episodes. the aim was investigation of outcome in ns patients, retrospectively. clinical, histological data and treatment responses of children presenting with ns from to were reviewed. all patients were treated with steroid treatment firstly and classified as steroid sensitive ns (ssns) and steroid resistant ns (srns) according to clinical or laboratory responses. there were patients, male and female, had followed-up for . ± . months. age at onset ranged from - (median ) months. seven patients were admitted with hematuria and ns ( mpgn, mgn) that excluded from this study. patients were treated by only classical steroid treatment. thus, ( . %) patients were ssns and classical steroid therapy was successful in this group. of all ssns patients were evaluated with biopsy ( fsgs, dmp) because of frequently recurrent ns. in srns group ( patients) with one cytotoxic agent, complete and stable remission was induced in patients ( in fsgs, in mlh, in dmp) while patients ( in fsgs) who responded to more than one cytotoxic agents had partial remission with symptomatic relief. five children ( in fsgs) were refractory to all cytotoxic therapies. cyclophosphamide (cp) was used as the first cytotoxic agent in patients and induced complete remission in ( . %). the patients who relapsed following cp and patients who failed to respond were treated with further cytotoxic therapies such as cyclosporine a (cs) or mmf. in patients, cs was used as the first cytotoxic agent and induced remission in patients ( . %). steroid must be the initial drug in childhood ns. cp could be used successfully as an immunosuppressive agent in srns patients. aim: annexin v has a molecular weight of - kda and has been reported to possess anticoagulant activity, inhibition of phospholipase a , regulation of membrane transport, proliferation and signal transduction. it is reported that urinary annexin v concentration may be an indicator of apoptosis and acute renal injury related to the urinary protein level. the aim of this study is to define the role of urinary annexin v, serum annexin v concentrations as new prognostic tools and follow criteria in children with steroid sensitive and resistant ns. methods: annexin v concentrations were measured in serum and hour urine samples in steroid sensitive nephrotic syndrome (ns) patients in both relaps and remission periods (group and respectively) and in steroid-resistant ns (group ) and sex and age matched healthy controls (group ). total protein, albumin, cholesterol concentrations and hour urinary excretion of protein and creatinine were measured in all groups. results: in steroid resistant ns group (group ), median of urinary annexin v/creatinine ratio was significantly higher than all the other groups ( . ng/g creatinine (min-max: . - . ) vs . ng/g creatinine (min-max: . - . ) in group (p: . ); . ng/g creatinine (min-max: . - . ) in group (p: . ), and . ng/g creatinine (min-max: . - . ) in group (p: . )). serum annexin v concentration was significantly higher in group (median . ng/ml) than in group (median . ). no significant correlation was found between urinary protein excretion and urinary annexin v/creatinine ratio. conclusion: remarkably increased urinary annexin v/creatinine ratio could be used as a determinant factor in children with steroid resistant ns, and it may be a prognostic factor in these children. v. baudouin , f. bernaudin , a. garnier , t. kwon , m. peuchmaur , g. deschenes , c. loirat hôpital robert debré-aphp, service de néphrologie pédiatrique, paris, france chic, service de pédiatrie, créteil, france cgvhd is the most common late complication of hsct. clinical manifestations mimic lupus disease but renal involvement is unusual. a year-old boy underwent hsct from an hla-identical sibling donor for sickle cell disease. he received myeloablative therapy (cyclophosphamide, busulfan, antithymocyte globulin). prophylaxis of acute gvh consisted in prednisone and mmf until month . moderate skin and mucosa cgvh appeared at month so that prednisone and mmf were restarted. at month prednisone was stopped and mmf decreased to half dose. at year, while clinical features of cgvh intensified, fortuitous diagnosis of ns was done. glomerular filtration rate and blood pressure were normal. biopsy showed membranous glomerulonephritis and mesangial hypercellularity. immunofluorescence confirmed granular immune deposits of igg and c treatment consisted in prednisone ( . mg/kg/d for month, progressively tapered to . mg/kg/e.o.d at month ) and cyclosporine ( mg/kg/d, trough levels - ng/ml). proteinuria decreased to < . g/l in months. cyclosporine was progressively stopped between month and without relapse of proteinuria. ns associated with cgvhd had been reported in about patients ( patients < yr-old). retrospective studies estimate occurrence around % of patients with cgvhd. it was secondary to membranous glomerulonephritis in % of cases, minimal changes disease in %. strengthening of immunosuppression led to complete remission in % of patients with minimal changes disease and % of those with membranous glomerulonephritis ( % partial remission). usual treatment consisted in prednisone ( %) and cyclosporine ( %). this manifestation of cgvhd is probably underestimated and can occur at the same time or later than other clinical features. early detection of proteinuria in patients with cgvhd is recommended to adapt immunosuppressive treatment. objectives: to see if cyclosporine a (csa) is safe and effective in reducing proteinuria in children with the iga nephropathy (igan) or the henoch-schoenlein purpura nephritis (hspn). methods: the biopsy proven patients ( with igan, with hspn) who showed increased proteinuria (> +) for longer than months were included. the blood level of csa, serum chemistries, urine analysis and complete blood cell counts were carried out every other month along with the physical exams. results: csa was given at an amount of . . mg/kg/day for . . months in average. complete remission of proteinuria in ( . %) and partial remission in ( . %) were achieved by csa treatment. five ( . %) non-responders were discontinued for csa treatment in the middle of the trial. the ration of urine protein to creatinine was initially . . and reduced gradually with time to . . , . . , . . at , , months after csa treatment, respectively. twenty eight patients showed hypertrichosis, three experienced transient elevation of serum creatinine, and two complained difficulties in taking the medication due to severe nausea. for . months after completion of the csa treatment, patients redeveloped proteinuria and had to receive the nd csa trial. no clear difference was observed in the pharmacokinetic profiles of csa attributable to the non-response or recurrence. follow-up renal biopsies were carried out in patients after completion of the csa therapy and no csa toxicity was found. there was no alteration of linear growth pattern. conclusions: this study has a limitation of lacking the control group but the csa treatment is assumed to be very effective and a safe method to attain the remission of proteinuria in pediatric patients with the igan or hspn. j. madrigal , e. fernandez , p. noguera , p. carranza the aim of this retrospective study was : ) to correlate the histopathological diagnosis with steroid response,persistent hematuria, hypertension and or abnormal renal function tests (gfr) ) to evaluate the response of the patients with srns and sdns to the oral cytotoxic drugs , in a period of consecutive years. ) to correlate the response of this group of patients to the oral cytotoxic drugs with their histopathological diagnosis ) to observe the incidence of fsgs in costarrican children during a period of years. ) based on these observations, reevaluate the indications of the kidney biopsy in our patients . we reviewed all the clinical records of patients with the diagnosis of ns and in whom a kidney biopsy have been done. patients with incomplete data were excluded. two consecutive reviews were made: the first included all patients diagnosed between january and december (group a) and the second, between january and december (group b). a total of medical records were analyzed; patients were excluded, and the remaining were studied. results: all patients had been referred for edema or new onset nephrotic syndrome before treatment had been initiated. in our patients the steroid response was also the most important factor to predict the histological diagnosis and the response to the treatment with cytotoxics. the presence of hematuria and abnormal serum creatinine at the time of diagnosis were a predictive factor for the steroid response but not for the histological diagnosis. arterial hypertension achieved statistical significance only between mcns and fsgs but it was useful as a predictive factor for the hystological. in our group of patients with srns treated with cytotoxics, . % with mcns responded, versus . % of the patients with dmgn p< , . a. guersoni, v. mello, v. benini, s. laranjo children with srns are exposed to prolonged and high doses of steroid therapy and other immunosupressants that can lead to a variety of serious side effects. these include statural growth impairment, obesity, osteoporosis, cataract, hypertricosis and psychological disturbances.we carried out a prospective single-center study to evaluate the efficacy of mycophenolate in children with steroid-resistant disease, female and male, aged . ± . years. histological findings were: minimal change disease (mcd) in children, focal segmental glomerulosclerosis (fsgs) in and membranous nephropathy in one. all patients had been treated with at least one course of cyclophosphamide, metil-prednisolone in , while had also been treated with cyclosporine before mmf. the initial dose of mmf was mg/m per day, together with a minimal reduction dose of corticosteroids associated with angiotensin ii receptor blockers (arbs) and sinvastatin.three patients went into complete remission, into partial remission and showed no remission. partial remission was described as loss of edema and improvement in symptoms, despite persistence of significant but improved proteinuria, that was classified either as moderate or low proteinuria according to the level. side effects were: diarrhea (n= ), neutropenia (n= ), infectious disease (n= ). mmf is an important new therapeutic option when associated with angiotensin ii receptor blockers (arbs) and sinvastatin for srns with mcd or fsgs, providing improvement in edema and symptoms despite persistence of proteinuria, with no compromise of physical appearance or risk of nephrotoxicity. background: primary focal segmental glomerulosclerosis (fsgs) that is resistant to steroids and other immunosuppressive agents has a guarded long-term prognosis. patients who fail to respond to current treatment may benefit from therapies that inhibit renal fibrosis and retard progressive loss of kidney function. objective: the font study (novel therapies in resistant fsgs) is a phase i clinical trial designed to test the safety, tolerability, and pharmacokinetics (pk) of novel agents that reduce renal fibrosis in patients with resistant fsgs. methods: patients, age - yr and egfr > ml/min/ . m , with resistant fsgs who fail treatment in the nih supported trial evaluating cyclosporine vs. dexamethasone plus mycophenolate mofetil or who are screen failures due to prior exposure to these drugs are eligible. patients are assigned to receive rosiglitazone mg/m per day po or adalimumab mg/m every other wk sc. the treatment phase is wk and patients undergo an initial (wk ) and steady state (wk ) pk assessment. results: patients have been screened and have been randomized to each test therapy. patients have completed rosiglitazone therapy and have completed adalimumab. four serious adverse events have occurred in patients receiving rosiglitazone, none related to the study drug. fatigue ( %), gastrointestinal complaints ( %), and headache ( %) were the most common adverse events in patients given rosiglitazone. the outcomes in the adalimumab group have not been analyzed. conclusion: these preliminary results indicate the feasibility of performing phase i assessments of novel agents that can target renal fibrosis in patients with resistant fsgs. the findings will be used to design phase ii randomized clinical trials in this cohort of patients at high risk of progression to end stage renal disease. supported by grant niddk r . object: to study the effect of fty on glomerulosclerosis and expression of cell cycle regulatory proteins in subtotal nephrectomized rats. methods: rat were divided into sham-operation group, glomerulosclerosis model group and fty treated glomerulosclerosis group, rats in each groups. the rats in later two groups were subjected to / nephrectomy. after operation, the treat group was fed with fty for weeks. the expression of collagen, fibronectin, and cycline, p , p were determined by immunohistochemistry methods. results: after treatment with fty , up began to decrease from w after operation, significantly lower than in model group (p< . ). the model group showed higher level of scr from w, which was much higher than in control group (p< . ). in fty treated group, scr level were much lower than in model group. fty could obviously inhibit the expressionof col-and fn in glomeruli and attenuate the extent of glomerulosclerosis. moreover, fty could upregulate glomerular expression of p and downregulate glomerular expression of p and cycline. the expression levels of p and cycline were significantly lower in treatment group than in model group (p< . ), but still higher than in control group (p< . ). p expression in glomeruli was stronger in treatment group than in model group (p< . ), and lower than in normal group but without significant statistic difference. conclusion: fty can diminish urine protein excretion and prevent glomerulosclerosis in subtotal nephrectomized rats. this protective effect is presumed to be associated with its role in downregulation of cycline expression and upregulation of p expression in glomerular cells, and inhibition of extracellular matrix accumulation in glomeruli. the authors illustrate severe side effect of steroid therapy ulcerative gastroduodenitis-and rare complication (multiple cerebral thrombo-embolism) in the case of a year old girl with steroid resistent nephrosis. in childhood occurence of thrombosis in steroid sensitive nephrosis syndrome is . %, while it comes up to . % in steroid resistant cases. on admittance she presented the classic symptoms of nephrotic syndrome. one month after the initiation of steroid therapy haematemesis, melaena occurred, and after appropriate therapy was cured. due to the progression of the nephrotic syndrome, steroid shot and later immunesuppressive therapy was started. eight weeks after onset she became unconscious for a shortwhile and had a transient episode of right hemiparesis. at the same time ct and mri disclosed bilateral parieto occipital ischemic territorial vascluar lesions, with relative sparing of the cortical ribbbon. following icu observation her state rapidly improved and after a two week period she became free of symptoms. renal biopsy disclosed the pattern of minimal change nephrosis with diffuse mesangial hypercellularity and a slight amount of igm positivity. immunological evaluation-with the capacitiy to reveal systemic immunological diseases remained negative. having been put on an evidence based protocol the patient's present nephrological state was unremarkable, with proteinuria less then g/day. in the present work the authors discuss the factors predisposing to thrombo-embolism with special emphasis on the possible preventive measures and therapy. igg autoantibodies to c q (antic q) have been reported to play a pathogenic role in immunecomplex mediated diseases (sle, apsgn, membranoproliferative gn, etc). the occurrence of antic q in adult patients with sle has been shown to correlate with disease activity and some immunological parameters (hypocomplementemia, anti-dsdna) and may be useful in the early diagnosis of lupus nephritis (ln) or even as a predictor of renal flares. the presence of antic q in children with apsgn was associated with more severe disease manifestations and a lack of spontaneous recovery. associations between antic q, c and c complement levels and disease manifestations in children with gn were investigated and compared with healthy controls. antic q were measured by elisa and c and c by immunoturbidimetry, respectively. of patients with gn were positive for antic q compared to / healthy controls. antic q were associated with active ln and hypocomplementemia: / patients with sle were found to be antic q-positive. nine of these had active renal disease at the time of blood sampling compared to / being antic q-negative. / antic q-positive patients had low c level and / had low c level. in children with apsgn, / were positive for antic q. antic q positive patients had significantly higher proteinuria, more often hypertension and c -hypocomplementemia. all patients in which apsgn did not resolve spontaneously were antic q-positive. antic q were associated with active nephritis and hypocomplementemia in patients with sle. in children with apsgn antic q-positive patients have more severe disease and stronger c -hypocomplementemia then those being antic q-negative. m. zahrane , l. fawaz , l. nesseim cairo university hospital, pediatric nephrology, cairo, egypt cairo university hospital, pediatrics, cairo, egypt cairo university hospital, cell pathology, cairo, egypt objective of the study: growth hormone (gh) and insulin-like growth factors are essential for normal growth and development. chronic renal failure (crf) results in major changes in the circulating growth hormone/insulin-like growth factor (igf) system. our aim is to study clinical and laboratory parameters of growth and osteodystrophy including igf and igfbp as part of the somatotropic hormone axis in egyptian children suffering from crf on conservative therapy. methods: egyptian children ( boys and girls) with a mean age of . y ( . to . y) suffering from crf on conservative therapy and controls were included in the study. ht, wt and tsf were measured and followed up for a period of months. at the end of the follow-up period serum for igf and igfbp , renal function, electrolytes, ca, p and alkaline phosphatase and acid base balance were measured and an x-ray of the left hand and wrist was done to determine their bone age by tanner and whitehouse. results: our study shows that children suffering from crf in egypt on conservative therapy have growth retardation with a mean ht of . sds, a mean wt of - . sds. tsf mean was - . sds. on the average the patients had a delay of . y (± . ) in their bone age. their height was retarded more than their bone age with a height age/bone age of . (± . ). alkaline phosphatase as a markers of renal osteodystrophy is significantly correlated to the height, height age, bone age and to the ph. the mean igf sds (- . ± . ) did not differ from that of controls while the mean igfbp sds ( . ± . ) was significantly higher in patients with crf than in controls. height and weight were significantly correlated to igf but not igfbp . there is a significant correlation between igfbp level and the glomerular filtration rate. conclusions: the imbalance between normal insulin-like growth factor-i (igf-i) and markedly increased igfbp plasma levels plays a pathogenic role for growth retardation in children with chronic renal failure. the lower the gfr the higher the igfbp level. the latters inhibitory action may provide hope for improving growth in cases of crf by reducing the level of igfbp or displacing igf from it. s. sultana , h. rahman , m. hossain bangladesh medical college, pediatric department, dhaka, uttara, bangladesh bangabandu sheikh mujib medical university, pediatric nephrology, dhaka, bangladesh objective: to find out the impact of different etiology of chronic renal failure on growth in children. methods: this prospective study was carried out in the department of pediatrics, bangabandhu sheikh mujib medical university (bsmmu), dhaka, bangladesh, from october to october . fifty children of both sexes under years of age with clinical and biochemical evidence of chronic renal failure (crf) with creatinine clearance (ccr) of < ml/min/ . m were included in the study. on the basis of underlying causes of crf, the children were divided into congenital (n= ) and acquired (n= ) groups. all patient's height and weight were measured. radiographs of hands, digits, ankle and knee joints, lumbar spine & skull were obtained to evaluate the presence of renal osteodystophy (rod) and for assessment of bone age. serum intact parathormone (ipth) level was also assayed in all patients. growth parameters and presence of radiographic and biochemical features were evaluated in two groups. results: crf children due to congenital anomalies had stunting and wasting in ( . %) and ( . %) cases respectively and the difference between two groups of crf patients was highly significant (p< . ). alkaline phosphatase ( . ± . u/l) and ipth ( . ± . pg/ml) were also significantly higher than acquired group (p< . and p< . respectively). radiographic features of rod were present in ( %) cases in congenital group in comparison to ( %) in acquired group and the growth zone lesion was the commonest type of rod in congenital group ( . %). conclusion: all efforts should be made to diagnose the presence of crf as early as possible, especially in infants and in children with early onset crf who seem to lose growth potential. introduction: in patients with thalassemia major the most important cause of morbidity and mortality is organ failure due to iron deposits, desferioxamine toxicity and anemia. this study was designed to define renal abnormalities associated with thalassemia and to find early marker (markers) of renal dysfunction. patients & method: thlassemic children ( female and male) with mean age of . ± . yr. were studied. all of them were received desforioxamine. age and sex matched healthy children were involved in the study. blood and timed urine sample were obtained for hematologic and biochemical tests. the results were compared between case and control group. results: mean value of bun, serum creatinine, creatinine clearance, serum electrolytes, urine osmolality, fractional excretion of sodium and potassium were not statistically different between two groups. level of urinary nag (n-acetyle-beta-d-glycosaminidase) was significantly higher in patients than in controls (p: . ). there was a positive relation between urinary nag and duration of disease (p: . ). the was no statistically significant relation between urinary nag and serum ferritin. tubular function was not altered by hypertransfusion. conclusion: proximal tubular dysfunction is found in thalassemic patients. measuring urinary nag can guide the physician to find the early tubular abnormality in patients without frank renal dysfunction. severity of the abnormalities is correlated with the duration of disease. the present study aimed to investigate the effects of isolated ma and ma associated with mild renal function impairment on fracture healing in rats. ma was induced by chronic ingestion of % ammonium chloride solution as the unique source of liquid and renal dysfunction was produced by unilateral nephrectomy. thirty male holtzman rats ( - g) were divided into six groups: control group (c,n= ) non-operated rats receiving tap water, acidotic group (ac,n= ) non-operated rats ingesting % ammonium chloride; sham water (s,n= ) sham-operated animals receiving tap water; sham acidotic (sac,n= ) sham-operated rats ingesting % ammonium chloride; nephrectomy water (n,n= ) nephrectomized rats ingesting tap water; and nephrectomy acidotic (nac,n= ) nephrectomized rats ingesting % ammonium chloride. after one week, blood samples were obtained to measure ph and gases, and a fracture of the right tibia was manually produced. four weeks later, fracture healing was evaluated by radiological and histological parameters. blood ph and gases, serum electrolytes and creatinine were also determined. data were compared by anova followed by newman keuls or fisher's exact test. fracture healing in nac, ac, sac animals was significantly altered as compared to c group. there was an additive effect of metabolic acidosis and unilateral nephrectomy in fracture healing process as shown by the comparison of sac and ac rats using radiological and histomorphometrical parameters. there was no difference between electrolytes and creatinine levels in all groups at the end of the experiment. this study showed a higher frequency of delayed fracture healing and nonunion in the presence of ma, which is worsened by unilateral nephrectomy. our data indicated an important interaction between bone and kidney in acid base homeostasis. introduction: dent disease, an x-linked recessive tubulopathy, is historically characterized by lowmolecular weight proteinuria, hypercalciuria, nephrocalcinosis/lithiasis and slowly progressive renal failure. most cases are caused by mutations in the clcn gene (dent disease , omim # ), some patients with dent like phenotype have defects in the lowe syndrome gene ocrl (dent disease , omim # ). patients: male patients from families with urinary findings resembling dent disease are reported. in patients, mutations in the clcn gene were found, in patients ocrl mutations. all children have increased values of urinary alpha- -microglobuline, but also unselective glomerular proteinuria. / have mild hypercalciuria, / demonstrate mild renal insufficiency. amost all patients have increased echogenicity of renal parenchyma, but mild medullary hyperechogenicity is found only in of patients. metabolic acidosis or renal phosphate wasting is not found. interestingly, of children have increased values of creatinine kinase of unknown origin, clinically asymptomatic and independant of clcn or ocrl mutations. conclusion: the phenotype and genotype of dent disease is very heterogeneous. diagnostic criteria of dent disease and of lowe syndrome should be discussed. e. sahpazova, d. kuzmanovska, l. spirevska, n. ristoska bojkovska pediatric clinic, nephrology, skopje, macedoniathe nutritional condition of children ( males and females) mean age . ± . (range - years) with moderate renal failure have been followed for three year. glomerular filtration rate (gfr) was measured by creatinine clearance calculated with schwartz formula and was ranged from . to ml/min per . m . the nutritional condition was determined by anthropometrics and nutritional measurements. the patients were divided in four groups depending of their protein intake, primary disease, ages and glomerular filtration rate. all patients were following an -ad libidum -diet. nutritional intake was determined by minimum of two -day prospective dietary diaries. % of children received significantly lower protein intake. the mean protein intake (% of who recommendation) determined by dietaries of patients with -sub-optimal intake -was . % vs. . % in patients with -adequate protein intake -(p< . ). all patients have a calorie intake of at least % of the who recommendations. the relative distribution of calories was . % from proteins, . % from carbohydrates and . % from lipids. nitrogen balance in patients was positive and correlated most significantly with increasing energy intake (r= . ). average values for height, weight, triceps skin fold, mid-arm muscle circumference, and body mass index were within sd of the mean of the normal population. the protein intake, primary disease and age of the children did not have any effect on growth and development. only patients with more advanced renal disease showed small score for height and growth velocity. key words: chronic renal failure; uremic children; nutritional status; nutritional intake; u. aslanova , t. morimoto , e. farajov , n. kumagai , n. sugawara , a. ohsaga , y. maruyama , s. tsuchiya , s. takahashi , y. kondo tohoku university, pediatrics, sendai, japan tohoku university, medical informatics, sendai, japan tohoku university, physiology, sendai, japan nihon university school of medicine, pediatrics, tokyo, japan the extracellular calcium-sensing receptor (casr) located in either luminal or basolateral cell membranes of various types of renal tubules including proximal tubules, henle's loop and collecting ducts has been thought to play a fundamental role in electrolyte metabolism. to further identify the physiological roles of the casr, we examined the effects of ca + and calcimimetics neomycin (neo), gentamicin and gadolinium chloride gd + on the intracellular ph (phi) of in vitro microperfused mouse medullary thick ascending limb (mtal) cells of henle's loop, by loading the cells with fluorescent ph indicator ', '-bis-( -carboxyethyl)- -(and- )-carboxyfluorescein and measuring the ratio of fluorescence emission at nm after exciting the dye at and nm. in a steady-state condition in hepes-buffered solution, the phi in the mtals was . ± . (n= ). a concentration of micromol/l neo in the basolateral side decreased the phi after min by - . ± . (n= , p< . ). the other calcimimetics showed similar effects on phi, whereas none of these calcimimetics in the lumen affected phi. na + removal or the inhibition of na + and proton transport with amiloride, bumetanide, or bafilomycin did not eliminate the effect of neo on phi. on the other hand, clremoval clearly eliminated the neo-induced phi decrease (- . ± . vs - . ± . in clremoval, n= , p< . ). thus, we have demonstrated for the first time that the casr is involved in the regulation of the phi in the mtal and requires clto exert its effect. background: paediatric nephrologists are often consulted for atypical rickets of renal or non-renal origin. the comeback of vitamin d deficient (classical) rickets in armenia and elsewhere is not only a public health problem but also a new diagnostic challenge for nephrologists. the aim is to analyse all paediatric patients seen in with bone deformities and suspected rickets at the arabkir hospital in yerevan. patients and methods: patients with bone deformities came spontaneously or were referred by one of us (gk). routine serum chemistry was done in yerevan. further investigations, if needed, and urine chemistry were performed in zurich. patients with rickets due to renal insufficiency were excluded. results: in we have seen patients ( males) with rachitic bone deformities aged - months (mean ± . ) at diagnosis. of these, patients had florid vitamin d deficient rickets and had sequelae of rickets but were radiologically and biochemically cured. these children with classical rickets had to be distinguished from patients with other forms of rickets: x-linked hypophosphataemia (xlh; ), vitamin d dependant rickets type ( ), and renal fanconi syndrome ( ) due to fanconi-bickel syndrome and idiopathic. conclusions: (i) the rising number of vitamin d deficient rickets is of concern and due to neglected prophylaxis, (ii) children with classical rickets came late and were in the same age range as patients with atypical rickets, (iii) hence, and because of the larger number of rachitic children, an increased awareness of nephrologists -including a full diagnostic work-up -is needed in order not to overlook rare forms of rickets, (iv) polar vitamin d metabolites should not be used before the precise type of rickets is known. b. spasojevic-dimitrijeva, m. kostic, a. peco-antic, d. kruscic, d. paripovic, m. stanic university children's hospital, nephrology department, belgrade, serbia t. porowski , w. zoch-zwierz , j. konstantynowicz , k. taranta-janusz medical university of bialystok, st department of pediatrics, bialystok, poland medical university of bialystok, department of pediatrics and auxology, bialystok, poland there are no published data on calcium oxalate (caox) crystallization and therewith associated kidney stone disease in children. the aim of this study was to determine bonn risk index (bri) in children with urolithiasis in relation to healthy age-and sex-matched controls and to assess possible associations between bri values and the size of renal stones. methods. in this cross-sectional study, we compared bri in caucasian children and adolescents ( girls, boys) aged - years (median: . ) in whom kidney stones were newly diagnosed and healthy age-and sex-matched controls ( girls, boys) without urolithiasis. urinary ionized calcium [ca + ] was measured using a selective electrode, while the onset of the spontaneous crystallization was determined using a photometer and titrating with mmol/l ammonium oxalate (ox ). the calculation of bri value was based on [ca + ] to (ox ) ratio. high resolution renal ultrasonography was done to estimate the size of renal stones. results. our results showed that bri values in children with renal stones were greater compared with healthy children without stones. bri was -fold greater, bri/kg body weight - -fold greater, bri/per . m b. s. - -fold, whereas bri/bmi was even -fold greater in cases with stones than in controls. no significant association was observed between bri and the size of stones. interpretation. children with kidney stones demonstrate increased bone risk index compared with healthy subjects without urolithiasis. an increased bri during growth, although unrelated to renal stone size reflects the risk for crystallization of calcium oxalate and may suggest early metabolic disorders leading to urolithiasis. this simple method appears to be accurate and cost-effective, thus bri may be widely used for discrimination between stone-formers and healthy children. m. dixit, n. dixit florida children's hospital, florida children's kidney center, orlando, united states acute tubulo-interstitial nephritis (atin) is an important cause of acute renal failure resulting from a variety of insults including rare immune complex-mediated tubulo-interstitial injury. drugs including non-steroidal anti-inflammatory drugs (nsaids) are far most frequent cause of atin, but overall as an entity it remains under-diagnosed as symptoms resolve spontaneously if the medication is stopped. we present a -year-old male who developed acute renal failure weeks after aortic valve surgery. he was put on aspirin following surgery and took ibuprofen for fever for nearly a week prior to presentation. he then presented to the emergency department feeling quite ill and was found to have bun of mg/dl, creatinine of . mg/dl and serum potassium of . meq/l. dialysis therapy was immediately initiated. a kidney biopsy showed inflammatory infiltrate consistent with atin. however, very intense tubular basement membrane (tbm) granular deposits of polyclonal igg and c were noted. he needed dialysis for nearly two weeks and was treated successfully with steroids. his renal recovery and disappearance proteinuria took almost a year. in conclusion, we present an unusual case of tbm immune complex-mediated atin due to nsaids with severe but reversible renal failure. the effect of corticosteroid therapy on bone metabolism in nephrotic syndrome background: nephropathic cystinosis is characterised by lysosomal cystine accumulation leading to generalized fanconi syndrome. defective tubular reabsorption of proteins, mainly by the multi ligand receptors megalin and cubilin, is considered to be the cause of proteinuria in cystinosis. whether increased glomerular permeability contributes to proteinuria in cystinosis is investigated in this study by evaluating ) urinary protein pattern in cystinotic patients and healthy controls ) expression of megalin, cubilin and their ligands transferrin, albumin, a -microglobulin (a m) and b -microglobulin (b m) in renal tissue. methods: urine of cystinotic patients and controls (n= ), aged - , were immunoblotted using antibodies against megalin, cubilin, transferrin, albumin, a m and b m. additionally, urinary levels of igg, albumin, a m and creatinine were measured. results are expressed as mg/mmol creatinine (median, range). presence of proteins in semithin paraffin sections from cystinotic and control kidneys was evaluated using antibodies mentioned before. results: cystinotic patients had increased urinary excretion of , p < ) and all tested ligands of megalin and cubilin. immuno histochemistry showed comparable expression of megalin, cubilin and their ligands in convoluted proximal tubules (pt), while the ligands in straight pt were only present in cystinotic patients. conclusion: a selective proteinuria with high molecular weight protein excretion such as igg indicates increased permeability of glomerular filtration barrier in cystinosis already at an early age. the presence of the megalin and cubilin ligands in endocytic vesicles suggests functional endocytosis. however, the enhanced staining of the ligands in cystinotic straight pt may be a result of incomplete reabsorption in convoluted pt. background: dent's disease and lowe syndrome are the most frequent x-linked tubulopathies. dent's is characterized by lmw proteinuria, hypercalciuria and nephrocalcinosis. in ca. %, this phenotype results from mutations in the clcn -gene. lowe syndrome (congenital cataract, mental retardation and generalized fanconi syndrome) is due to mutations in the ocrl gene. stunted growth is another typical finding in lowe patients. recently, in a subgroup of dent patients ocrl gene mutations have been demonstrated (dent- disease). aim of the study: comparison of the growth pattern of patients with clcn and ocrl mutations. patients: boys with proven mutations in clcn (n= , mean age . ± yrs) were compared with those with dent- disease (n= , ± yrs) and those with ocrl mutations and a lowe phenotype (n= , . ± . yrs). comparison of z-scores for height, weightand bmi. results: clcn positive boys had a significantly higher height-sds (- . ± . ) than ocrl positives (dent- : - . ± . /lowe: - . ± . ). there were no significant differences in bmi-sds and weight-sds. the difference between weight and height sds as a parameter for obesity in these small-statured children was higher in lowe than in classical dent patients, with intermediate values being found in dent- . discussion: although the renal phenotype of dent- patients is identical with classical dent, the former are more stunted. therefore, the abnormal growth pattern in dent- patients cannot be ascribed to renal dysfunction. taken together with other findings (elevated ck and ldh, mild mental retardation) our findings illustrate that dent- is indeed a mild variant of classical lowe syndrome. quantitative ultrasonometry of the calcaneus in children with idiopathic hypercalciuria lesch-nyhan syndrome is a very rare x-linked recessive disorder characterized by mental retardation, spasticity resembling cerebral palsy, choreoathetosis, self-mutilation and hyperuricemia. self-mutilation behavior is a hallmark of the disease. hyperuricemia leads to hyperuricuria and uric acid nephrolithiasis. we report on a -year-old boy with lesch-nyhan syndrome with no self-mutilation behavior who was erroneously diagnosed as having athetotic cerebral palsy. besides, he had no renal stones, the only renal abnormality detected were hyperechoic renal medullary pyramids, sonographicaly indistinguishable from medullary nephrocalcinosis. bone disease is frequently observed in children with homozygous beta-thalassemia (thal). we have observed an increased prevalence of renal stones in these patients. in order to understand the cause of this predisposition to renal stone formation we investigated markers of bone metabolism in our thal children. we studied thal children (age range - years; females and males) with no eviodence of renal stones. thal was diagnosed with haemoglobin hplc study and genetic typing. all received blood transfusion and iron chelants on a regular schedule. serum levels of pth, osteocalcin, telopeptide c-terminale (cross-laps) were determined with eclia technique; serum vitamin d ( ohd ) with elisa technique. serum calcium, phosphate, uric acid, bicarbonate, creatinine, alkalin phosphatase and sodium, calcium, oxalate, citrate and creatinine in hours and fasting urine were determined with common methods. as controls we studied children with comparable age. serum pth and vitamin d were increased in % of our patients, serum osteocalcin in % and telopeptide c-terminale (cross-laps) in %. hypercalciuria was observed in %, hyperoxaluria in % hypocitraturia in %. significant correlation were found between pth and osteocalcin (p< . ) cau/cru (p< . ); osteocalcin and cross-laps (p< . ) and vit d and cau/cru (p< . ). bone disruption due to bone marrow expansion may produce an increase in vit d and pth production with hypercalciuria producing renal stones. losartan is an angiotensin ii subtype (at ) receptor antagonist used for controlling blood pressure and urinary protein excretion in patients with hypertension and chronic renal disease. there are a few reports about the clinical implications of at- receptor antagonism that may interfere with the kidney's defense against an acid load and may thereby exacerbate metabolic acidosis in the literature. the suggested mechanism is that at- blockade by losartan exacerbates acidosis by inducing a distal-tubular acidification defect.we observed metabolic acidosis and hyperkalemia in five patients ( females/ males, age ranged - years) whom were given losartan. during the second week of the therapy all patients revealed a metabolic acidosis with (ph; ranged , to , and hco ; ranged , to mmol/l) hiperkalemia (ranged , to , mg/dl). the etiologies of chronic renal disease in the patients were focal segmental glomerulosclerosis (fsgs) in one, lupus nephritis in one and three had undergone renal transplantation according to different etiologies. glomerular filtration rate was higher than ml/sec/ , m in all patients. immune suppressive regimen of renal transplanted patients was based on tacrolimus in two patients and on cyclosporine a in one. both renal transplanted patients and other two patients with fsgs and lupus nephritis were all receiving steroid, enalapril and mycophenolate mophetil at the same time during the losartan therapy. metabolic acidosis and hyperkalemia were recovered within a week following the exclution of the losartan. in conclusion, we think detailed and controlled studies are necessary to determine the pathogenesis of the metabolic acidosis due to losartan and patients must be followed up very closely for the adverse effects of metabolic acidosis and hyperkalemia during the treatment. objectives of study: bartter's syndrome is a rare renal tubular disorder characterized by hypokalemia and metabolic alkalosis. it is also known to be effectively treated with potassium supplement, potassium sparing diuretics and indometacin. we experienced two sibling cases whose problems were incompletely solved with above mentioned conventional treatment, but rather completely with adjunctive therapy of regular hemodialysis with dialysate of low bicarbonate concentration. case : this male patient was diagnosed of bartter's syndrome when he was months old. he was treated with potassium supplement, aldactone and indometacin with marked improvement. but he still had some problems of retarded growth, severe headache and episodes of marked hypokalemia which needed repetitive admission. when he was years old, we put him weekly hemodialysis with dialysate of low bicarbonate concentration ( meq/l). with hemodialysis, he has been in good condition for years with stable blood ph and serum potassium levels. case : this female patient, the elder sister of case , was diagnosed of bartter's syndrome at one year of age. with those therapy on conventional medications, she seemed to grow out of failure to thrive, but needed repeated admissions due to episodes of dehydration and hypokalemia. after start of weekly hemodialysis with low bicarbonate dialysate, for one year she has been on good control of blood ph and serum potasium level, and was never admitted with those episodes. conclusion: regular hemodiaysis with dialysate of low bicarbonate concentration can be considered as effective adjunctive therapy in intractable bartter's syndrome. a. deguchtenaere, a. raes, j. dehoorne, c. vande walle, r. mauel, j. vande walle university hospital gent, pediatric uro-nephrologic center, gent, belgiummonosymptomatic enuresis nocturna (mne) may be associated with nocturnal polyuria (np) and low urinary osmolality during the night. besides vasopressin, recent studies have stressed the possible role of renal sodium-handling, hypercalciuria, prostaglandins and/or osmotic excretion.the aim: was to study circadian rhythm of gfr and diuresis in a highly selected group of children with persistant np. methods: population existed of children with mne and np, age - y, males. controls n= children, - y with mne, but no np. (=b). renal function during h concentration-prophyle, with timed urine samples, and measurement of p and u for na, k, osmol, creatinin. calculation of gfr by creatinine, uosmol, feosmol, diuresis vol (ml/min), fena, fecl, fek, u k /u k +u na %. statistics: paired t-test p< . between d and n, unpaired t-test, between the groups. conclusion: children with nocturnal polyuria have not only lost their circadian rhythm of diuresis and sodium-excretion but also of gfr. another observation for a reanl involvement in mne. sarcoidosis is a systemic disorder of unknown etiology, rare in children, characterized by the presence of noncaseating granuloma in affected organs. we report a -year-old boy of french african origin who presented with left hearing loss followed by bilateral deafness within months. a history of bilateral uveitis was secondarily unveiled. mild renal insufficiency (creatinine level μmol/l ; clearance: mmol/min) was diagnosed prior to cochlear implant surgery. a percutaneous renal biopsy evidenced a granulomatous interstitial nephritis with widespread interstitial fibrosis. complementary explorations showed elevated lysozyme activity at μg/l (normal < ) with elevated cd /cd ratio in bronchoalveolar lavage specimen. pulmonary function test was notable for mild diffusion impairment. cerebral mri demonstrated abnormal enhancement involving the periventricular white matter and the intracanalicular portions of both viii cranial nerves. cerebrospinal fluid showed abnormal hyperlymphocytosis ( lymphocytes per mm ) while protein was normal. three weeks after admission, bilateral uveitis recurred and was cured by local steroid therapy. despite intensive treatment with intravenous prednisone g/ , m /j per day, successive days per month associated with oral prednisone during months, glomerular filtration rate did not improve. in conclusion, sarcoidosis may apparently be revealed by acute bilateral deafness, and prompt diagnosis is needed to avoid permanent lesions. gfr cystcin= . cystc - . , formgfr= *height (cm)/s-creat (mmol/l). d difference between c inulin and tested method. conclusion: none of the tested methods seems to reveal hyperfiltration in type diabetes patients as clearance of inulin. the best correlation was found to clearance of iohexol and second best gfr estimated by /cystatin c. creatinine clearance overestimates and formula clearance underestimates gfr in diabetic patients without nephropathy. objective: to study the effects and mechanism of fty on the renal interstitial fibrosis in unilateral ureteral obstructic rats. methods: fouty-five males sd rats were randomly divided into sham-operated (sham), unilateral ureteral obstruction (uuo) and uuo treated with fty (uuo+fty ) group. . mg.kg - .d - of fty or vehicle was administrated through daily gavage and begun from two days before the operation till being sacrificed. -hour urine protein, blood urea nitrogen and plasma creatinine were determined. the renal tubular interstitial fibrosis lesion and the expression of α-sma,col-i, cd , ed were scored semi-quantitively. results: the amount of hours urine protein was much lower than that in uuo group, (p< . ). serum creatinine in fty treated group were significantly lower than those in uuo group (p< . ). the scores of renal interstitial fibrosis were lower in fty group than that in uuo group. α-sma expression was limited to vessels in sham group, but extended to renal tubule and interstitium in uuo and fty treated group, while relatively weaker expression was observed in fty group than in uuo group. some collagen expression was found in sham group, which was much enhanced in uuo group and mainly distributed in renal interstitium, the expression in fty group was also increased compared to sham group, but much lower than that in uuo group. obvious lymphocyte and macrophage infiltration were found in tubular interstitial area in uuo group but significantly less in fty treated group (p< . ).conclusion: novel immunomodulator fty can obviously inhibit renal interstitial lymphocyte and macrophage infiltration, renal tubule cell transdifferentiation, and interstitial fibrosis, thus prevent renal disease progression. background: the mesangial cell, especially as a fundationtal component in normal mature glomeruli, is essential to keep glomerular capillary lumen open and to maintain efficient ultrafiltration. loss of mesangial cells due to pathologic conditions such as glomerulonephritis leads to impaired renal function. the exact developmental origin of mesangial cells is unknown. it has been established that mesenchymal stem cells, which are derived from bone marrow, have a potential to differentiate into different lineages in response to different environments. the purpose of the study is to examined the effect of platelet-derived growth factor (pdgf) in the differentiation of bone marrow-derived cells into mesangail cells. method: isolated bone marrow cells were cultured in the medium containing collagen type i within hours, and then transferred to collagen type i.-coated dishes. the cells attached to collagen type i. in the following days were maintained in the differentiation medium containing % horse serum, μmol/l, and μmol/l of pdgf and all-trans retinoic acid. results: after cultivation under the above condition, approximately % of cells expressed β actin and desmin, which highly resembled cultured mesangial cells in rat. the induced cultured cells changed into a wide range of shapes from spindle to stellate. the results indicate that bone marrow-derived stem cells could differentiate into mesangial-like cells in vitro.